Thinking about Your first physical therapy career move? My advice for recent physical therapy graduates.
By Thomas Janicky, PT, DPT
At this year’s Graham Sessions, Jamey Schrier spoke about fear being a fierce detractor from allowing us to realize our life goals. It is safe to say that everyone has experienced fear in their life whether it was minutes before the interview for your dream job or seconds before the starting gun of a big race. We often easily have the ability to overcome the fear of things we can touch, see, and hear. It is the fear of things that we cannot see, touch, hear, understand, or predict that can triumph over even the strongest among us. Fear of the unknown is a crusher of dreams and can often force us into making comfortable choices, which can lead to complacency and mediocrity. It can stifle the ability to be disruptive in our clinical practice and in a market that requires innovation and fresh ideas. Comfort puts us into the mindset of “this is how we have always done it;” it perpetuates the use of outdated treatment practices and thinking that there is a one-size-fits-all model in the way we deliver our services. History has shown us that innovation is bred through risk taking, learning from failures, and from those who have harnessed the nurturing guidance of mentors who instead of teaching us what to think, teach us how to think. So why is it that a very small percentage of the human population are innovators?
More and more of those who identify as millennial are seeking and craving opportunities to break the mold of the outdated “career ladder” and create new and interesting opportunities for growth within our workplaces. We are looking for different ways to define success and that often does not mean landing a comfortable 9 to 5 job. We are not interested in perpetuating an outdated system and instead we look to create better opportunities for ourselves, as well as the employees, associations, and consumers we belong to and work with. Those who understand this will describe this behavior as creative, bold, “outside the box,” courageous, and innovative. Those who do not understand this behavior will describe it as arrogant, entitled, defiant, disloyal, and reckless. I am describing the millennial physical therapist.
Today’s practice owners are frequently coming face to face with the millennial physical therapist. I think it is quite funny when practice owners approach me asking for advice on how to communicate with “my kind” as if we were delicate organisms being discovered for the first time. As a millennial myself, I want practice owners, educators, and leaders in the profession to fear us less by understanding us a little more. I want them to realize that they can harness the power of this “reckless and fear devoid” millennial with mutual benefit for their practice and the growth of said millennial. In the long run, this could in fact lead to the development of both individuals and ideas that lead to innovation that could benefit the professional association, private practice, and the profession as a whole. It is with that idea in mind I wanted to share five tips for hanging on to your millennial physical therapist.
1. Let the baby bird fly!
Much like the mother bird pushing her young ones out of the nest, do not be afraid to push us outside of our comfort zones and come to solutions on our own. Put the spoon down and see what happens, but avoid being harsh if we fail and instead discuss it and help us learn from it. Perhaps given your previous experience you hold the piece of the puzzle that can turn our failure into a genuine learning experience. We all want some form of mentorship, and your experience is extremely valuable to us. I am pretty sure this is not just a millennial thing; micromanaging can quickly frustrate anyone. If you treat your employees like the paranoid mother in the passenger seat of her teenager’s vehicle, your actions will get old quickly. I am not saying that we do not need guidance or assistance, but freedom to make decisions and learn from our mistakes creates learning experiences and avenues for growth for both parties. After all, you want to encourage your team members to learn to make decisions on their own.
2. We really, really like technology!
If you have yet to discover the power of technology you are missing out on a huge avenue for patient/client/employee engagement. With a large percentage of the population now owning a smartphone, it is a poor generalization to say we are the only ones “obsessed” with technology. The truth is we grew up with it and we understand it and that perplexes those who were not afforded the same luxury. Take advantage of this opportunity; allow your millennial physical therapist to get creative in this avenue. Patients/clients will usually jump on board if you can offer them something that saves them time. A study conducted by the analytics firm International Data Corporation concluded that on average smartphone users check their Facebook 14 times a day,1 imagine the marketing opportunities your tech savvy millennial can have for your clinic. Don’t hate it, embrace it.
3. If you are in the business of perpetuating the same old ideas, you probably will not hold on to your millennial physical therapist too long.
Do not take this statement the wrong way, of course there are guidelines to follow and systems in place, but do your best to hear us out. Outside the box thinking leads to innovation in practice, it inspires new ways of interacting with patients/clients as well as referral sources. I would encourage all practice owners to eliminate words such as “cannot” or “impossible” from their vocabulary when interacting with millennials. Hear us out, and encourage us to present our case. If something is lacking, maybe you have the missing piece. Frankly, a millennial that hears these words often enough will mostly likely seek opportunities elsewhere in search of someone who can at least entertain their ideas.
