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What Is the New Normal?

By Terry C. Brown, PT, DPT

As I sit down to write this letter, we are approaching the Private Practice Section (PPS) Annual Conference and I am looking back at the first year of my tenure as PPS president. The word that strikes me is “change” and it is all around us. Nothing is static. Payment models are changing: ICD-9 is now ICD-10. Practices are consolidating. Insurance companies are merging. Quality research proving the efficacy of physical therapy is being published. New models of practice are emerging that challenge the status quo. Education models are evolving. PPS has a new executive director and a new president.

Change is all around us. Maybe it is time we acknowledge that change is the new normal. I have seen the word transformed used when speaking of our profession’s objectives, but this word implies an end point or a goal to be reached. I believe evolution is what we are seeing, and it is constant. As a profession, we can evolve or we can try to hold the ground that we have had in the past. Evolution will require that we move out of our comfort zone and reach out to achieve new and challenging goals. The growth and progress necessary to achieve our goals is best accomplished together with PPS being the conduit to success.

I am proud of PPS and all of our members who are leading the evolution of our profession. We are at the forefront of many changes and will be fighting to gain access in others. By attending the PPS annual conference you will be exposed to many of the initiatives that are ongoing within the section. If you were unable, to be there then please read the annual report and see for yourself the evolution that is occurring. Change is constant, how we respond to it is critical. PPS is evolving right alongside the industry, and we will continue to advance our members’ ability to provide quality care to their clients.


Relationships Old and New

By Stacy M. Menz, PT, DPT, PCS

One of my favorite things about November is the Private Practice Section (PPS) Annual Conference. I still can vividly remember the first PPS conference I attended. It felt a bit like drinking from a firehose. Before I arrived, I did not know what I did not know (and it was a lot). I showed up at the conference not knowing a single person and by the time I left I felt like I not only had amassed an inordinate amount of new information, but that I had also developed an amazing network of people that I could call on with questions and collaborate with for future initiatives.

Measurement Concerns


The number of measurement tools available per body part creates difficulty in comparing results.

By Alfonso L. Amato, PT, MBA

The introduction of Functional Limitation Reporting (FLR) by the Centers for Medicare and Medicaid Services (CMS) requires the use of a functional measurement tool. However, CMS has no recommendation or endorsement of what functional measurement tool to use in the outpatient rehabilitation setting.

Rehabilitation has led the way in health care by developing the science of measuring and reporting outcomes. A multitude of functional outcomes measures are available through commercial and open-access sources for nearly every type of patient health condition seen in rehabilitation. Although variety is typically considered positive, for rehabilitation professionals, this variety leads to a problem. The number of measurement tools available per body part can create difficulty in comparing results between patients, or between practices.

A simple head-to-head comparison of functional change between measurement tools is impossible. Let us analyze a common scenario. Two therapists are treating patients who have knee pain. Each therapist chooses a different functional measurement tool to measure function. Therapist A uses the Lysholm Knee Rating Scale and Therapist B uses the Lower Extremity Functional Scale (LEFS). Both tools are valid and reliable functional measurement instruments; both use a higher score to report better function. The LEFS top score is 80 points; the Lysholm top score is 100. Each therapist will report the resulting functional score from each instrument.

The challenge arises when you want to compare the outcomes between these two patients. A score of 40 on the LEFS is not the same as a score of 40 on the Lysholm. You cannot compare a patient’s outcome measured by the Lysholm with a patient outcome measured by the LEFS. Even with two measures with the same scaling of 0-100, a score of, say, 47 does not mean the same thing as a score of 47 on the other measure. Even if the necessary sophisticated statistical analyses were performed to “link” or “crosswalk” the scores of one measure to another, any change in scores would not be comparable. That is, clinical and statistical interpretations of change— the minimum clinically important difference (MCID) and Minimum clinical difference (MCD)—would remain unique to each measure.

