Integrating Treatment of Underserved Populations in Today’s Private Practice

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With many clinicians flocking to larger areas with seemingly more potential patients, there are many other areas with underserved populations who are in need of physical therapy services.

By Emily Monson, PT

Being a private practice physical therapist is very versatile. We have the ability to start a career wherever we wish to open a practice: in a large city, in a rural town, or in a bustling suburban area. With the possibility of having our careers anywhere, it is important to remember that there are plenty of underserved populations that do not get the necessary attention they deserve, as providers often flock to areas where there are seemingly more potential patients.

I began my physical therapy career fresh out of graduate school in a city of about 50,000 people. The mid-sized city had the population to support a large hospital system, as well as private practices such as the one in which I worked. In physical therapy school, we are taught in-depth evaluation and treatment methods, but are rarely taught aspects of small business that would be useful to managing a private practice clinic. During this time, I had the opportunity to learn the design, administrative aspects, and daily operations of a successful private practice.

Very quickly, I found the private practice setting to be my niche, and I decided that I wanted to continue in that field when I soon moved to a very small, rural area of about 1,000 people. I took all the knowledge that I learned from that experience and put it into starting my own small, private practice clinic in an area where residents previously had to travel far distances for physical therapy care.

My practice started as a small outpatient clinic, and has grown over the past 10 years, adding specialties in industrial rehabilitation, cash-based services, sports medicine, and more. With five physical therapists, an athletic trainer, massage therapist, and occupational therapist, we are now the one-stop therapy clinic for our small community. By strategically placing our clinic in a low-cost site, we have been able to provide quality care to an underserved population while still being profitable. Also, through teaming up with satellite medical clinics in the area and further establishing a community perspective, residents value our clinic even more.

It is a common misconception that you cannot be successful in private practice in a smaller community. Just because a town is small does not mean that they have a lesser need for therapy services. Many times, those who are in pain do not or cannot travel far for the physical therapy care they need to get better, so by placing a practice within their means, you can appeal to those patients in need.

The key to being successful in underserved, rural areas is to establish yourself in the community, do your research, and create a practice that caters to the specific needs of that small community.

  1. In a small community, residents know each other well. They make an effort to get to know members of their community and bond through shared values and interests. If you are new to a community, get to know the members, leaders, and industry so that you can become a more trusted and active member in the community.
  2. Do your research! Does the community revolve around agriculture? Is there a busy factory nearby where many of the residents work? Does the local high school have a growing athletic program? What age are most of the residents? Knowing these things will help you to decide what services will be most important to the members of the community. For example, if a large number of residents work in a factory, there may be a greater need for an industrial rehabilitation specialist to help return injured workers to their jobs. If the local high school has an athletic program but does not have an athletic trainer to oversee practices and games, and to treat injured athletes, then consider adding an athletic trainer to your staff to better serve the school and students. Remember that your private practice can boast more than just outstanding physical therapists and physical therapy assistants; it is possible that your community may be in need of a massage therapist, speech therapist, occupational therapist, or athletic trainer. Bottom line: Do your research and design your practice around the needs of the community. The more adaptable you are to the community’s needs, the more valuable your clinic will be.

Overall, think about what you can do for your patients (besides providing excellent therapy care) that will help them most. For example, by scheduling appointments within 24 hours of referrals, you can appeal to patients who have tight schedules and need immediate care. Also, by taking the time to verify benefits and insurance from day one and helping patients understand financial obligations each step of the way, you will appeal to those who may be worried about physical therapy financially. Working with your practice management team to make sure that you have successful billing and insurance programs will make a big difference to your patients.

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The unique part of being a private practice clinician in a small community is that this setting allows you to really mold your practice around the needs of the residents. Not only is it great having a personal connection with patients and living in the community where you work, but also it is incredibly rewarding to know that you are serving a community that may not otherwise have received the care they needed without your practice. We can be guides to these patients every step of their recovery and truly make a difference in their lives.

You will find that being a clinician for an underserved population becomes more than just seeing patients and helping them overcome physical ailments; it becomes a part of you and you will become a very important part of their lives. I encourage you to take the plunge and choose to provide care for underserved populations; it is very rewarding and can indeed be done!

Emily Monson, PT, is an Impact editorial board member and owner of Clear Lake Physical Therapy & Rehab Specialists. She can be reached at emily@therapy1.net.

