Inertia, Fear, And Models Of Care In Orthopedic Physical Therapy

We see the trends taking place throughout the physical therapy world with countless orthopedic conditions. Third party payers are not approving as many visits for physical therapy. Reimbursements are decreasing. Clinicians and patients alike are frustrated. 

One example of this is the rehabilitation process post-anterior cruciate ligament (ACL) reconstruction. There are oftentimes many "protocols" utilized, benchmarks to measure, milestones to make, and function to regain. Traditional approaches have been relatively time- and visit-intensive in the past.

What becomes more and more evident is the growing rift that exists between stakeholders. Payers want to minimize costs. Patients want to return to activity quickly. Clinicians want to be reimbursed reasonably while providing effective care. These stakeholders don't always see eye-to-eye.

Fortunately, this problem reduces itself nicely to some simple solutions.

Having worked within an orthopedic setting for the vast majority of my career, I would suggest that there are 3 options to consider:

1. Change the treatment approach. If we use ACL reconstruction as an example, the solution begins long before the patient enters the surgeon's realm. The importance of self-responsibility in care must be emphasized - from surgical consultation to physical therapy assessment and treatment.

Physical therapists will need to re-consider their role in the care of the patient with an ACL reconstruction. How can physical therapy be optimized? What level of physical therapist input provides a true value-added benefit? How much of the rehab process is truly patient-centered? Can technology be leveraged in any way, and can it be done so effectively to improve outcomes?

2. Change the business model. Many will say that a shift to a cash-based practice is the solution. I disagree with this for one simple reason: the incentives are unchanged. The more visits, the greater the income. Changing from insurance-based to cash-based is not an actual change in the business model as much as it is a change in when you get reimbursed and how much paperwork you complete along the way.

Changing the business model will require something far more innovative and disruptive. For example, offer the services in a way that promotes an outcome for the problem, not a "per visit" payment strategy that equates "more visits" with "greater options".

3. Keep complaining. This is the easiest option. We could just keep complaining about how insurance companies are driving care, how they won't approve visits, how they are mean and horrible in paying less per visit, etc. Yes, we've all heard these before.

Unfortunately, most clinicians will select option 3 for two primary reasons - inertia and fear. It is easiest to just put your head down, bear with it, control costs, see more patients, employ less costly clinicians, and keep complaining about how it effects your bottom line. And I get this, because inertia is a common scourge for many of us in all facets of our lives. Then, there is fear - that stepping out of the box and doing something different won't be accepted or financially viable or that patients won't buy into it. But if you are patiently waiting for "the right moment" to safely do so, you will be waiting forever. 

Let me tell you this: if you have a better model of care utilizing a better reimbursement paradigm - and it creates value to the stakeholders - there will be many that will stand up and take note. That list will include third party payers, patients, and the health care system as a whole. If the model accomplishes a better outcome, more effectively, in a more patient-centered way, and costs less, then you can bank on getting a whole lot of attention somewhere along the line.

Models of care in orthopedic physical therapy will have to be disrupted significantly in order to evoke real change. As they say, if you do what you've done, you will get what you've got. But I ask you - is that an acceptable option for clinician, patient, or health care system as a whole?

If not you, then who? If not now, then when?

Photo credits: curran.kelleher

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