Translating Practice Outcomes to Your Bottom Line
By Troy Bage, PT, DPT, MBA
To say health care has changed since many of us first entered the physical therapy profession is probably a gross understatement. Regulations are more stringent, competition is stronger, documentation requirements are greater and reimbursement is lower. Most physical therapy practices are looking for an edge to compete in today’s health care environment. In our competitive field, practices need tools to improve quality and service, need to maximize reimbursement, and must differentiate themselves from other practices and other health care options to be successful. Outcomes measurement and reporting can be a key ingredient to competing for the future.
The Institute of Healthcare Improvement1 developed the “Triple Aim” as a framework for optimizing a health systems performance. The Triple Aim is comprised of:
- Improving the patient experience of care (including quality and satisfaction)
- Improving the health of populations
- Reducing the per capita cost of health care
Center for Medicare & Medicaid Services (CMS) and many insurers have used this framework as they assess the ramifications of the Affordable Care Act (ACA) and how to reform the health care system. Outcomes play a key role in measuring the patient experience and their overall health and function. Additionally, outcomes allow you to measure value (outcomes and costs) to address the final point of the Triple Aim.
In outpatient physical therapy practice, the most common outcome measurements are patient reported outcome measurements (PROMS) or more commonly referred to as functional outcome measurements. In Michael Porter’s article “Measuring Health Outcomes: The Outcome Hierarchy2,” in the New England Journal of Medicine, he notes functional improvement as a patients’ second most important concern. From the patients’ perspective, only survival ranks ahead of function in the post-injury phase.
When implementing outcomes into your practice, it is important to assess both the functional and patient perception measures. The most commonly used functional measurement tools are listed in the table below. They are all well researched and have strong reliability and validity. Additionally, these measures are not physical therapy specific. They are universal in health care and allow therapists to measure the same outcomes a physician may be utilizing.
|Oswestry Disability Index (ODI)||Lumbar spine|
|Neck Disability Index (NDI)||Cervical spine|
|Lower Extremity Functional Scale (LEFS)||Lower extremity|
|Quick DASH (Disability of the Arm, Shoulder and Hand)||Upper extremity|
In addition to those listed above, there are multiple other specific and general tools to measure functional outcomes. There is also significant research comparing the different PROMS available online3,4.
Patient perception measurements are valuable to gather information on the patients’ view of their experience and care. They can include pain (visual analog scale or VAS), satisfaction, perception of functional improvement, and perception of goals met. These measurements relate directly to the first Triple Aim, improving the patient experience of care.
There are commercial database systems available that measure, record, and report on functional outcomes. The most commonly known and utilized systems are Focus on Therapeutic Outcomes (FOTO), Web Outcomes, and Care Connections. These systems aggregate the data, compare clinicians and practices across their database, and produce reports to allow for deeper analysis and reporting of the outcomes. Additionally, the first two have risk adjusted their databases to allow “apples to apples” comparison of patients with varying comorbidities and complicating factors. Systems like these are not necessary to measure outcomes, but provide some tools and resources to add value to a practice. Additionally, the American Physical Therapy Association (APTA) has created an outcomes registry at PTOutcomes.com. The APTA is still developing their registry, but they are using the tools listed above in addition to CMS measurements like Physician Quality Reporting System (PQRS) and Functional Limitation reporting.
Outcomes To Create a Return on Investment (ROI)
When used properly, outcomes should have a strong return on investment (ROI) for any practice. It is important to understand how to use the outcomes to best maximize their potential return.
Improving Patient Care and Service
Everyone believes they provide great care and service, but can you prove it? There is no practice that intends to give mediocre care and service, but we all know they are out there. A study by Valderas et al demonstrated that outcome measurement improved treatment processes (like diagnoses), communication, and overall clinical resolution of diagnoses.5 Outcome measurements give practices a chance to prove their results. The test data should also be used internally to assess treatment and service approaches. Great outcomes and satisfied customers will always be a vehicle for practice growth.