When reporting change in function between patients, measurement properties of the tool are just one aspect in the comparison equation. Patient characteristics must also be taken into consideration. Certain patient factors affect functional outcomes and need to be considered when making a direct comparison. The science of outcomes has evolved to equalize patients via risk adjustment. The main factors considered via risk adjustment often include gender, age, and acuity of the condition. To accurately compare effectiveness and efficiency of care, risk adjustment is required. When comparing functional change of “knee patients,” even with the same functional measurement tool, you cannot compare functional change of each patient because you do not know what other confounding variables have influenced the patient’s potential for change. Risk adjustment accounts for the variables that influence the patient’s ability to respond to treatment and allows for one patient to be compared with another accurately. Using more risk adjustment variables allows you to better account for as many patient differences as possible.

No one wants to be punished for caring for the patients who are sicker, more severe, more complex, more difficult to get better, but that can happen if reimbursement is using a system that does not take risk adjustment into account.

Functional limitation reporting utilizes a G code modifier, which does not specify the specific measurement tools used. Use of different measurement tools can confound the understanding of the functional improvement as a result of care. The G code functional limitation levels are broken down into 20-point increments of change on a 0-100 scale. The following example can show how the reporting of change in a G code level may not provide an accurate picture of true functional change:

Patient A’s functional score at admission places the patient at the bottom of a G code scale; Patient B’s functional score at admission is placed at the top of a G code scale. Both patients had 19 points of change, but one is reported to be in a higher G code and the other patient remains in the same G code. This issue may lead to a missed opportunity to fully understand the change in function the G code reporting process was designed to capture. G code reporting, or a system like it, will possibly be the basis for future reimbursement policies. There is the real possibility that the rehab provider may be paid differently based on the G code level change, rather than on the patient’s actual functional change.

In summary, functional outcome reporting is here to stay. It will become the common language for reporting efficiency and effectiveness in outpatient rehab. It will increasingly be the basis for reimbursement. How do we ensure that reporting functional change will accurately reflect the benefit the patient received from the rehab provider, and that the rehab provider is paid fairly and credited for their contribution to the patient’s welfare?

A functional reporting system that has the following attributes will be the best opportunity to accurately measure and report functional outcomes, and become a basis for future reimbursement policy:

  • The industry settles on a functional outcome measurement system used by all providers.
  • The measurement system provides for the most accurate risk adjustment available for valid comparison of providers and treatments.
  • The measurement system has psychometric properties that ensure high responsiveness, validity, reliability, and precision of measurement.
  • The required G code method of reporting functional limitation allows for accurate reporting of change that captures true patient improvement.
  • The measurement system has risk-adjusted predictive analytics that most accurately predict discharge functional level.

These five attributes of a functional outcomes reporting system will provide the basis for a fair and accurate process to fully understand patient change, better inform policy initiatives, and guide evidence-based practice. 

Alfonso L. Amato, PT, MBA, is the president of FOTO, a private outcomes management and reporting company. He can be reached at alamato@fotoinc.com.

An Apple a Day


Take the pain out of your rehabilitation marketing.

By Brandon Moser

If you have a chance, look at some health industry advertisements. Do you see a difference in their visual marketing? It should come as no surprise that they are similar—a lot of toothy grins from 30-somethings; slightly graying yet attractive women gardening; guys on bikes; and dream teams of confident health care professionals standing together (including a guy with his arms folded, wearing scrubs, and a lady wearing glasses and in a lab coat while carrying a clipboard). Oh, and do not forget the apples. Apples always mean a healthy lifestyle.

Before I entered the marketing and advertising world 20 years ago, I was a physical therapy practitioner. I had some great patients that took their home exercises seriously. I also had patients who constantly complained their rehabilitation was not happening quickly enough. When the patient was pushed for details, it was evident they were not doing the necessary effort outside of the clinic to recover as fast as they hoped. There are similarities in marketing.

Health care providers often take shortcuts in their marketing and promotion. Then they are unsatisfied with the results. There are no shortcuts in rehabilitation—and there are no shortcuts in creating effective, revenue-producing marketing.

