The emerging healthcare environment requires expanded patient access while delivering optimal outcomes and cost. As healthcare moves form a fee for service model to alternative delivery and payment models, there are opportunities for physical therapy to revolutionize the delivery of musculoskeletal medicine. Physical therapists are uniquely qualified to spearhead musculoskeletal care through direct access with the potential to improve patient satisfaction and outcomes while limiting unneeded medical care. While this model has been described in the military, there are few descriptions of this PT First approach in the private payer arena. This session will provide the attendee with a multifaceted perspective on the impact of physical therapy in emerging, collaborative healthcare models. Approaches to payers and employers with the business implications will be presented that influence these new models. Key strategies to implement a scalable, best practice model will be discussed including the logistical challenges and corollary solutions in the private arena. We will discus our experience implementing novel delivery models for management of neck, back, shoulder and knee pain. The session will deliver practical solutions to the challenges of implementing, assessing, and adapting a theoretical construct to a working viable program. Finally, the session will discuss how the use of a a large Patient Outcomes Registry and analysis of “big data” can drive best practice and inform development of the program.
3. Session Learning Objectives
Identify opportunities for physical therapy to integrate into
current emerging delivery and payment models.
Describe approaches to payers and employers with the
business implications will be presented that influence these
new models.
Understand challenges and potential solutions to successful
implementation of a new program.
Identify key factors and metrics to understand if program is
viable long term solution.
4. Gameplan
What is PT First and what’s taking so long?
What are payers and employers looking for from alternative
payment models?
Key Implementation Strategies for Successful Training
Monitoring, Feedback, and Clinical Reporting: What to do after
“Go Live”
Analysis and Reporting for Business Intelligence
5. Why MSK? Why Now?
$865
BillionEstimated Value of the National MSK
Market
5.7%
20% Of Medical Expenditures
Of GDP
6. February 20, 2017
MSK Overview – Patient Demand by Body Part
National MSK analysis via commercial claims data
75%Of all MSK cases are
Spine, Knee & Shoulder
7. % of MSK Touches
Therapy
Clinic Visits
Standard Imaging
Office Procedure
Advanced Imaging
ED/Urgent Visits
Specialist
Procedure
Home Health
50% Therapy
SG2 2012 Report
Does Therapy Matter?
8. What Health Systems See
Increasing pressure to improve while decreasing costs
Emerging value-based reimbursement1
2
75%
Chronic conditions
account
for
of
healthcare
costs
In the U.S. and
Growing
Medicare patients is
readmitted within 30 days
1
9. Pressures on Health System
Most health systems are ill-prepared for
this demand
Patients
Employers
Payers
Facing more lost time
More informed Payment Reform
10. Why Do Health Systems Care?
• Lower inpatient volume
• Higher orthopedic costs but limited control
• Physician dissatisfaction
• Lower reimbursement rates
• Uncertainty about how to manage episodic/bundled payments and population
health
• Organizations that don't move fast enough in a changing landscape
• Leakage of patients during the continuum of care
• Market fragmentation
11. Full Service Health System Integrated Delivery System
Employed
Medical Staff
Faculty
Employed Physicians and Outpatient Services
Payers
Post Acute
Services
Diagnostic
Center ASC
Post Acute
Services
Payers
Hospital System vs.
Healthcare Delivery
System
PT
12. What If??
(1) Identify appropriate patient
population…
High volume
cases/admissions
Variations in clinical
practices
(2) Obtain commitment from
Leadership/Clinicians
(3) Assemble interdisciplinary
team
(4) Data review & Benchmarking
(5) Evaluation of current
practices
(6) Establish outcomes
measures/indicators
(7) Sequential event
mapping with outcomes
triggers
(8) Staff & Patient education
(9) Implementation of
pathway
14. SpineAccess Alberta
SpineAccess Alberta will
include multidisciplinary
teams at two pilot centres
who will assess, triage and
treat patients with back
problems.