Hope and Opportunity

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Physical therapists have the ability to lower insurance costs for employers by simply communicating.

By Sturdy McKee, PT, MPT

Amid the doom and gloom and fear surrounding our profession, there is great hope and opportunity. Though clearance houses are still cropping up trying to take advantage of providers and payers, payment structures are fundamentally changing. Sixteen percent of covered workers at small firms (3-199 workers) and 83 percent of covered workers at larger firms are enrolled in plans which are either partially or completely self-funded, similar to 2012 (15% and 81%). Six percent of firms offering fully-insured plans report that they intend to self-insure because of the Affordable Care Act (ACA).1 This means that the employer, not the insurance company, is now on the hook for medical costs and will realize the savings if they manage their costs well.

Despite this shift, there remains a focus on siloed costs. By dividing orthopedic costs into separate silos, the traditional payers are missing the big picture. Not enough emphasis is on the overall costs of providing care to employees, and the resultant value from the money employers are spending exists. The employers’ frustration is both palpable and understandable. Health care costs and premiums are the only area where employers sit down with their vendors each year and get less and less while spending more and more. In nearly every other category, they either receive more for the same money or receive the same for less money.

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There is Hope

Michael Connors of Performing Arts Physical Therapy of North Texas in Fort Worth has contracted directly with the Texas Ballet Theater Company. His practice is able to bring exceptional value to the organization by preventing injury and treating injured dancers in order to allow them to continue to do what they love to do: perform. Michael estimates direct savings for the Ballet Company at $100,000 last year. Beyond the financial benefit, this past year the Texas Ballet had a grueling 28-day, 45-performance schedule for The Nutcracker. Compared to previous years, this past season saw them finish with no dancers missing a performance due to injury. That is right, zero missed performances, and the only change was bringing physical therapists in to help the dancers.

Marc Guillet of Agile Physical Therapy in Palo Alto has a direct contract with a major internet search company in Mountain View, California. Agile provides physical therapy treatment and prevention services onsite. Marc calculates that between hard costs and the softer costs of lost time from work, and travel to and from appointments, that the return on investment for the contracted company is three times their annual investment.

We know that reducing injuries in professional sports can keep players on the field and result in both dramatic results and savings. The same is true for employers of every stripe. The dollar amounts may not be as dramatic for a single employee, but the results and cost savings’ potential are still dramatic. We, as physical therapists, have an opportunity to help employers keep people working and productive while avoiding unnecessary imaging, injections, surgeries, and drugs. In many cases we are the most effective and the most economical solution. We simply have to do a better job of communicating this to employers. They are looking for solutions to this ever-increasing problem and are not aware that we can help. If they do not know about us because we are too busy in the clinic then there will be no change. And think of all the people we could be helping who are navigating the health care system without a map—going down the wrong paths and grasping at straws when we are right here ready to help them.

The underlying incentive structure has changed

While we have all been focused on the Affordable Care Act (ACA), International Classification of Diseases, tenth revision (ICD-10), Physician Quality Reporting System (PQRS), and the like, the underlying incentive structure for providing health care has changed. As referenced above, many employers no longer pay premiums to an insurance company, but operate under a self-funded insurance program. They no longer shift the risk to a third party payer, but are in fact increasingly that payer. They are now the ones assuming the risk. But they are taking advice from the now third party administrators who are still acting as if they were the payers. The problem with this paradigm is that individuals typically had coverage under the same payer for only about two years. The incentives were to delay care and manage the silo. They did not have an incentive structure to manage the full pie, at least to the same extent that now exists, and they never developed the tools and systems to fully realize the benefits of managing the entire pie.

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Most employers hope to keep their employees engaged for longer than two years. Therefore they have a vested interest in keeping their employees healthy, whether they are at risk for injury on the job or on the softball field. So there is an increasing incentive to invest in prevention, and to make substantive changes to clinical pathways, especially in areas still managed under the siloed model of controlling health care costs. Where the employer is the ultimate insurer, there is also less incentive to determine whether something is paid under workers compensation or under general health care benefits. However, because of the advice employers have been getting from traditional payers, this paradigm shift is slow in being realized.