4. Get ready to dream big! Millennials often set lofty career goals.
It has been my experience that many professionals discourage new professionals from embarking into private practice, entrepreneurship, or creating different ways of selling what we do to the public, when having little if any practice experience. Innovation comes from taking risks and as millennials we are absolutely fine with that. Personally, I would rather fail doing what makes me happy than succeed in something that makes me miserable. We are not interested in perpetuating the ideas of the ones before use but creating new experiences and opportunities.
5. If you have a “career ladder” within your business with a ceiling and/or attic, we probably will not stick around long.
Millennials crave something to work toward, and a career opportunity with endless room for growth is most desirable. This path does not have to take the form of a ladder and it probably should be more flexible. Not all of us want to become managers or chief financial officers; we are seeing millennial physical therapists finding new opportunities and passions in things such as community outreach/education, research, marketing, and public relations. Do not be afraid to tap into the nonclinical skills and passions that your millennial physical therapist brings to the table. This may allow your business to explore opportunities that it has not found or had the resources to explore yet. These are great topics to discuss at the initial interview. Ask your millennial physical therapist what they are passionate about and how they plan to be innovative in their new workplace.
Embracing the unique characteristics of your millennial physical therapist can facilitate unique and exciting opportunities for your private practice. Taking the extra steps to understand your millennial physical therapist can help create an environment that will keep them engaged and excited about the future.
1. Levitas, D. (2013, March). Always Connected How Smartphones And Social Keep Us Engaged. Retrieved March 20, 2016, from www.nu.nl/files/IDC-Facebook Always Connected (1).pdf. Accessed March 2016.
Thomas Janicky, PT, DPT, is an outpatient physical therapist at Johns Hopkins Hospital in Baltimore, Maryland. He is also a member of the American Physical Therapy Association (APTA) Private Practice Section (PPS) editorial board. He can be reached at firstname.lastname@example.org and on twitter @TJ_Janicky.
What is the effectiveness of measuring outcomes?
By Dan Fleury, PT, DPT, OCS
A fairly hot debate on the effectiveness of using outcomes to drive evidence-based practice exists. I have heard arguments from opponents and proponents, and they both have some valid points. I have even had the opportunity to participate in case reviews with a national health insurance provider to see what happens on the “dark side” when reviewing a case for decisions related to payment and continued care. That experience working with the health plan was extremely valuable in helping me understand why physical therapy continues to be a target of continued regulation, documentation burdens, and decreased payment. Their smoking gun: They were able to extrapolate your outcomes data. That is right, they are looking at each and every one of your charges and visits per patient. It really was an “ah-ha” moment.
Most incidences of denial of payment or denial for continued visits are due to “insufficient documentation.” Your patient gets a letter in the mail stating that the therapist did not provide enough information to the person paying the bill to warrant payment. This leaves you scratching your head because you thought you documented everything and you clearly identified that the patient made great functional progress and was close to reaching recovery.
Most likely the person reading your documentation and making that decision is not a rehabilitation provider and, furthermore, they have no idea what you are talking about in your attempt to wow them with your anatomical, biomechanical, musculoskeletal, and neurological jargon. They have no idea why a seemingly small restriction or loss of motion is worth the bill you have submitted, and therefore you receive a denial and it is blamed on you. Gone are the days when a payer simply accepts an educated and licensed rehabilitation provider’s jargon and ever changing goal status as an indicator of your skills as a provider and the payment for services.
We are all good therapists, and we all get patients better, right? Our patients tell us that we are good, they like us, and they keep coming back. Is that not enough? This sort of thinking is not understood by nonphysical therapists. They want and need a simple number backed by evidence that has been validated by research and shows functional improvement. Almost every contract negotiation, payment, or care discussion that I have been involved in over the past 5 years, I am met with the same response: Show me the data! Having the data to back up our claims of being great clinicians has proven invaluable. Here is an example of one success that I have had using outcomes in progressing my practice.
My company was born out of the idea that physical therapy could be provided in a better, faster, and less expensive delivery system—a clinically driven concept spearheaded by the underlying premise that only highly skilled interventions backed by evidence are employed as a first-line treatment for musculoskeletal injuries.