At these pilot sites, these
teams will help clear the
health system of backlogs of
patients waiting for
unnecessary consultations
and it will help the 10 percent
who do need a specialist, see
them faster.http://www.albertahealthservices.ca/Strategic%20Clinical%20Networks/ahs-scn-bjh-spine-access.pdf
15. Imaging?
New Zealand physiotherapists
are able to refer patients for x-
ray and ultrasound (US)
imaging.
Australia
Wisconsin 2016…..
Littlejohn F, Nahna M, Newland C, Robins S, Hefford C (2006): What are the protocols and
procedures for imaging referral by physiotherapists? New Zealand Journal of Physiotherapy
34(2): 81-87.
16. Unique Models (PT First)
Allow for innovation
Must be Patient-Centered
Demands Direct Access
Must fit within the Scope of
Practice
http://forces4quality.org/node/6347
17. Scope of Practice
Licensure is required in each state in which a physical therapist
practices and must be renewed on a regular basis, with a
majority of states requiring continuing education as a
requirement for renewal.
PTs must practice within the scope of physical therapy practice
defined by these state licensure laws (physical therapy practice
acts).
The entire practice act, including accompanying rules,
constitutes the law governing physical therapy practice within a
state.
http://www.apta.org/Licensure/StatePracticeActs/
18. What is “PT First”?
3 Types of Direct Access
Unrestricted: No referral language in the physical
therapy practice act.
Provision: No referral needed to access physical
therapists examination, evaluation, and intervention with
certain provisions.
Limited Direct Access: allows for access to evaluation
and access for certain types of treatment.
19. Patient satisfaction and outcomes superior
Decrease utilization of
numbers of PT visits,
imaging ordered,
medications prescribed,
additional non-physical therapy appointments
There was no evidence for harm.
Phys Ther. 2014 Jan;94(1):14-30.
20. What is taking so long?
Practice Act issues
Placement in healthcare system
”Turf” wars
Payer issues and awareness
Employer awareness
Clinical hurdles
Training insufficiencies
Risk of rogue clinicians
Data Integration issues
23. “PT First” and Payers
Evidence-based approach provides value
Tracking data is key
Data has to tell a story that demonstrates savings, reduce
fragmented care & unnecessary care
Pair with patient outcomes & satisfaction
How the data is compiled and collected matters
24. Identify potential service models, patient populations,
geographic overlap
Benefit design improves effectiveness, but not necessary
Need well-defined implementation plan; need to drive the
process & keep it front & center
IT integration improves results
Ongoing communication is essential
Collect data and make modifications as needed
“PT First” and Payers
27. Genesis
Identification of need
Consultation with recognized specialists
Proposed solution
Encouragement of PT as access point for musculoskeletal
complaints
Evidence based medical screening
Capitated shared risk payment model
Standardized evidence informed treatment pathways
28. Genesis
Proposed solution
Encouragement of PT as access point for musculoskeletal
complaints
Evidence based medical screening
Capitated shared risk payment model
Standardized evidence informed treatment pathways
29. Implementation v1.0 (2012)
Access: During first visit an onsite MD had to “bless” the
care plan
Screening: As above with 10 item questionnaire
Payment: $20 copayment regardless of deductible status
Training: 8 hours training for neck and back management
Scope: 12 clinics with 40 participating therapists
30. Lessons Learned in the First
6 Months
Patients did not mind coming via direct access (70% in first year)
Patients did not like paying a physician copay when they added
no value
Physicians did not like their busy clinic days disturbed by PT
coming to say they needed another patient “blessed”
Programs change quickly when the HR department receives 18
phone calls in a month regarding erroneous copayments
Too large of a rollout lead to inconsistencies in care and process
31. Lessons Learned in the First
6 Months
If you design a program for early acute access
You’ll get a ton of patients with long term symptoms
But despite your reservations they get better
32.
33.
34.