There is a huge unmet market and need

Only 7 percent of people with low back pain who first see their primary care provider ever get to a physical therapist, and 30 to 50 percent of people with low back pain, depending on geography, see a chiropractor first for their initial care. Fifty percent of those who do see their primary care physician are given narcotics for low back pain. Screen Shot 2015-06-25 at 3.18.30 PM Prescription drug abuse is a growing problem in the United States. By getting someone to physical therapy within 14 days of initial onset from low back pain we know that we can save the system thousands of dollars, improve functional outcomes, and get the patient better faster.2 This means less lost work time, improved function, lower costs, and a potentially much larger market for physical therapists—simply a win for everyone involved. It is important that we begin telling the story and getting the message out to all of the parties who could share in this win.

Imagine if you bypass the major “payer” in your area and go directly to the employers who are now increasingly the actual payers. Imagine demonstrating the cost savings that they might realize by simply directing people to get physical therapy first. If we are only seeing 7 percent or fewer of the people who have low back pain then we are likely also not seeing a significant percentage of those with shoulder, knee, hip, ankle, or neck pain and dysfunction. Our market penetration is minimal at present. And that means we are not helping the majority of people we could be helping. And that also means we have an enormous opportunity through educating the public and employers to increase our market size while making the new third party administrator less and less relevant.

Resources

1. About.com. What is a self-funded health plan? From Kelly Montgomery, former About.com Guide. Updated November 12, 2008.

2. Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.

3. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD. (Total does not include lost employer productivity due to employee medical absence.)

4. Website www.drugabuse.gov/publications/research-reports/prescription-drugs/director. Accessed May 2015.

Sturdy McKee, PT, MPT, is a PPS member and the co-founder and chief executive officer of San Francisco Sport and Spine Physical Therapy, SleepSling, and ScheduleDoc.co. He can be reached at sturdymckee@gmail.com, www.linkedin.com/in/sturdy or @Sturdy.

Get in Control

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Focus on what you can change, no matter how small.

By Brett Gajda

“We can’t solve problems by using the same kind of thinking we used when we created them.” —Albert Einstein

There is perhaps nothing more frustrating than a situation where your level of control is small but the impact of not having control is potentially large. Imagine being in the middle of the ocean in a rowboat when a storm hits. All you can do is figure out what small moves you can make to increase your chances of survival. What you cannot do is stop the rain, stop the wind, or stop the waves.

I work with businesses all over the world and it seems like every week I get into conversations with people in different industries about how things are tough in their industry. Through these discussions, I have realized that in every industry there are things that are out of a business’s control, which can have a negative effect.

Through conversations with owners of private practice physical therapy clinics, I know this is no different for you. There are many issues you are facing as an industry, as well as an individual business owner. Here are just a few of the topics that I have heard discussed:

  • Declining reimbursements from insurance companies
  • Increasing cost of education and resultant increased debt load when entering the workforce
  • Over regulation
  • A professional identity crisis resulting in decreased public awareness of what physical therapy is

Some of you might read that list and relate. Others might want to add 10 more things. Either way, this is your reality. A lot of items on this list are no different than the earlier analogy of the storm. You cannot control it.

So, what can you do? What is the best strategy?

In Stephen Covey’s classic book The 7 Habits of Highly Effective People (Simon & Schuster, 2013), Habit 1 is Be Proactive. Within this habit, he talks about two circles—the Circle of Concern and the Circle of Influence. The Circle of Concern is the collection of things you have no control over. Common items in this infinite circle include the national debt, the market, and laws. The Circle of Influence is a group of things you can do something about: how you eat, how you exercise, your spending, your attitude, what you learn, how you treat patients and colleagues, and how you practice on a daily basis.

When I hear and read people in the business world address this model, I most often find it turns into a conversation around attitude, which makes sense. One of the biggest things within the Circle of Influence that you can control is your attitude. That said, it can also be frustrating when a storm is barreling down on you and someone says, “Well, you just need to change your attitude.” While I believe an attitude shift helps tremendously, sometimes it is just putting a Band-Aid on a situation.

So outside of changing our attitude, what can we do in our approach and actions to not only “deal with,” but also to change things that we feel we have no control over?

