Total Cost


Broader scope, bigger footprint in a changing health care system.

Dear Editor:

The physical therapy profession has many great qualities, one of which is resiliency. Over the course of our profession, we have been able to maintain our relevance in a constantly changing health care delivery system.

In an environment where patients have more limited access to physical therapy because of a decrease in approved visits and high copayments, we must find ways to retain our patients. There have been many publications detailing conceptual business models that allow us to have “add-on” services that provide a revenue stream and increase the footprint of our practices.

The ability to get beyond the [add-on service] is critical. When adding medical fitness services to our business, we developed evidenced-based protocols, allowing us to objectively measure a patient’s function and medical status by using widely accepted medical metrics (i.e. A1(c), body mass index, and blood pressure). Many functional tests—timed up-and-go for example—can be measured at the initial evaluation and following exercise intervention, which demonstrate improvements and validate continued care. This is not a new idea, and these concepts are perfectly detailed in a recent Impact article “Rehabilitation to Fitness,”1 We must be careful to measure and track data that may not seem relevant to measuring a patient’s actual fitness and long-term functional status. For instance, strength is important, but is there enough research that determines what a 42-year-old female should be able to lift overhead? Gamboa asks many appropriate questions when discussing standardized measures and measuring baseline fitness.

For the complex and medically compromised patient, evaluation goes far beyond ROM to strength and functional testing. Integrating medical metrics and functional metrics, while collecting the appropriate data, determines the “best practices” for specific populations. Additionally, developing a system to assess whether the physical therapist-supervised fitness program had any effect on the total-cost-of-care has been our goal. We had the good fortune to be asked by a family practice group to collaborate with them by integrating our physical therapy practice and medical fitness model with their medical practice. From a business standpoint, we remained separate, but in the delivery of care we integrated our rehabilitation/fitness and their medical services. This paved the way for chronic disease patients, low functioning dependent patients, and patients who required exercise to maintain or improve health and function.

Once these protocols and programs were in place, we were able to show measurable improvements in our metrics, as well as improvements in health status. In our chronic disease patient populations, following our integrated supervised protocols, on average these individuals succeeded in decreasing body mass by six percent, waist circumference decreased eight percent, body fat decreased six percent, subVO2 improved 23 percent, and their overall fitness score improved by 19 percent. Additionally we have seen statistically significant changes in the medical metrics traditionally used by the physician. For example A1(c) and pulmonary flow measures all improved, as well as blood pressures, and depression scale responses. The final and perhaps the most important piece of our puzzle was to translate our improved health metrics for these patients into decreased health care costs.

Fortunately, we found a partner in our local Blue Cross Blue Shield (BCBS). In a study that BCBS designed involving high-risk patients, the family practice and our physical therapy/fitness service would track the metrics we developed, and BCBS would track and compare the cost-of-care for these patients for 12 months while the patient participated in our supervised fitness model. To date, 125 patients have been enrolled, and 50 have completed the 12-month program. Of the 50 patients who began the study, 37 patients stayed with the program to its completion. These 37 patients, on average, demonstrated a 28 percent decrease in their total-cost-of-care for the 12 months of participation. BCBS realized a 4:1 return on investment in this study and is now proposing a shared savings approach to the care of this population. We recognize that the number of participants in the study is a relatively low number, but we will enroll 150 patients into this study on a rolling basis this year. In addition, other “medically oriented gym” clinics are running parallel studies.

Our experience has crystallized that medical fitness services and fitness club participation integrated with a physical therapy practice is not simply an “add on” service. The evidence has compelled us to move toward a model where the medical fitness and fitness membership component is the umbrella, and the necessary medical services are provided under that umbrella. These participants will spend a majority of their time in the supervised fitness arena and not using costly, and often unnecessary, medical care. From a business standpoint, the total cost-of-care reductions can have enormous implications for “shared savings” contracts and employee health programs for self-insured companies.

The physical therapy profession, although ancillary in its definition and in many respects in its engagement, has the opportunity to become the driver of medical care delivery, health care cost containment, improved health status, improved reimbursements, and the leader in developing value-based business models. We are no longer ancillary. It is our ability to remain resilient and relevant as the environment of health care evolves and provides us leadership opportunities.


Russell A. Certo, PT, OCS
MOG at Grand Island Physical Therapy, PC

William J. McCormick, MS, PT, CSCS
Maine MOG


1. Gamboa, Jennifer. Rehabilitation to Fitness. Less transition more integration, IMPACT January 2014.

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