TelePT: Physical Therapy 2019 and Beyond

The world telehealth industry, currently valued at $6 million is widely expected to balloon to $19.5 billion by 2025. Advances in primary care, behavioral health and healthcare education have fueled this growth and continue to blaze the trail for medical specializations and other ancillary healthcare services. Remote video visit Physical Therapy or TelePT is becoming more widely accepted as an excellent alternative to office visits for acute musculoskeletal (orthopedic) injury triage, rehab visits and chronic care physiologic monitoring.

Don’t expect TelePT to replace traditional PT any time soon. The initial applications of this new modality will be part of a hybrid model for patients. Those who have demanding lifestyles and would benefit from multiple weekly visits during a rehab term will choose to participate in 1 or more TelePT sessions with their PT each week. These visits won’t replace office visits or a well-crafted Home Exercise Program, they will enhance the rehab program and add value for the patient.

This week I spoke with Anang Choksi from Reflexion Health, the developers of VERA (Virtual Exercise Rehab Assistant). VERA was used in a randomized control trial with post-op Total Knee Replacement patients in cooperation with Duke University Medical Center. Utilizing a hybrid model of virtual visits and in-office visits, the study showed an average cost savings of $2745 per patient versus traditional PT alone. Choksi said they are very happy with the results and this has helped Reflexion in their efforts to market their product to providers, payers and patients.

VERA is an automated virtual rehab program designed by Reflexion Health…. “VERA is uniquely designed to deliver home-based, on-demand therapy sessions. The platform’s engaging avatar – combined with 3D biometrics, comprehensive remote monitoring by clinicians, and telehealth visits – saves patients steps, money and time.” Check it out for yourself. I’d like to know your thoughts – Reflexion Health – VERA

What does that mean for our profession? Are humans going to be replaced by robots? As Choksi says, “VERA and other telehealth platforms will free up PTs to use more of their higher-level skills that differentiate them in the assessment and treatment of patients with musculoskeletal conditions.”

What PT wouldn’t want to be done counting reps and not knowing whether their patients ever do their Home Exercise Program? The role of PTs will change in the coming years as health care delivery evolves and digital health matures. If you had any doubts that telehealth will be a part of the PT landscape, let those thoughts go and get on for the ride.

Houdini Physical Therapy

Growing up I had a buddy who thought he was a tough-guy. He would always say, “I could beat that dude up with my hands tied behind my back.” Quite a concept. Most people couldn’t do anything with their hands tied, but if you think about it, maybe you could. As a PT, could you treat your patients with your hands tied?

We’re moving towards a time when an increasing amount of PT treatment will be provided remotely. It’s not a matter of if, but when. How will PTs adapt? Will they embrace this new medium? How will they learn how to offer PT without touching their patients? What level of quality should patients expect to receive from online PTs? If you’re a PT, do think you could treat any or all of your patients without touching them?

I’ve discussed this with many PTs. They usually express a sense of trepidation. “I’m not sure I’m going to know what to do.” It’s a good point. Where do you start and what do you do? TelePT is not a far reach from what you do every day, but with your hands tied behind your back. It’s going to take extreme skill or the aid of technology. There is help out there. Platforms like BlueJay Health offer features like:

• Exercise Videos
• Secure Messaging
• Video Conferencing
• Clinical Decision-making assistance
• AI assistance of ROM measurement

PTs will use these tools to enhance their ability to connect with their patients and increase communication across the healthcare spectrum. Remote visits won’t eliminate in-office PT, but they will shortly become a large part of the PT landscape.

The rules are changing, but we don’t have to work with our hands tied. We have the tools to be even more effective without our hands.

 

Is PT Done?

“My industry was destroyed by consolidation. Is that happening in PT now?” A buddy of mine who was the sales manager of a medium-sized printing firm in Chelsea asked me this today. I was at the APTA PPS annual meeting in Colorado Springs this past week. I didn’t do a formal poll but a many of the attendees were large groups looking to make acquisitions, and smaller groups expecting to get pitched. Word is that this year was nothing compared to the past two. This was a slow year.

Outpatient PT is still very fragmented. Approximately 25% of the industry is owned by the largest 10 groups. Unlike printing, the barriers to entry are fairly low for a licensed PT to put up a shingle. You don’t have to have expensive equipment or a 10,000 square foot space to house it. When the wave came through printing, it swept up or wiped out everyone because overall demand changed and larger players had a significant scale advantage.

The internet changed printing significantly. Digital documents reduced the demand for printed materials and consumers no longer needed to go to a print shop. They could order letterhead and business cards online from a printing giant for half the price of their local shop. The big guys weren’t acquiring the small, local shops, they were crushing them.

In PT, larger groups are acquiring smaller ones and integrating them into their business and culture. Some smaller ones are being passed by many of the enterprises, but others are still interested in the mom and pops for their culture, innovation, integrity and connection with their community.