Cost savings and utilization are important in proving that physical therapy intervention is effective and efficient in the management of musculoskeletal disorders. Blindly cutting utilization and costs does not necessarily translate into having a positive impact on meaningful functional outcomes. Can we have a positive effect on cost, quality, patient experience, and meaningful functional outcome?
We approached a large local medical group with this exact concept. The medical group has several locations and is also the administrator for a large health plan covering active and retired military and their families. Working directly with a medical provider who is also a payer gave us unique access to a breadth of data so we could analyze physical therapy–related cost and utilization accurately. We were able to extract and analyze the cost and utilization data of our network and compare that to over 450 therapy providers in their network. Due to our success on both cost and utilization, our network of 23 locations was chosen to continue being the providers of high-quality services for this health care payer.
During our analysis we noted one of the medical centers had eight primary care providers and a national chain physical therapy provider on site. The data was extracted on that specific location with careful attention paid to the prior 12 months to improve the validity of the pending before and after comparison. The analysis indicated that cost and utilization of their existing therapy provider were two standard deviations higher than the network’s mean, identifying them as strong outliers in the data.
We were granted a contract to replace the existing therapy provider and prove our concept. After interviewing the medical staff and the health plan utilization review medical director, it was clear that a modern evidence-based practice that could accommodate same-day access for the large ticket items, low back pain, neck pain, shoulder pain, and knee pain, could have an impact on decreasing costs related to unwarranted imaging and specialist referrals.
At this point we had been tracking outcomes for several years using a web version outcomes database. The system we use is a computer adaptive test (CAT) that applies risk adjustment criteria based on specific criteria such as age, comorbidities, fear avoidance, diagnosis, and insurance carrier type, increasing the validity of the comparison between patients. For example, we know that not all back pain patients are created equal; this system adjusts the baseline and predicted outcome based on the risk-adjusted criteria to more accurately compare patients with like diagnosis.
The outcomes data can be drilled down further to compare a therapist or a facility’s efficiency, overall functional change, and patient satisfaction. The outcome data is compared to the outcome data of over 12,000 other physical therapists across the globe. The outcomes can be sorted by specific body part or surgical intervention. With 12,000 therapists and 450,000 patient encounters measured yearly we feel validated in assigning the predicted outcomes scores a safe representation of the national “average.”
This database has been shown to be meaningful, valid, and sensitive to change. (3,4,5,6). It has also been recognized by Congress and CMS through the National Quality Forum (NQF), which first endorsed their functional status measures in 2009. In 2010 CMS accepted the measures for use in the Physican Quality Reporting System (PQRS) program.
After one year, we completed an analysis on cost savings, utilization management, and functional outcomes of its integrated model of care. The data on utilization and cost was extracted from the payer database, and the outcomes were collected from my company’s outcome results from dates of service 11/1/2013–12/1/2014.
- Overall Patient Satisfaction: 99 percent
- Utilization decreased: 60 percent per case (compared to previous practice)
- Overall cost of physical therapy: 35 percent reduction (compared to previous practice)
- Functional improvements in the 7 CMS accepted measures compared to national average.
- Overall 46 percent higher
- Knee 71 percent higher
- Shoulder 57 percent higher
- Foot and Ankle 33 percent higher
- Spine 21 percent higher
- Hip 16 percent higher
- Neck 16 percent higher
The results overwhelmingly support the fact that outcome, evidence-based delivered care is not only less expensive but also that patients are highly satisfied, and the functional outcomes beat the national average!
1. Fritz, J et al 2015 : Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Article first published online: 16 MAR 2015DOI: 10.1111/1475-6773.12301c.
2. Childs et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research (2015) 15:150 DOI 10.1186/s12913-015-0830-3.
3. Wang et al 2010: Clinical Interpretation of Outcome Measures Generated from a Lumbar Computerized Adaptive Test. Physical Therapy (2010) Vol 90:9.
4. Wang et al 2009: Clinical Interpretation of Computer Adaptive Test Outcome Measures in Patients with Foot/Ankle Impairments. JOSPT (2009) Vol 39:10.
5. Wang et al 2009: Clinical Interpretation of Computerized Adaptive Test Generated Outcome Measures in Patients with Knee Impairments. Archives Physical Medicine and Rehabilitation (August 2009) 90:1340-1348.
6. Deutscher, Daniel et al 2009: Associations between Treatment Processes, Patient Characteristics and Outcomes in Outpatient Physical Therapy Practice. Archives Physical Medicine and Rehabilitation (August 2009) 90:1349-1363.
