Are We Limiting Our Role in Health Care?
Russell A. Certo, PT, OCS | Lynn Steffes, PT, DPT
Let me tell you a story. My wife and I (R. Certo) adopted a Korean child when he was 5 months old. When he was turning 16, he asked if he could visit the orphanage that he came from. By the time we made the arrangements with the orphanage and arranged for the 86-year-old foster mother to be in attendance, our son was 17. When we arrived, and after meeting with the foster mother and shedding many emotional tears, we were asked to visit with the founder of the orphanage. We met Dr. Kim in his office; he was 95 years old and exactly how you would envision an older, wiser man. My wife and I sat in two chairs across a coffee table from our son and Dr. Kim; they sat on a couch. After a few pleasantries and some exchanging of gifts, Dr. Kim asked us permission to pose a few questions to John Russell, our son. At that moment it was clear to us we were no longer a part of that conversation. Dr. Kim asked our son if he was a Christian, if he attended church, and if he knew the commandment to honor thy father and mother. John Russell answered yes to all those inquiries. Dr. Kim looked our son square in the eye and said, “You are where you are supposed to be.” The hair on the back of our necks stood up, and an emotional chill ran through us. He then proceeded to tell John Russell how life growing up in an orphanage would have been for him, and it was not a pretty picture. Dr. Kim also told him that of the 40,000 children who had passed through this orphanage, John Russell was only the third child Dr. Kim had ever seen again. Ten years later, that adopted child is a Navy Special Ops specialist proudly serving our country and making our world a safer, better place for all of us.
We as a profession are the most qualified service delivery team to provide exercise and movement activities for people in our community with chronic disease, movement disorders, and diagnoses that make life difficult. There has been a push throughout health care to provide preventative programs to improve the conditions of these populations in hopes of reducing the total cost of health care. Policy makers both public and private have wrongly pushed the idea that responsible prevention needs to be a priority, to be accessible and subsidized. In delivering medical fitness and lifestyle management services, our 12 years of combined experience has found the most important aspect of success with this population is engagement. Strategies and a systematic process must be developed to both identify and encourage these patients in need of our expertise. As we do with every patient, creating a relationship will keep the patient both participating and actively making self-driven lifestyle decisions. These patients need to feel as if they are in control of the changes they will make.
Additionally, our experience has demonstrated that not everyone in need of these specialized lifestyle services is ready to commit to making needed changes. We have found that in general the patients who are in the worst health and needing the most costly treatment are the most difficult to convince to adopt strategies for better health. In a collaborative effort with primary care physicians, we have been able to successfully identify those patients who are ready for change and can successfully complete a 6-month medical fitness program with impactful outcomes and demonstrated cost of care reductions. We have in fact been able to bend the cost curve downward in these chronic disease populations.
The physical therapy profession is perfectly positioned to be the community experts in lifestyle management delivery. We have a long-standing reputation in the health care community as problem solvers and are trusted to provide cost-effective interventions. We have relationships established with primary care physicians and are looked at positively by many of our community members. We have earned the right to be heard, and we already have a seat at the table. Unfortunately, our profession has yet to adopt lifestyle medicine services, and we have allowed fringe health care groups and other professions to move into the space. Personal trainers, athletic trainers, chiropractors, and the fitness industry have promoted themselves as the experts in exercise and fitness as it relates to disease and dysfunction.
At our core, physical therapists account for disease and dysfunction when developing appropriate exercise programs and needed lifestyle changes. This service can be successfully implemented in just about every setting a physical therapist can be found. A single-site private practice can deliver these services in collaboration with primary care. A multisite office or a corporate entity with hundreds of offices can use these programs to differentiate itself in the marketplace and grow their business. Hospital-based therapy, school-based therapy, and industrial-based therapy can adopt these programs and deliver them to the patients and employees they engage with. By adding these services to our profession, we can effectively shut out fringe groups and become the community expert in assisting patients to successfully manage lifestyle programs. We should be taking these patients into our offices, and after an appropriate evaluation, determining what services they need. As part of a complete lifestyle plan of care, we should be helping these patients obtain the right service by the right person at the right time. Nutrition, exercise, education, medical care, and community-based agencies are all part of lifestyle management. Our profession should be the driver of this health care. This is a natural evolution and progression for the physical therapy profession.
Many of us have been successful in obtaining reimbursement for patients with balance disorders who have a high risk for falls. Additionally, we have been effective in getting insurance companies to pay for medical fitness referrals for patients with chronic disease. It is not easy, it takes work, and it is not a “build it and they will come” proposition. These services can help a practice grow. In a time of decreasing reimbursements and outside threats to our viability, medical fitness and lifestyle management can vault us back into a position where we control our destiny.
Despite our success and our data-driven outcomes, insurance companies have not wholeheartedly accepted our preventative model as an agent of change and health care cost reductions. Sadly, these payers of care have a short-term view of their subscribers. They talk about preventative services and pay for a few of them—mammograms, colonoscopy, and other screening tools—but will not pay for true preventative services for chronic disease. These payers operate in a 12-month window and readily admit that they cannot be assured these subscribers will be their customers next year so they cannot be guaranteed that they will reap the rewards of preventative care. Our success includes taking morbidly obese patients and reducing their weight by half. Patients with high blood pressure and statin medications have improved so much they no longer need these medicines. If more of us were delivering these services, our profession would be seen as a more valuable partner in the health care system.
All is not lost; opportunity abounds. Medicare has announced it will begin paying for diabetes prevention services beginning in 2018. Under an experimental program, Medicare used YMCA health coaches to provide pre-diabetic services to patients. Medicare found it reduced spending by $2,650 per person.1 However, in order to participate in this program in 2018, the facility must be approved by the Centers for Disease Control and Prevention (CDC). Another opportunity is in the self-insured market. Fifty percent of health care is controlled by self-insured companies who have a vested interest in the health of their employees. Employees and their health are viewed by many companies as an asset. The employer also understands they may have a 30-year relationship with their employee. As a payer of health care, these companies are now looking for partners who can deliver an effective corporate employee health program that is way beyond any “wellness” program they have tried in the past. Who better to serve this market and capitalize on this opportunity than the physical therapy profession? The physical therapist who is already delivering a workers compensation and pre-work screening service for a company is in the best place to deliver a total workplace well-being program that includes the management of employees with chronic diseases. We all can become the “Director of Wellness” for any self-insured company. As more patient-driven consumer plans are enacted, we will become the providers of choice, assisting patients to navigate the medical and community services.
Our call to action is to become the providers of choice when it comes to offering medical fitness plans of care, medical fitness exercises, and to use our expertise in managing chronic disease. If we as a profession do not, if you as an individual do not position yourself to be that expert in your community, someone else will. Recently the Medical Fitness Association and the Clinical Exercise Physiology Association formed a partnership with the stated mission: “We strive to improve the health, fitness, and quality of life for persons living with a chronic disease or condition.” The YMCA and the fitness industry are also ready to pounce on this opportunity.
As a profession we have been able to give patients back their lives. We effectively rehabilitate our patients and return them back to an independent life. We can tell you from experience that providing lifestyle management services, for us, has been far more rewarding than the rewards from traditional patient care. Lifestyle management transforms lives! One of the unintended positive consequences of a doctoral physical therapy program is a group of therapists who have an educational background rooted in exercise science. If Dr. Kim were standing before us, he would remind us that as a profession “We are where we are supposed to be.”
Lynn Steffes, PT, DPT, is the founder of BrainEX. She can be reached at firstname.lastname@example.org.
Russell Certo, PT. OCS is the founder of Trilogy and MOG. He can be reached at email@example.com.