Leadership Onboard the USS Fee-for-Service

Health care delivery and payment reform.

By Peter Rigby, PT/MPH*

For years I believed that reimbursement for physical therapy would improve organically as health care reform initiatives improved our health system.

I no longer believe this evolution-theory to be true. I now believe that substantive change requires a revolution. John Adams said the real American revolution was not the war. The real revolution occurred before the war ever started. It was the change in the way colonists saw themselves in relation to the British monarchy. This is undoubtedly true of all revolutions. They start with small change in the hearts of individuals. Large-scale change happens when a critical mass becomes willing to fight for their beliefs.

My evolution-theory grew from years of experiences as rehabilitation services director within a large health system. I was given many opportunities to imbed physical therapy into care pathways and bundles. Discussions with leaders from other disciplines convinced me that physicians and administrators actually understand the inherent value of physical therapy services. It therefore seemed logical that as collaboration intensified and deepened, improvements in physical therapy compensation would organically follow. The flaw in my thinking was my failure to recognize that all health professions are making decisions in survival mode. Think of the RMS Titanic. People were making decisions in the middle of nowhere, expecting to sink within an hour. How different would their decisions have been if the Titanic was in sight of shore, expecting to sink in a week? A spectrum of reactions can be expected from people on board a Titanic. On one end of the spectrum, there are those who simply give up and drown. On the other end, there are those who panic, grab the lifeboats, and leave others to perish. There is also a middle group of individuals who are willing to descend into the cold water and take their chances on grabbing a piece of the destroyed vessel and swimming. All health professions need to find leadership from within their ranks to lead collaboration. All professions need to find and support bold “middle-group” leaders.

First, it is important to appreciate the amazing gains our profession has made through a largely evolutionary process. Hospital care is an excellent illustration. The physical therapist’s current role in acute hospital care is dramatically different from the role we played in hospitals at the beginning of my career. A vestige of the-way-we-were can be seen in physical therapy’s ongoing classification as an “ancillary” service in hospital structure. By definition, ancillary services “provide necessary support to the primary activities of the hospital.” In my opinion, services provided by nursing, laboratories, and diagnostic imaging remain ancillary. These services are ordered a la carte by medical doctors (MD) and executed under strict MD guidelines and specific parameters. Ultimately, information from these orders produces actions and information in support of MD decisions. Physical therapy no longer fits the “ancillary” definition. Although we were clearly ancillary when hospitals were paid fee-for-service (FFS) for therapy services, we are no longer ancillary. FFS reimbursement for inpatient therapy incentivized hospitals to use us to drive revenue. Under the current bundling Diagnosis Related Groups (DRG) payment system, physical therapists evaluate patients for safe discharge and treat patients according to our judgment, not according to MD prescription. Physical therapy has evolved into a well-respected role in acute hospital care. This consultative role extends into the ambulatory (or “outpatient”) setting where primary care physicians (PCPs) refer patients to physical therapy with only a general diagnosis (e.g., “low back pain”). We then “evaluate and treat.” Physical therapy is well respected in ambulatory care.

Care bundling has been one driver of our changed status in the health care provider community and will undoubtedly play a large role in stimulating future change in delivery paradigms reimbursement methodology. Care bundling requires strategic alignment of a chain of small silos of complementary services. Each silo has a domino relationship with its adjacent silos. Services of physical therapists and PCP providers align well within one domino-silo. The success of this alignment, and by extension the entire provider chain, depends on sharing a vision of excellence and reducing variation in patient care. Sharing a common vision and reducing care variation requires leadership. Key characteristics of much-needed physical therapy leadership:

• Leaders must come from within our profession. Outsiders do not understand the balance PTs must strike between individualizing care planning to accommodate patient uniqueness and standardizing care planning to reduce treatment variation.
• Leaders must be bold. Unfortunately, many physical therapists also do not understand the barrier that treatment variation represents to the future of our profession, and many even argue that variation should be promoted. Changing this perspective reaches to the core of a physical therapist’s professional identity. A change of this magnitude will require courageous leadership.
• Leaders must have allegiance to advancing our profession at large. Physical therapists are competitive by nature, and private practice tends to attract the more competitive among us. Competition is a healthy stimulus for innovation and business success. Business success often results from fielding a unique approach. We don’t have to share everything, such as aspects that give us a unique competitive edge, but we need to identify a core set of treatment standards and establish care norms.

In the opinion of patients, employers, and health care providers, the USS Fee-for-Service has already sunk. Revolution of thought has already swept the nation. We are all now searching for leadership to shape a rational and just system to meet the health care needs of our country and for clinical excellence to be fairly compensated. Positive change will occur when individual providers and provider groups with competing interests unify within a collaborative system. FFS lifeboats will not bring us to a safe harbor. We need courageous leaders who can take action that supports our profession.

Peter Rigby, PT/MPH, was the director of rehabilitation at the University of Washington Medicine for 20 years. Today he is the executive director of In Home Health Agency. He can be reached at pjrigby7@gmail.com.

*This author has a professional affiliation with this subject.