Show Me the Data!

What is the effectiveness of measuring outcomes?

By Dan Fleury, PT, DPT, OCS

A fairly hot debate on the effectiveness of using outcomes to drive evidence-based practice exists. I have heard arguments from opponents and proponents, and they both have some valid points. I have even had the opportunity to participate in case reviews with a national health insurance provider to see what happens on the “dark side” when reviewing a case for decisions related to payment and continued care. That experience working with the health plan was extremely valuable in helping me understand why physical therapy continues to be a target of continued regulation, documentation burdens, and decreased payment. Their smoking gun: They were able to extrapolate your outcomes data. That is right, they are looking at each and every one of your charges and visits per patient. It really was an “ah-ha” moment.

Most incidences of denial of payment or denial for continued visits are due to “insufficient documentation.” Your patient gets a letter in the mail stating that the therapist did not provide enough information to the person paying the bill to warrant payment. This leaves you scratching your head because you thought you documented everything and you clearly identified that the patient made great functional progress and was close to reaching recovery.

Most likely the person reading your documentation and making that decision is not a rehabilitation provider and, furthermore, they have no idea what you are talking about in your attempt to wow them with your anatomical, biomechanical, musculoskeletal, and neurological jargon. They have no idea why a seemingly small restriction or loss of motion is worth the bill you have submitted, and therefore you receive a denial and it is blamed on you. Gone are the days when a payer simply accepts an educated and licensed rehabilitation provider’s jargon and ever changing goal status as an indicator of your skills as a provider and the payment for services.

We are all good therapists, and we all get patients better, right? Our patients tell us that we are good, they like us, and they keep coming back. Is that not enough? This sort of thinking is not understood by nonphysical therapists. They want and need a simple number backed by evidence that has been validated by research and shows functional improvement. Almost every contract negotiation, payment, or care discussion that I have been involved in over the past 5 years, I am met with the same response: Show me the data! Having the data to back up our claims of being great clinicians has proven invaluable. Here is an example of one success that I have had using outcomes in progressing my practice.

My company was born out of the idea that physical therapy could be provided in a better, faster, and less expensive delivery system—a clinically driven concept spearheaded by the underlying premise that only highly skilled interventions backed by evidence are employed as a first-line treatment for musculoskeletal injuries.

Cost savings and utilization are important in proving that physical therapy intervention is effective and efficient in the management of musculoskeletal disorders. Blindly cutting utilization and costs does not necessarily translate into having a positive impact on meaningful functional outcomes. Can we have a positive effect on cost, quality, patient experience, and meaningful functional outcome?

We approached a large local medical group with this exact concept. The medical group has several locations and is also the administrator for a large health plan covering active and retired military and their families. Working directly with a medical provider who is also a payer gave us unique access to a breadth of data so we could analyze physical therapy–related cost and utilization accurately. We were able to extract and analyze the cost and utilization data of our network and compare that to over 450 therapy providers in their network. Due to our success on both cost and utilization, our network of 23 locations was chosen to continue being the providers of high-quality services for this health care payer.

During our analysis we noted one of the medical centers had eight primary care providers and a national chain physical therapy provider on site. The data was extracted on that specific location with careful attention paid to the prior 12 months to improve the validity of the pending before and after comparison. The analysis indicated that cost and utilization of their existing therapy provider were two standard deviations higher than the network’s mean, identifying them as strong outliers in the data.

We were granted a contract to replace the existing therapy provider and prove our concept. After interviewing the medical staff and the health plan utilization review medical director, it was clear that a modern evidence-based practice that could accommodate same-day access for the large ticket items, low back pain, neck pain, shoulder pain, and knee pain, could have an impact on decreasing costs related to unwarranted imaging and specialist referrals.

At this point we had been tracking outcomes for several years using a web version outcomes database. The system we use is a computer adaptive test (CAT) that applies risk adjustment criteria based on specific criteria such as age, comorbidities, fear avoidance, diagnosis, and insurance carrier type, increasing the validity of the comparison between patients. For example, we know that not all back pain patients are created equal; this system adjusts the baseline and predicted outcome based on the risk-adjusted criteria to more accurately compare patients with like diagnosis.

The outcomes data can be drilled down further to compare a therapist or a facility’s efficiency, overall functional change, and patient satisfaction. The outcome data is compared to the outcome data of over 12,000 other physical therapists across the globe. The outcomes can be sorted by specific body part or surgical intervention. With 12,000 therapists and 450,000 patient encounters measured yearly we feel validated in assigning the predicted outcomes scores a safe representation of the national “average.”

This database has been shown to be meaningful, valid, and sensitive to change. ^(3,4,5,6). It has also been recognized by Congress and CMS through the National Quality Forum (NQF), which first endorsed their functional status measures in 2009. In 2010 CMS accepted the measures for use in the Physican Quality Reporting System (PQRS) program.

After one year, we completed an analysis on cost savings, utilization management, and functional outcomes of its integrated model of care. The data on utilization and cost was extracted from the payer database, and the outcomes were collected from my company’s outcome results from dates of service 11/1/2013–12/1/2014.

Results:

• Overall Patient Satisfaction: 99 percent
• Utilization decreased: 60 percent per case (compared to previous practice)
• Overall cost of physical therapy: 35 percent reduction (compared to previous practice)
• Functional improvements in the 7 CMS accepted measures compared to national average.
  • Overall 46 percent higher
  • Knee 71 percent higher
  • Shoulder 57 percent higher
  • Foot and Ankle 33 percent higher
  • Spine 21 percent higher
  • Hip 16 percent higher
  • Neck 16 percent higher

The results overwhelmingly support the fact that outcome, evidence-based delivered care is not only less expensive but also that patients are highly satisfied, and the functional outcomes beat the national average! 

REFERENCES

1. Fritz, J et al 2015 : Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Article first published online: 16 MAR 2015DOI: 10.1111/1475-6773.12301c.

2. Childs et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research (2015) 15:150 DOI 10.1186/s12913-015-0830-3.

3. Wang et al 2010: Clinical Interpretation of Outcome Measures Generated from a Lumbar Computerized Adaptive Test. Physical Therapy (2010) Vol 90:9.

4. Wang et al 2009: Clinical Interpretation of Computer Adaptive Test Outcome Measures in Patients with Foot/Ankle Impairments. JOSPT (2009) Vol 39:10.

5. Wang et al 2009: Clinical Interpretation of Computerized Adaptive Test Generated Outcome Measures in Patients with Knee Impairments. Archives Physical Medicine and Rehabilitation (August 2009) 90:1340-1348.

6. Deutscher, Daniel et al 2009: Associations between Treatment Processes, Patient Characteristics and Outcomes in Outpatient Physical Therapy Practice. Archives Physical Medicine and Rehabilitation (August 2009) 90:1349-1363.

7. Deutscher, Daniel et al 2007: Implementing an Integrated Electronic Outcomes and Electronic Health Record Process to Create a Foundation for Clinical Practice Improvement: Physical Therapy 2008 88:270-286.

8. Delitto, Anthony et al, Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.030.

Dan Fleury, PT, DPT, OCS, is a PPS member and is a partner and director of Development of the Pinnacle Rehabilitation Network LLC. He can be reached at dan@pinnaclerehab.net.