35. Reload v2.0
Encouragement of Direct Access
No MD Blessing and 2nd copayment
As described fee for service payment model with patient
copayment regardless of deductible status
Outcomes
45-60% reductions in disability
High patient satisfaction
Decreased health spend for hospital system (Imaging, Pharm)
Decreased PTO Usage for those in program
37. 2016 “SSK” Expansion
Stagnate growth of program
Minimal hospital investment
Revitalization
New found hospital support
Opportunity to intergrade Knee and Shoulder patients
Move to real time process and outcome monitoring
Opportunity to refine screening process
40. • 2012-2014 ATI partnered
with Greenville Health
System (GHS) and BCBS
SC to initiate clinical
pathways
• GHS adult beneficiaries
with back and neck pain
eligible to seek initial care
with 4 select co-located
ATI clinics
Back
Back
Neck
GHS Musculoskeletal
(MSK) Program
41. • 2016 ATI partnered with
Greenville Health System
(GHS) and BCBS SC to
initiate clinical pathways
• GHS adult beneficiaries
with spine, shoulder, &
knee pain eligible to seek
initial care with 9 select
co-located ATI clinics
Knee
Spine
(Neck/Back)Shoulder
GHS Musculoskeletal
(MSK) Program
42. • Beginning Jan 1 2017
• Expand program to include hip
• >50% of LBP has hip
complaints
• 12% of non traumatic MSK
visits
• Add 4 more ATI locations
Neck/Back
Hip/Knee
Shoulder
MSK Program
For Spine, Shoulder, Hip, and Knee Pain
43.
44. PCP
Urgent Care
Ortho Center
Refer back
< 25% improvement
Non MSK symptoms
Follow-ups
@ 6 visits/30 days
IF> 25-50% better
Then…
Follow-ups another
30 days with
expectation of
> 50% improvement 45
45. Ultimate Lessons Learned
How do you eat a horse?
Changing health system behaviors is harder
Ongoing process
These things happen with one MD and one therapists deciding this
is how patients should be seen
Turf protection and hubris is overcome with jealousy of their colleagues
Be like a duck
Ferocious monitoring and course correction everyday
Just as we planned when reporting out on great outcomes and huge
savings
48. • 509 discharged from PT
• Average age = 47.4 years
• 79.5% are female
25% 31% 36% 6%
Body Region
MSKore
• The majority of patients were in the 35-55 age range, with a
predominance of women similar to GHS population.
• As for Body Mass Index, 56% of patients normal or less BMI.
Lumbar
Shoulder
Knee
Cervical
34%
31%
15%
20%
Diagnostic Diversity:
Percentage of total patients by
body region
403
106
Female Male
Patient Demographics
CY16 Jan 1 – Dec 31
49. 50
96%
Patient
satisfaction
Patient Outcomes
CY16 Jan 1 – Dec 31
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Neck Low Back Shoulder Knee
PercentFunction
ATI OrthoPathPatients
Pre Improvement
12% 13% 21% 28%
• 60% direct to PT
• 85% without further
medical referral
• 7.8 visits/patient
51. FEEDBACK TO CLINICS
Lutz et al Ortho Section Platforms Friday 12:45
Patient
improvement <
the predicted
risk adjusted
outcome
Patient
improvement >
the predicted
risk adjusted
outcome
You are
here
52. FEEDBACK TO CLINICS
Lutz et al Ortho Section Platforms Friday 12:45
Patient
improvement <
the predicted
risk adjusted
outcome
Patient
improvement >
the predicted
risk adjusted
outcome
You are
here
53. Annual Program Growth
54
25,000 covered lives/year
0
100
200
300
400
500
600
Year 1 Year 2 Year 3
NumberofPatients
In Program Out of Program
> 32%
> 85%
Neck & Back
4 clinics
Neck & Back
6 clinics
Neck, Back,
Shoulder, Knee
13 clinics
54. 0
2
4
6
8
10
12
14
16
18
Year 1 Year 2
NumberofPatients
In Program
Out of Program
9.7
visits/
patient
15.5
visits/
patient
9.5
visits/
patient
16.2
visits/
patient
Annual Visit Comparison
55
25,000 covered lives/year
Populations were
similar in terms of
• Age
• Gender
• BMI
• Comorbidities
• Diagnostic mix
• Chronicity
55. Improved Access
• ATI appointment within 48 hours
Reduced cost
• >26% reduction is total MSK health
spend
Avoidance of unnecessary treatments
• 44% reduction in advanced imaging
Increased patient satisfaction
• 93% Patient Satisfaction Score
Improved outcome
•57% increase in patient functional
outcomes
Decreased absenteeism
• < 3.3 days/case sick time
56. Projected 3 year US Savings
85%
66%
80%
84%
71%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Advanced
Imaging
Emergency
Visits
Physician
Visits
Pharmacy Therapy Surgical
15-33% savings
across service lines
26% overall savings
Total US MSK Spend
$900 billion $180 billion
Projected Savings
57. Analysis and Reporting for
Business Intelligence
Chris Stout, PhD, Vice President
Research and Data Analytics
61. It was nice to come to ATI work with
workers’ comp outcomes
because…
Outcomes are VERY Quantified
– RTW at the same job description and PDL
or not?