I met with many types on the sell side at PPS. Some were wide-eyed and bushy-tailed, there to learn the ropes and absorb all they could about running their practice and acquisition opportunities. Many were much savvier, with deep knowledge of EBITDA, multiples and earn-outs.

It all made me realize a few things:

1. I didn’t know what the hell I was doing when I sold my practice to MOTION
2. I feel very fortunate to have joined a superior group that has given me the opportunity to pursue an exciting and challenging career in PT
3. The future is very bright for PT
4. Large and small PT groups will continue to thrive because of passion, technology and demand

There’s still plenty of space for individual players, but I’m enjoying being on the big team. That’s because our success has been based on maintaining much of the local charm that made our practices what they were before we partnered. It’s a team effort. We care. We innovate. We have fun doing it.

Have you grown?: The changing face of PT administration and delivery

I don’t travel much so I don’t see the incremental changes. I get to notice the big shifts. Like when you haven’t seen a growing child in a year or more, it’s obvious that they’ve sprouted 2 inches and their features have changed.

I don’t know that it’s always so smooth, but when I arrived at a busy NYC airport at 8:30am today, I walked right to my terminal, was whisked through security and easily scooted to my gate in less than 10-minutes. To think that I was stressed out on the Van Wyck – silly! Even the line at the food court, packed with harried travelers, took less than 2-minutes.

How did everything get so efficient? Better hiring and training? Probably. Better facilities? Not exactly – this was Laguardia which is undergoing it’s largest facelift in decades. Technology, logistical improvements and changes in consumer behavior? Bingo.

I checked in on the airline app last night. I didn’t check a bag – that’s a behavioral change for me. I know, everyone else has been doing this for years. I’m a little slow to adapt – creature of habit. More on that later. I use TSA Fast Check, so no “shoes off” at security.

My point here is how do we apply this to PT? Airlines have dramatically increased efficiencies in the past 10-years. Why? Because they were getting killed by fuel prices, competition/price wars, and increased consumer expectations.

So what does this have to do with PT? We function in a low-margin environment. Rent, labor and insurance expenses increase as reimbursements stagnate or decrease regularly. PTs burn out if production is pushed too hard and their lives typically are not made easier by EMRs. So where’s our opportunity to fast-track security or get patients to carry their own baggage, per se?

Automation is improving. Apps like BetterPT connect patients to their local PT provider and allow for remote registration. Eventually they will automate verification of benefits and possibly acquire authorization of treatment when necessary. That’s the equivalent of eliminating the check-in counter at an airport. The great practices will still have patient liaisons and administrative experts to greet clients with a smile and assist those who require it. But imagine if you could cut your admin staff in half or have them perform higher-level tasks to enhance the patient experience and help the practice grow.

Clients would have to change their behavior and expectations but they’re doing that already. CityMD, a NYC Urgent Care group has self check-in kiosks that allow patients to scan their drivers license and insurance card right into the system instead of verbally communicating their info in front of a room full of waiting patients or having to fill out 7 sheets of demographic info by hand. This technology will come to PT shortly, especially because most visits are repeats. That eliminates the need for standing in line at check-in every visit.

Even better, how about not even having to come to the office for your PT sessions? That’s a behavioral change but it should happen in increments. Telehealth PT or TelePT is changing our delivery model. Most patients who require outpatient PT get a script from a doctor of 2-3 visits per week. Very few can attend 3 sessions every week. What if they could do 1 or 2 of visits with their PT every week from home or work? PTs have been doing home visits since before I was practicing, but that’s ridiculously inefficient. Some patients require the hands-on assistance and protection of a professional at all times but most patients are issued a home exercise program by their PT and they’re expected to perform these exercises properly every day with no feedback on their performance. Most don’t do the exercises and most that do them, do them wrong. The result is slower healing, more visits, lost work/family time….inefficiency.

Changes are already happening in healthcare and they’re coming to PT soon. Between automation of administrative functions and increased remote care, PT clinics may look a lot different in the near future. Don’t stay away for too long or you’ll be shocked when you return.

Value-Based Care is Coming to PT

“Price is what you pay. Value is what you get.” – Warren Buffett

Every PT private practice owner knows the challenges of getting paid by a third-party. You treat a patient, submit a claim and wait 30-90 days, sometimes more. Then you get paid the same amount as a provider down the street who has provided half the quality, delivered half the value. In New York, reimbursement is essentially based on a Fee-For-Service model. The more patients you see and the more services you provide, the more you get paid. The Value-Based Care model of reimbursement is coming and it’s about to change all of that.