I think that one of the errors people make in addressing issues in their Circle of Concern is that they look at these issues through a lens of quantity instead of a lens of quality. They look at a problem and think the biggest impact will be made through tackling the biggest piece. So, for example, when 99 percent is out of their control, they feel it does not make sense to focus on the 1 percent that you can control. They think, “If I focus on the 1 percent, what difference will it really make?” It seems futile.

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And so instead, they focus on the 99 percent that is out of their control. Because it feels like even if they just change some of that 99 percent, they have solved a larger piece of the problem. However, this is your Circle of Concern. Where you stand right now, no matter how hard you try, no matter what you do, that boulder will not move. Focusing on the 99 percent is what is actually futile.

And in the process, you will probably just get more frustrated, exhausted, drive yourself crazy, and take it out on others—it will have a negative effect on you, your family, your business, your patients, and your life.

Last week, I was speaking with a colleague about this concept, and he used an analogy from wrestling about how we can move things that are currently in our Circle of Concern to our Circle of Influence.

He shared with me that at certain points in a wrestling match, you can be at a severe disadvantage. Your opponent is on top on you, you are pinned down, you can barely move, and you are inches away from losing the match. And in those moments, almost nothing is in your control. However, if you panic and think, “How do I get out from under him?” you just get even more discouraged. The only thing you can do to have any chance of survival or success is to look for one thing that you can influence in that moment. One thing that maybe you can change.

The example he gave me is you suddenly look over and you see that with your hand you can reach his hand, which is gripped on your right wrist. And the only thing you can influence is the grip he has on your right wrist. And so with your hand, you work on loosening his grip. His grip being 1 percent of the problem that you are facing, but the only part of the problem you are facing that you can influence.

Now imagine you loosen that grip, and then his arm moves. Now you have access to 5 to 7 percent of the problem, and you realize, “Oh, I think I can move my arm out now.” And so you focus on that, and you move your arm and spin your body just a bit. You see his leg and think, “I may be able to grab his leg and flip him.” All of a sudden you now have access to 50 percent of the problem.

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You see, from where you stand, you may only be able to influence 1 percent of the problem. However, once you change that 1 percent, it actually changes the entire landscape of the situation. And then sometimes, from that new place, that new perspective, you gain access, or expand your Circle of Influence, to a part of the problem that was previously only in your Circle of Concern.

For instance, declining insurance reimbursements or Medicare’s therapy cap may seem to be in your Circle of Concern, and completely outside of your control. However, in each situation, where can you find the “wrist” or the one percent that is inside your Circle of Influence? Can you meet with a legislator; can you educate your patients?

Oftentimes, people are discouraged from taking action because they already have the mindset of “It is not going to work” or “It will not make a difference.” The missing piece is realizing or remembering that you do not know what new perspectives or possibilities will open up, once you make a small change. When you influence that 1 percent, what else does it potentially open up in your Circle of Influence?

Going back to Stephen Covey’s Habit 1, a Proactive person looks at issues through a lens of quality, not quantity. They understand that the only place that they can truly be proactive is in their Circle of Influence.

Do not get caught in the trap of thinking that if you need $100, getting $1 won’t make a difference. Because when you have $1, you now have $1 to invest. If you invest it wisely, you can turn that $1 into $3…and maybe that $3 into $10. It does not matter how big or small what you can influence is, because it is the only thing you can influence. And so for the sake of effectiveness, success, and sanity—start there.

Brett Gajda is a global consultant, trainer, and speaker for Fortune 1,000 companies, as well as entrepreneurs. He is also the writer/host of the Where There’s Smoke podcast. He can be reached at brett@raiseyourvalue.com.

Surviving and Thriving

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How to stay successful In the new world of health care.

By Rob Worth, PT, DPT, MS, OCS, MTC, ATC/L

“If you are prepared to accept the consequences of your dreams then you must still regard America today with the same naive enthusiasm as the generations that discovered the New World.” —Jean Baudrillard, French semiologist. “Utopia Achieved,” America (1986, trans. 1988)

Surviving and thriving in the new world of health care and integrated health care systems can certainly be a daunting thought. Depending on where in the country you practice, you may already be seeing many alliances forming around you and maybe you are not sure what, if anything, you should be doing about it. Fortunately, new world innovation still comes down to a few age-old attributes: value, relationships, and integrity.

