Integrating PT First CSM 2017

INTEGRATING A “PT FIRST”
APPROACH IN EMERGING
HEALTHCARE MODELS
Chuck Thigpen, PhD, PT, ATC
Bridget Morehouse, PT, MBA
Tom Denninger, PT, DPT, OCS, FAAOMPT
Chris Stout, PhD

Disclosure
 No relevant financial relationship exists

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.

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

Why MSK? Why Now?
$865
BillionEstimated Value of the National MSK
Market
5.7%
20% Of Medical Expenditures
Of GDP

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

% 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?

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

Pressures on Health System
Most health systems are ill-prepared for
this demand
Patients
Employers
Payers
Facing more lost time
More informed Payment Reform

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

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

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

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

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.

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

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/

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.

 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.

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

Executing “PT First”
 Payers
 Employers
 Unions
 Value-Based Arrangements

“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

 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

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

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

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

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

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

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

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

Medical Screening
 Previous Criteria

Medical Screening
 Opportunity

• 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

• 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

• 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

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

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

Knee
Spine
(Neck/Back)Shoulder
2016 “Report” Card

• 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

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

How am I doing?
96 86 71 26 15 9 8 6 5 4 174 63 43 22 12 2 7 6 5 3 1
48.6% 49.2%
43.5%
41.9%
54.3%
51.5%
46.4%
49.5%
44.8%
37.7%
59.0%
72.6% 73.8%
70.8%
80.1%
77.1%
74.0% 75.0%
66.8%
70.8%
67.7%
71.0%
0
50
100
150
200
250
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Total DCPatients# # of Patientswithcompletedoutcomes Avg STDInitial Avg STDFinal
11.0
8.9
6.9
13.9 14.9
10.6
15.3
8.5 9.4 8.8
15.0
Benchmark - top
10%
Clinician 1 Clinician 3 Clinician 5 Clinician 7 Clinician 9
Avg PTVisits
Operational &
Patient OutcomesBUT,
BUT,
BUT…..
.

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

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

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

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

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

Analysis and Reporting for
Business Intelligence
Chris Stout, PhD, Vice President
Research and Data Analytics

Well…
Why is working in healthcare so hard…?

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!

I was always frustrated with the
disconnect of collecting PROs in real-
time for the clinician (as well as me!)

But we may have
cracked the code

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.”

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.

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.

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®

• 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.

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

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

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

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

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

Not a problem of too little,
but too much

• 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…

If you read 1 article/15 minutes
You would have to read >10
articles
For 2.5 hours/day
7 days/week
Forever…

>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…

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

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

Please be in touch
Chris.Stout@ATIPT.com
or visit DrChrisStout.com for these
slides and references

Integrating PT First CSM 2017

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