7. Deutscher, Daniel et al 2007: Implementing an Integrated Electronic Outcomes and Electronic Health Record Process to Create a Foundation for Clinical Practice Improvement: Physical Therapy 2008 88:270-286.
8. Delitto, Anthony et al, Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.030.
Dan Fleury, PT, DPT, OCS, is a PPS member and is a partner and director of Development of the Pinnacle Rehabilitation Network LLC. He can be reached at email@example.com.
Creating value strategies either increases revenue or decreases your expenses.
Dr. Laurence N. Benz, PT, DPT, OCS, MAPP, and Dr. Rob Wainner, PT, PhD, DPT, FAAOMPT, ACC
One of the first principles that we teach in strategy is that value-creating strategies have to either increase your revenue or decrease your expenses. In essence, the value focus must translate at some point to your bottom line. Therefore, if you collect outcomes in your practice, then they should translate to your overall bottom line. However, the way clinical outcomes best translate to your bottom line is not how you might expect.
In our experience, practice owners are often frustrated because they do not see an immediate and direct impact of outcomes on their financial results. Here, I will look at clinical outcomes from a holistic perspective—one that we think will deepen your appreciation for how clinical outcomes play a role in creating a value strategy as well as a source for financial gain.
By an old school definition, we were taught many years ago that outcomes can be measured in terms of clinical (functional) or patient satisfaction, loyalty, and experience. When clinical outcomes are discussed as part of a strategy, most clinicians and clinic owners confine their perspective to third-party systems that collect traditional outcomes and then aggregated and eventually result in summary reports and searchable databases.
We have been encouraged that unless our practices collect functional outcomes, we will not be in the game with payers and our data must be our talking points. In fact, the American Physical Therapy Association (APTA) and specialty firms have made strategic initiatives to enter in the repository and reporting business using proprietary and other means that allow for providers to submit data and for consolidations, analysis, and summary. More recently, the mandated Physician Quality Reporting System (PQRS) caused a real tipping point and an opportunity for these approved registries to combine clinical outcomes with required Centers for Medicare and Medicaid Services (CMS) reporting.
But where are the “goods” to support the focus on clinical outcomes and pay for performance (P4P) initiatives? Are payers moved in a way that matters when we present our outcomes to them in an effort to substantiate our clinical efficacy? There is minimal evidence that any of our third-party produced outcomes have ever been used to obtain anything other than standard form contracts. Has any of this helped produce revenues or gains in one’s financials? Despite the lack of evidence, the pressure and emphasis continues.
For years our practice has systematically collected and reported traditional clinical outcomes using an outcomes database system (there are plenty of acceptable systems out there), as well as non-traditional measures using CARE (Compassion and Relational Empathy questionnaire) along with patient loyalty scores. But are clinical or functional outcomes enough? We do not believe so, simply because there can be assumptions surrounding their conclusions. Adding patient loyalty or a measure like CARE can be great additions simply because they are drivers of intrinsic motivators around areas that physical therapists (PTs) value: empathy, compassion, positivity, listening, and letting the patient tell their story and set their own goals.1 The CARE measure even allows each PT, clinic, or company to see how they rate versus a standardized database of more than 5,000 physios in Scotland!
At the same time, we have used a simple financial metric related to the return we get from our outcomes: “return on quality.” Return on quality (ROQ) is the actual cost of collecting, analyzing, and training incurred from quality initiatives and determine whether our resulting incremental revenues are worth the cost. When looked at from that perspective, an easy conclusion would be they have not. The trouble with looking at ROQ is that it only looks at direct expenses and revenues and does not take into account the most significant factors related to indirect costs in our business: the well-being, productivity, and retention of our therapists.
A natural question would be “how do outcomes affect these significant, indirect cost-related factors?” The simple answer is internal motivation. While the concept is simple, Dan Pink, author of Drive The surprising truth about what motivates us, has done an excellent job helping us identify the essential elements of internal motivation as they relate to meaningful work: autonomy, mastery, and purpose (A.M.P). The question then becomes how to leverage these three elements in an intentional way in order to build internal motivation.2
When considered in the context of A.M.P., one can see where focusing on and measuring outcomes is a nearly perfect fit in a practice like ours, where clinical excellence is a cultural pillar. Our therapists are able to exercise a high degree of autonomy in managing their patients. We also heavily support their pursuit of clinical mastery with certification, residency, and fellowship training in terms of time and tuition. Both of these elements are undergirded by a higher sense of serving and purpose. What we have found is that outcomes are a linking element that helps practically integrate all three elements of A.M.P by providing our therapists a standard to aim for and a mark to measure themselves by. Said differently, by setting a bar you can measure your growth by, as well as compare yourself to others is an essential element to facilitate and sustain internal motivation.