– How many days passed before RTW?
– Nice, clean, and tidy!
62. I was always frustrated with the
disconnect of collecting PROs in real-
time for the clinician (as well as me!)
66. 67
Passionate about Patient Satisfaction:
Since its inception, ATI has been focused on our mission to provide the highest quality of care in a friendly and
encouraging environment. We have the most inclusive, methodologically sound, and productive program in physical
therapy. Last year alone, we sent out 222,354 patient satisfaction surveys and received 55,082 in return (a 25%
response rate).
• Each day, returned surveys are scanned into our IT infrastructure and are immediately available to the Clinic
Director and Operations Leadership. This allows the Clinic Director to share praises with the staff, as well as
address anything that is not exceeding expectations related to quality of care or customer service. It is a concrete
example of how the benefit of a strong IT platform enables ATI to maintain an extremely high-touch
management environment where clinicians and managers can be immediately responsive to patient feedback.
• We are not content with small samples or biased data, so ATI invested in industry-leading methodology and was
published in Advance for Physical Therapy for “What Patients Want: Innovative uses of patient satisfaction data in
quality improvement and clinical management.”
67. 68
ATI also introduced the use of the Net Promoter Score (NPS) to the physical therapy industry. The NPS is a
customer loyalty metric used across many industries, including healthcare. It was introduced in Fred Reicheld’s 2003
Harvard Business Review article on the topic. Patients are asked, on a scale of 0-10, how likely they are to
recommend ATI to friends and family. ATI outperforms many other well-known companies, which is a reflection of
our commitment to delivering on our mission for every patient, every day.
68. Pioneering Patient Outcome Management in PT:
ATI embedded a complete set of functional outcome tools directly into our EHR that are concise, easy to complete,
reliable, valid, and universally recognized and respected by professionals in the field. They are immediately scored,
have descriptive pop-up result information, and provide patient item responses. The findings are available to the
clinician in real-time, and are aggregated for post-discharge analyses.
69. Leveraging quality clinical outcomes and
member satisfaction scores, the Patient
Outcomes Report establishes a baseline of the
existing care continuum and its impact on
patients’ quality of life. This customizable tool
facilitates the creation and implementation of
care plans that enhance clinical effectiveness,
reduce the cost of care, and improve the
patient experience.
MSKore is a proprietary tool developed by ATI to reference various descriptive
analytical aspects of patient care specific to musculoskeletal (MSK) conditions
Enhancing Patient Clinical Outcomes While
Favorably Influencing the Episodic Cost of Care
for Musculoskeletal (MSK) Conditions
MSKore®
70. • 41% of the population in this examination was male, 59% female.
• Most were between the ages of 50 to 59, with females exceeding males in this age group.
• The majority of patients fall into the normal category, followed by those considered to be
overweight.