Differentiating Your Practice
Although a rising number of clinicians utilize PROMS as part of their treatment and documentation, it is estimated that less then 20 percent of practices aggregate and report on their outcomes. This creates a great opportunity for practices to promote their results to physician groups and differentiate themselves from other practices. Remember, everyone believes they are great—your outcomes can help prove it. When presenting outcomes to physicians, it is important to know your audience. Primary care physicians are usually more interested in the patient perception measures (pain, satisfaction, etc.). Orthopedic surgeons tend to gravitate to the functional PROMs. Every spine surgeon will know about the Oswestry, whereas most primary care physicians will not.
Create Value with Payers
Payers are increasingly looking for tools to measure outcomes in physical therapy. The primary measure for most payers is currently cost of care. Unfortunately, this does nothing to account for the value created by physical therapy.
Some insurers are taking forward thinking steps with outcomes. Priority Health, a regional insurer based in Michigan, is in its second year of providing incentive payments to practices that report on and meet certain outcomes guidelines.6 Kenneth Walker, director of Ancillary Provider Contracting at Priority Health, says, “We are strong believers in the value of physical therapy. Having tools to measure a clients’ functional improvement will help us better align reimbursement with results.”
Blue Cross and Blue Shield of Louisiana developed the Quality Blue program to “help physical and occupational therapists identify best practices and promote high-value healthcare for patients.”7 Blue Cross worked with therapists to develop Quality Blue for physical therapy and occupational therapy, examining how to effectively boost patients’ health outcomes and satisfaction with their therapy experiences.
Many insurers still do not know the “right” measures for outcomes. However, functional improvement, satisfaction, and cost are the three areas that will be the focal points. These three measurements are in perfect alignment with the Triple Aim of health care.
In Michael Porter’s Harvard Business Review article, “The Strategy That Will Fix Healthcare,” Porter clearly, but simply outlines the direction for health care. “The overarching goal for providers, as well as for every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.”8 Our responsibility as practice leaders is to create the value measurements to ensure that the positive impact of physical therapy is represented appropriately in healthcare reform. There is no question there will be changes coming in the future with regards to how we are reimbursed. However, any reform must be based around quality measures and not simply coding changes.
Each practice can utilize these quality measures to supercharge growth, maximize reimbursement, and improve the quality of care, service, and communication. Our profession needs to take the initiative to measure, report and promote our outcomes regularly. This paradigm shift, which is underway in many practices, will ensure a bright future for our patients, our practices and our profession.
1. IHI.org Accessed December 2015
2. Porter M, Lee T, What is Value In Healthcare? N Engl J Med 2010; 363:2477-2481 December 23, 2010
3. Registry of Selected Functional Physical Therapy Outcome Measures With Minimal Detectable Change Scores Jeffrey S. DeRenzo, DPT Candidate Research Project Advisor: Stacy Fritz, PhD, PT. http://www.sph.sc.edu/dpt/dpt-rehab/pdf/registry_of_outcome_measures_with_mdc_2010.pdf Accessed 2015
4. http://www.rehabmeasures.org/rehabweb/links.aspx Accessed December 2015
5. Valderas JM1, Kotzeva A, Espallargues M, Guyatt G, Ferrans CE, Halyard MY, Revicki DA, Symonds T, Parada A, Alonso J. The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Qual Life Res. 2008 Mar;17(2):179-93. http://www.priorityhealth.com/provider/manual/performance/pt-incentives
6. Healthcare Journal of New Orleans – http://healthcarejournalno.com/hjno-enews/291-enews-for-april-16-2014/1422-bcbsla-launches-ptot-program
7. Porter, Michael The Strategy That Will Fix Healthcare. Harvard Business Review, October 2013
Troy Bage, PT, DPT, MBA, is the chief operating officer of Upstream Rehabilitation and is based out of Chattanooga, Tennessee. He is a Private Practive Section (PPS) member and can be reached at email@example.com.