Defining Values

Are we ready and how do we account for the variety of our patient population?

By Eric Cardin, PT, MS

The aroma overtakes you as you enter: fresh baked cookies—homemade, placed on a white plate, and draped with a white dish towel. Once a month, sometimes it seems like once a week, patients bring cookies, hugs, and big smiles. Clearly we have done something right. However, are there G-codes for “the patient brought us cookies”?

Is value in physical therapy simply the cost of a service? When a patient defines value, how does it differ from how the clinician defines the same thing? Patients experience physical therapy for an extended period of time, which is a great opportunity for them to define their own personal experience and make a judgment on the outcome of their care. Clinicians tend to be disconnected from the measurement of value, oftentimes finishing the case with a quantification of change in impairments and increasingly through the use of standardized questionnaires and tests. Outcomes are measured against a known baseline or some reproducible benchmark. We discuss and place a high importance on patient customer service, but when we accept that “value” is defined by the patient’s experience and their outcome, are there some things we should be talking about that are not easily defined?

Private practice physical therapy is as diverse as the communities we serve, and patient populations can vary widely across geographic areas. Variations in populations, when further dissected, bring variations in age, education levels, and culture. Who our patients are, where they are from, what their life experiences are, what their education level is—these are all questions of who our patients are as individuals. When we measure their response to therapy and ask them to describe the value of their experience, we need to consider the variables that are beyond our control.

Some of the easiest patients are the ones who arrive to your office prepared. They’ve done a little research, they are thoroughly motivated, in their mind you are the professional—the expert—and they are ready to follow your lead to a positive outcome. These patients attend therapy regularly and they are diligent with out-of-clinic recommendations. As therapists we are eager to hand them a functional scale or a customer service survey. Other patients are more of a challenge. Every therapist has an example in their mind of former patients who range from “difficult” to “nightmare,” and the reality is that we’ve got to measure how they “value” therapy as well. As much as we turn and will turn to technology and standardized tests to find these answers, are we prepared and capable of accurately measuring value? Statistically, do we exclude these patients from the measure as outliers? The reality is that oftentimes more challenging patients who are not technically difficult (in that they lack clear demonstrable comorbidities) can present intangible challenges based more on the emotional and social aspects of an individual. These challenges can be cost drivers. Two patients with the same surgeon start therapy in your office on the same day after the same surgery and receive the same care. One is done in 10 visits and one in 20. Both are restored to normal function; both are happy with their outcome. In an era of value-based payments, are we praised or penalized for returning both to their prior level of function?

Continued discussion and advocacy is needed to ensure that we are not ignoring outliers. We must make sure that a market driven by value does not force difficult patients into higher concentrations in certain markets or out of access to quality physical therapy in general. Physical therapy is as unique as it is important in the health care continuum, and as it continues its reach and scope it will see a continued expansion of patients who access care. With more patients, we as a profession need to be ready to accept and care for all those individuals. Cookies or no cookies.

Eric Cardin, PT, MS, is a PPS member and executive director of South County Physical Therapy in Auburn, Massachusetts. He can be reached at ecardin@sc-pt.com.