71. 12,520
9,116
Female Male
42% of the population in this examination was
male, 58% female.
Most were between the ages of 50 to 59, with females far exceeding males in this age
group.
The majority of patients fall into the obese category, followed by those considered to be
overweight.
3
%
32% 32
%
33
%
Patient Demographics
72. Referral Diversity: Percentage of total
referrals by physician specialty
Physician Specialty
Orthopedic
Family Practice
Internal Medicine
Podiatrist
Physician
Assistant
Neurosurgeon
Physical Medicine
and Rehabilitation
56%
12%
7%
2%
3%9%
2%
Physician Demographics
The Majority of referrals came from Orthopedic Physicians
Distant second was Family Practice and Internal Medicine Physicians
15,000
5,000
0
10,000
Orthopedic
Family Practice
Internal Medicine
Physician Assistant
Podiatrist
Neurosurgeon
Pediatric
Physical Medicine
& Rehabilitation
OB/GYN
Health Care Education
Nurse Practitioner
Other*
Neurologist
All Referring Physician: The number of
referrals by type
73. 74
As XYZ-Comp may have regions in Illinois that would
benefit from more outpatient treatment venues as well as
improved rural outpatient coverage, this examination notes
regions of Member density and potentials of partnership.
Patient Distribution by Clinic
ATI Investment in
Market-Specific
Outpatient Therapy
74. Physical Therapy at ATI
Body Part
Total Number of
Patients
Mean PT Duration Days
Average Number of
Comorbids
Most frequently occurring
comorbidity
Neck 987 xxx 2.6 Arthritis
Shoulder 1919 Xxx 2.2 Arthritis
Elbow/Wrist/Hand 765 Xxx 2.2 Arthritis
Low back/Lumbar spine 2265 xxx 2.8 Arthritis
Hip 879 Xxx 2.6 Arthritis
Knee 2309 Xxx 2.2 Arthritis
Foot 1429 Xxx 1.8 Other Allergy
Totals 10553 xx.x 2.3 Arthritis
75. Payer
2016 Clinical Staff & Customer Service Clinic Facilities
RESP #
Patient
Satisfaction
Clinical
quality &
treatment
Professional
attitude, &
appearance of
all staff
Customer
Service of all
Staff
Billing and
Payment
process
explanation
Were clearly
defined goals
set for your
treatment?
Were your
treatment
goals achieved
Overall
comfort &
appeal of
clinic
Location
of clinic
XYZ 1696 92.94% 98.21% 99.45% 98.59% 89.87% 93.82% 95.44% 97.32% 99.37%
ALL ATI 28877 93.68% 98.09% 99.10% 98.62% 93.12% 94.23% 94.50% 96.82% 99.30%
Quality and Patient Satisfaction
80. • 3600 statistical articles are published
on average each year
• Do you know how long it would
take you to keep up…?
Just for Coronary Heart Disease…
81.
82. If you read 1 article/15 minutes
You would have to read >10
articles
For 2.5 hours/day
7 days/week
Forever…
86. >15,000 prior-managed bills were loaded and rerun
against the ODG Treatment UR Advisor for each ICD9-
CPT combination on frequency, number of visits,
recommendations from ODG Treatment, and the "Bill
Review Payment (or ODG Approval) Flags" divided
into Green, Yellow, Red…
87. Green, OK to auto-pay up to ODG Codes for
Automated Approval max number of visits;
Yellow, OK to auto-pay up to 25th %tile
number of visits
Red, need to review
88.
89.
90.
91.
92. Apple HealthKit
In 14 of 23 major hospitals are trialing
(Google and Samsung discussing
health-based technology plans)
Healthcare + fitness apps =
comprehensive picture
Send to MD or case manager
93.
94.
95. Please be in touch
Chris.Stout@ATIPT.com
or visit DrChrisStout.com for these
slides and references
Notas do Editor
Chuck
Chuck
Bridget
Bridget- Alliane, Outcome work group and Moran- mention here