Value. Though the uncertainty of new payment models (i.e., per diem based on patient severity and treatment complexity, bundled payment, etc.) is intimidating, there will always be a place for the highest quality physical therapy services that are provided at a reasonable price. Be that provider. The health care system is in dire need of a solution that provides cost-effective care for patients and prevention/wellness for populations. For example, through providing onsite industrial injury care and prevention for one of our client companies, our practice saved the company over $100,000 in their fourth quarter alone. This is real value that we as physical therapists can provide. It is an exciting time for physical therapists, especially those providing direct access care, because we are uniquely positioned to step up and become the cost-effective solution for managing conservative musculoskeletal care. Do you provide cutting-edge, cost-effective care to your patients? Do you track and measure your outcomes? Imagine the value to your patients if your treatment techniques provide the same quality outcomes but allow them to finish their treatment in three to four fewer treatment sessions. With today’s higher copay and/or higher deductible plans, you could be saving your patient hundreds of dollars in direct out-of-pocket expenses. Patients will very quickly see the value in your services and you will quickly become the provider of choice.

Relationships. Being a provider of high-value physical therapy services is the cornerstone of success. However, if you are not engaging in discussions with employers, insurance companies, physician groups, as well as involving yourself in the community, you are going to miss out on some opportunities and find your practice to be less a part of integrated systems of care in your community than you would like. Do you have a specialty service that no one else in your area offers? Is there some special training that you and your staff have that will allow your team to be essential to a network that is forming, or one that already exists but might have a lack of providers in your geographic area? This is a great “door opener” to help get you at the table and secure the continued success of your practice. You may find that your practice does not offer a service that your community needs. If you are always trying to stay current with the needs of your community and local referral sources, it will help you anticipate how to grow your practice for future survival. When it comes to key players in the integrated systems of care in your community, if you are not sitting at the table you may end up missing out. Collaboration is key—form a network with other like-minded private practices and align with other health care providers and groups. Although many of us gravitated toward private practice for the autonomy and independence, there is oftentimes strength in numbers. You do not have to join a group, but it is better to be asked than to miss the opportunity completely.

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Integrity. As everyone is jockeying for positions in this evolving health care world, maintaining integrity in your clinical practice and your business interactions will allow your practice to have a positive reputation that endures. In September of 2014, the American Physical Therapy Association (APTA) launched the Center for Integrity in Practice as part of its Integrity in Practice Campaign (www.apta.org/Integrity), designed specifically for physical therapists, physical therapist assistants, educators, students of physical therapy, and leaders to better understand fraud, abuse, and waste in health care. It is vital for us to understand the impact that fraud and abuse have on the profession of physical therapy, on individual physical therapists, and on their freedom to practice. The goals of this center are to help physical therapists and physical therapist assistants identify and understand the risks and possible pitfalls associated with fraud, abuse, and waste. The site provides some specific solutions and resources to help members reduce risks, improve care, and also to help navigate our complex regulatory and payment environment. If you have not taken the time to explore the content in this part of the APTA web page, add it to your to-do list. Business integrity is not a place to take shortcuts—instead it should be the cornerstone on which you build your practice. Having integrity in your practice will help to create opportunities for strategic alliances as integrated systems of care form.

It is a brave new world in health care and following the age-old attributes of creating value, developing relationships, and maintaining integrity will guide you in the right direction. Do not just live in the new world—be a part of creating it!

Rob Worth, PT, DPT, MS, OCS, MTC, ATC/L, is the president of Advanced Physical Therapy & Sports Medicine. He can be reached at rob@advancedptsm.com.

Innovation through Collaboration

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Mastermind or peer advisory groups bring like-minded noncompetitive businesses together to leverage their collective minds.

By Mike Horsfield, PT, OCS, MBA

Most great world and business leaders have a trusted group of advisors that they count on when making important decisions. King Arthur, Franklin Delano Roosevelt, Benjamin Franklin, and Andrew Carnegie all believed that collaborating with their peers was instrumental in their success. The concept of bringing minds together to create a powerful force was formalized in the early 1900s by Napoleon Hill in his two books The Law of Success and later expanded in his bestselling classic Think and Grow Rich.

The Mastermind principle is the coordination of knowledge and effort of two or more people who work toward a definite purpose, in the spirit of harmony. It is a unique concept that leverages the collective power of the group, creating a Third Mind. —Napoleon Hill

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