Integrated Practice Models


Stop struggling to find your place in new integrated care delivery models.

By Jim Plymale

“There is no longer any doubt about how to increase the value of care. The question is, which organizations will lead the way, and how quickly can others follow? The challenge of becoming a value-based organization should not be underestimated given the entrenched interests and practices of many decades. This transformation must come from within.”
—Michael Porter and Thomas Lee, “The Strategy that Will Fix Healthcare” Harvard Business Review; October 2013

A few physical therapist friends recently told me they are struggling to find their place in the new integrated care delivery models. It is not the first time I have heard this.

During these conversations, the word or sentiment that always sticks out is “finding.” It implies that the place of physical therapy is not obvious or predefined as we move from a practice-centered to a patient-centered model.

Although it often means different things to different people, at its core, integrated health care is a network of facilities and providers that work together to offer a continuum of services to a group of patients. The antitheses of fragmentation, integrated care models, such as Accountable Care Organizations (ACOs), Integrated Delivery Networks (IDNs), or Coordinated Health Networks, take collaborative, comprehensive approaches to putting patients in the middle.

So what does this mean to physical therapists? Every day, I talk to private practice physical therapists concerned that these systems will rob them of their independence or diminish the value they provide.

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I understand. Being an entrepreneur, I have often been faced with the challenge of finding my place in a crowded marketplace.

The challenge that exists for us all is to get better at convincing people that we are unique and necessary. For physical therapists, they must get better at doing this quickly. As health reform picks up speed and payment bundling changes the behavior of referral sources, there is real urgency for physical therapists to sell the value of their therapy and their unique ability to strengthen patient population health management.

Let’s break that idea down.


Consistent with Putting the Patient First?
In our company, we have often referred to this as the need to “sell the plan of care.” When the word “sell” is used with many physical therapists, I often get a visceral reaction that you might even consider repulsion. One therapist recently said to me, “I think of myself as more of a scientist, so I find the term sales objectionable.”

When I use the word “selling,” I’m using it in the sense that Daniel Pink used it in his book To Sell Is Human: The Surprising Truth About Moving Others. Pink argues that we are all salespeople, because we are all trying to convince others to part with resources in exchange for something they want or need.

It does not sound so bad when you put it that way.

It especially does not seem objectionable when you consider what we are selling: the value of physical therapy to improve overall patient health.

The Value of Physical Therapy

Commoditized Transaction or Lifetime of Impact?
At the 2014 California Physical Therapy Association annual meeting in Oakland, California, Jeff Hathaway, PT, gave a great lecture entitled “How Physical Therapy Can Transition from a Commodity to a Value-Based Model.” Jeff provided convincing evidence that payers and patients are treating physical therapy as a commodity.

Jeff argued that they perceive little differentiation among services and thus price—not quality—became the driver in a buyer’s decision. In other words, all visits are equal. Therefore, payers and utilization management companies pay the same lowest possible price per visit for all physical therapy, regardless of its outcome.

This is happening, with little to no patient outcry, because physical therapy has a value perception problem.

Jeff presented convincing evidence that “the right therapy at the right time” improves quality of care while lowering the total cost of care. In order to integrate successfully into ACOs, IDNs, and other networks, we must sell that evidence. We must differentiate the value of our services, or risk being marginalized and commoditized. Private physical therapy practices are in a great position to do so.

I have to confess, I am an optimist. I think you have to be an optimist to be an entrepreneur or to be a parent. I have also been witness to a transformation of another industry: the software industry from an on-premise, perpetual license model to a cloud-based, subscription model largely over this same decade. The key to this transformation was the recognition of the lifetime value of relationships rather than the transactional value.

Strengthen patient population health management

Guiding Patients to Wellness
Physical therapy practices can lead the movement to integrated, patient-centric models because physical therapy is inherently relationship based. This does not in any way diminish the requirements for the knowledge and skill of the therapists. I am simply calling out the fact that great therapists are defined by their ability to develop a relationship with a patient.

It is interesting what happens when I talk to physical therapists about their patient satisfaction scores. They tell me that the single biggest determinant of satisfaction and success is the quality of their therapist relationships. Great physical therapists are skilled at building trust with the patient. This trust is based on not only competence but also empathy.

There is a unique value that a hands-on coach who guides patients through a sometimes painful transition can bring to the overall management of patient health. It is this relationship-building ability that differentiates the therapist, and is a core asset for the health care industry as a whole as it transitions into a more patient-centric model of care.

We simply have to do a better job of selling our ability to provide excellence in outcomes at a better price than alternative interventions.

Finding Your Practice in an Integrated Care Model

As I said at the beginning of this article, in order to successfully find a high value place in ACOs, IDNs, and other integrated care delivery networks, physical therapists must sell the quality of their care and their ability to strengthen patient population health management.

The following are five fundamental steps to selling the value of physical therapy to decision makers in an integrated care delivery networks.

  1. Start with why. Not all care is equal. The right therapy at the right time can improve the value and lower the total cost of care. Silo-based utilization management that simply restricts access to care or lowers payment for care does not solve the fundamental problem. As Jeff Hathaway said, “More is not better, less is not better, better is better.”
  2. Measure value. We have to define what value is in terms that are meaningful to the patient and the payer (which now may be the employer). Of course this means defining outcomes and demonstrating that better outcomes lead to lower total cost of care. The key is making the outcomes truly comparable and meaningful.
  3. Articulate and align the incentives. This is about communicating the WIIFM—What’s In It For Me. This means all parties: providers, payers, and patients must perceive the tangible value of change. Did we improve quality and lower cost? Are we selling those results back to the payer, physician, patient, and even to our own staff? Providers must be willing to understand and share some of the risk and upside.
  4. Change the conversation, change the culture. One of my long-time mentors always says: “The culture lives in the conversation.” As long as providers talk purely about quality of care, patients about access, and payers about cost, we will not change the ingrained dynamics of silo-based delivery models and the resulting utilization management controls. As we change the conversation to value, we will shift to conversations about quality management and the total cost of care. This is where therapy can bring real value to patient population health.
  5. Invest in Data Analytics. The best way to change people’s behavior is to give them data that empowers better decisions. Much of the resistance to change is the challenge of gathering the necessary data while providing care. Invest in technology that simplifies data gathering and standardizes decisions at the point of care. Those better decisions will lead to better outcomes at a lower cost. And better outcomes will lead to better relationships with patients, physicians, payers, and the therapist.

The physical therapy industry is well positioned to not only find its place in integrated care delivery models but also to lead their creation. That is because of our unique relationships with patients—an aptitude that is proven by the data we gather.

But these relational skills and data do not matter if they happens in a vacuum. Finding our unique place in integrated delivery models starts with believing that what we have to offer will fundamentally improve the value of health care and improve patient lives. That is something truly worth selling! 

Jim Plymale is the president and chief growth officer at Clinicient. He can be reached at

Copyright © 2018, Private Practice Section of the American Physical Therapy Association. All Rights Reserved.

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