Cheap can be very expensive
I wish I had a nickel for every time we had a new customer come to us with a story about how they were disappointed by someone who had designed a terrible marketing piece for them. After further questioning, I usually found it was a result of the customer giving the business to the lowest-possible bidder.

The growth of your business, and your livelihood, depends on successful, effective marketing. And yet cost is always one of the biggest drivers in marketing decisions. Do not be cheap here. Be smart, because “You get what you pay for.” It is true. You also get what you do not pay for—such as stress, inferior quality, and dealing with more daily pain than a torn triceps surae muscle. Because if they are charging next to nothing, it means that they have next to nothing to offer. It does not mean spend indiscriminately. You do not need Don Draper to write your jingle. Just spend intelligently. And sometimes a little more than you may be comfortable with.

The truth is that solid, evidence-based marketing from industry experts will usually pay for itself and then some. If you choose the right marketing partner, with the right skill set, cost should never be an issue. You will be concentrating on bottom-line revenue potential rather than short-term costs. Being cheap with marketing dollars is an ailment for which there is no cure.

If you do not stand out, you do not stand a chance
The health industry has traditionally been very conservative in their marketing efforts. Whether it is due to past regulatory intimidation or just becoming creatively lazy due to the conservative nature of the health care industry, it provides an enormous opportunity for those who want to stand out from the crowd.

If you ever wonder why the response rates are low for your advertising, take a good hard look at your creative. Take a look at the images you are using. Are they different from the competition? Or are you walking along the same beaches, frolicking in the same parks, and gardening with the same slightly graying, attractive ladies? Are you overemphasizing the importance of representing all ethnicities to your audience at the expense of decreasing the emotional pull it may have with your audience?

Instead of using emotionally stirring imagery that truly tells the story of the organization’s brand, the pictures are spiritless and overused stock images that have no association with the copy, but do represent 80 percent of the ethnicities on earth because someone told them to represent all ethnicities in their marketing materials. This belief that organizations have to visually represent all cultures in their target market is just not true. I have yet to see valid evidence and peer-reviewed research that shows using models representative of the target demographic substantially increases conversion. However, if you go and really examine the health care space and all of the marketing, you will see an abundance of these, “We are the world” stock photos. Do not market yourself like everyone else. Break the mold and make your brand get noticed.

It is about results
Do not go through the motions with your marketing efforts. Remember the end goal—results and a healthy marketing return on investment for your organization. A patient cannot just walk into a rehab clinic and demand electrical knee stimulation. Before any therapies are recommended, there is a solid medical strategy put in place by a trained professional. Organizations cannot assume that a print ad or a web banner will cure their marketing pains—they also need a strategy in place before any modalities are recommended. Just like with physical rehabilitation, the more attention and effort it receives, the healthier you will ultimately be.

Brandon Moser is the president and chief executive officer of HowlandMoser Advertising. He can be reached at HowlandMoser.com.

“They” Think Alike

By Tannus Quatre, PT, MBA

Markets move together.

More specifically, markets have similarities that make them understandable and predictable. Think about the stock market, for example: Choose your market index, and, generally speaking, it will tend to move together with similar indexes in response to market conditions (economic growth, interest rates, etc.). Drill down to a specific sector within the stock market, and you will see even closer correlation. Tech stocks behave similarly to other tech stocks, pharma to pharma, and so on.

This is because markets are made up of humans, and we are wired to think alike. We are simple creatures. For both me and you it’s monkey see, monkey do.

This is a powerful understanding. Because we move together, think together, act together—we can be understood together. As uniquely weird and obnoxious as my teenagers may think I am, I am kind-of like my neighbor—and his neighbor, and his neighbor’s neighbor.

Understanding my neighbor (who happens to be of similar age, socioeconomic status, etc.), you can also—to a practical extent—understand me. This is where some basic market understanding and research can be extremely helpful.

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