If we dropped our third party outcome tools, what would be the unintended consequences? First, we would lose a significant part of what attracts physical therapists to our company in the first place: a model that incorporates clinical excellence, service excellence, and care and compassion excellence. This in turn would severely affect our ability to provide our therapists with credentialed post-graduate training programs at our current level of scale. Without the ability for our therapists to measure their individual performance and we our corporate performance, we lose accountability and the ability to aim for an evidence-based standard. Taken collectively, the total loss is greater than the sum of the individual parts. The result is that we experience the most damaging loss of all: a significant loss of internal motivation in our therapists.
At the end of the day, we strongly believe our clinical outcomes efforts substantially reduce or eliminate recruiting costs, staffing shortages, and turnover. There are a variety of formulas for determining those indirect costs if one wanted to go to that granular level, but we do not think there is a need to do so. A clinical excellence focused culture leads to higher engagement (an easy and established measure) and increased therapist satisfaction, both of which lead to higher patient satisfaction. By the way, the third party produced analysis is not critically important to us centrally, but it is to our PTs who desire the feedback and comparison to a larger database. Internally, we put more emphasis into our own metric-completion rates (number of new patients with outcome measures/total number of new patients) because it supports the intrinsic motivator of mastery and avoids what we see in the field as “cherry picking” selectively using only certain patients for outcomes.
The value creating strategy around outcomes counter intuitively is not about payers—it is about our knowledgeable workers and their motivation and internal reward systems: mastery and purpose. The strategy of outcome collections is about values—your values as an organization and what you are trying to produce. Show me an organization that does not enhance primary intrinsic motivators for PTs and we will show you an organization with frequent turnover and where extrinsic motivators like money and status are the primary emphasis.
The return on quality from a revenue standpoint is probably impossible to calculate but this reflects one of our core management credos: “at times we do not get what we measure, we get what we emphasize.” If you want a strong clinical culture that is accountable, third party clinical outcomes is a must—it is the modern day equivalent to a reflex hammer and goniometer. But if you want to see how they truly impact your bottom line, you will have to look beyond the obvious.
Dr. Benz is the chief executive officer and partner of Confluent Health that includes multi-state private practice physical therapy clinics, Evidence in Motion, and Fit For Work. He can be reached at Larry@physicaltherapist.com.
Dr. Wainner is Leadership Coach and partner of Confluent Health that includes multi state private practice physical therapy clinics, Evidence in Motion, and Fit For Work.
1. Mercer, S. W. (2004). The consultation and relational empathy (CARE) measure: Development and preliminary validation and reliability of an empathy-based consultation process measure. Family Practice, 21, 699–705.
2. Pink, D. H. (2011). Drive: The surprising truth about what motivates us. Penguin.
The best practices of the best practices.
By Dr. Laurence N. Benz, PT, DPT, OCS, MAPP, and Dr. David Browder, PT, DPT, OCS
One of the most important challenges physical therapy practice owners face is the decision about where to put their time and energy. Which decisions we make every day are the most important? What strategies are most likely to lead to excellent financial performance? Where should practice owners focus their attention? Said differently, what best practices should be adopted?
A best practice is the process of finding and using ideas and strategies from outside your company and industry to improve performance in any given area. Big business has used best practice benchmarking over decades and realized billions in savings and revenues in all areas of business operations and sales. Small business can reap even greater rewards from best practices. But what are the best practices in private practice physical therapy?
Incorporating pelvic health into your private practice.
By Jennifer Stone, PT, DPT, OCS, CAPP-certified pelvic floor practitioner
Few areas in physical therapy practice are subject to the level of stereotypes, misinformation, and intimidation as that of pelvic health, or what has traditionally been called “women’s health” physical therapy. Most therapists hear the term and approach it with an attitude of “you can not pay me to touch that with a 10-foot pole” and many businesses dismiss it without a second look. However, in so doing, therapists are doing their patients a huge disservice, and businesses are ignoring a huge potential for revenue and growth. Take a look at the following myths and the corresponding reality and perhaps you will reevaluate the level of need for your business.