The more you bill, the more you get paid, right? Not exactly. Any ethical practitioner is going to provide each patient with the least care necessary to have the greatest effect, even if more care/units/services could lead to greater reimbursement. The same goes for the daily caseload of patients. With every patient over a certain threshold for each PT, the quality of care diminishes, patients get frustrated and PTs burn out. Such a pattern can destroy a PT practice due to reputation with patients, frustration of staff and dissatisfaction of referral sources. We’ve all found our sweet spot and that’s how we’re here today.

Value-Based Care is what we’ve always considered to be ethical care and good business practice. Studies show that care improves and patient satisfaction increases with the amount of direct time a PT spends with a patient.1,2 As care improves, outcomes improve, referrals increase and profits rise. The top PT practices know this and have always functioned in this way. Now there are potential financial rewards for doing what we’ve always done.

Value = Quality/Cost3. In any business, the top performers are those who can master this equation. If an auto mechanic can fix your car the first time and he can do it less expensively than the competition, you’re going to keep going back to him. If your local diner has the best burger in the neighborhood and they can afford to sell it at the same price as the other burger joints, that’s going to be your spot. Third party healthcare payers are starting to utilize the same economics. Providers who achieve the best outcomes at the lowest cost will be rewarded with better contracts.

Alternate Payment Models (APMs) are payment models that offer incentive payments for providing high-quality, cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.4 Bundled care models are an APM that are catching on and have been successful in other parts of the country. For PTs, our role in a bundled care model will usually be a downstream partner in an episode of care. For example, when a surgeon performs a TKR, they will be paid a flat fee for the entire episode. That fee will then be split amongst all the caregivers involved in the patient’s recovery. Opportunities for increased payment result naturally from achieving excellent results without utilizing excessive resources. In addition, some models pay added bonuses for superior outcomes and patient satisfaction.

PT is considered to be high-value care (low cost-high efficacy) for back pain and other musculoskeletal conditions so payers are exploring efforts to encourage PT over costly imaging and addictive opioids. In a pilot study, Geisinger Health Plan (GHP) of Pennsylvania offered a value-based insurance design (VBID) version of the PT benefit package, referred to as the “PT bundle.” Under the PT bundle, a member who has a documented diagnosis of back pain is eligible to receive up to five PT sessions for a single copay, which is comparable to the typical copay amount for a single PT session.5 The results of the study suggest that the PT bundle, which follows the main principle of VBID by lowering financial barriers to PT, may have altered the course of treatment for back pain in such a way it is more consistent with the well-established treatment guidelines for back pain.5

Last week I spoke with a practice owner with 42 sites in Colorado, where 70% of musculoskeletal care is value-based. His group has adopted a software platform to utilize telemedicine, patient monitoring, and artificial intelligence (AI) in their plan of care to increase engagement and improve outcomes. They don’t even get paid for the telemed visits, it’s a value-add that improves their engagement, outcomes and leverage with payers. They’ve standardized care and proven their value to payers so effectively that they’ve been able to negotiate significantly higher reimbursements and exemption from the utilization process. Can you imagine life without OrthoNet? The PTs in his group have accepted accountability for case management and both sides benefit. This isn’t our reality yet but it’s not far off.

Going into effect January 1, 2019, Merit-based Incentive Payment System (MIPS) is Medicare’s version of VBID. Not everyone will be required to participate in MIPS but eventually we’ll all be faced with with challenges of value-based reimbursement. How do you plan on thriving in the new value-based landscape. Here are a few options I’ve surmised:

1. Cash business – Stay out of the third-party payer system. This is always a good option if it works with your patient population.
2. Assure that your EMR includes outcomes and patient satisfaction data collection. Most PT EMRs are on top of this and have strategies to help you improve these results.
3. Upgrade the value you provide at a reasonable cost. Encourage PTs to hit those coned courses; asses processes and patient flow in your office; upgrade equipment. Most importantly, engage your patients. Inevitably, patients who attend PT and comply with their program have better outcomes and are more satisfied than those that don’t.

The landscape of our healthcare system is always changing. There’s about to be some significant changes we haven’t experienced before in PT. Be prepared and you will thrive.

Resources:

1. https://academic.oup.com/ptj/article/82/6/557/2836972

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2527215/

3. http://www.apta.org/Blogs/PTTransforms/2018/4/10/VBC/

4. http://www.apta.org/Payment/Medicare/AlternativeModels/

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5459966/

I’m Back…..

It’s been a while but I’ve got that itch again. I’m gonna blog and I’m gonna do it regularly. There is no better way to keep my ideas fresh and more importantly, get them organized.

I’ve been thinking about a lot of things lately:

• Value-based care/MIPS
• Telehealth
• PT/OT/Speech
• The fast-changing healthcare landscape
• Running
• Tennis
• Youth sports
• Commercial real estate
• Acquisitions
• DeNovos
• PPS
• Social media
• “The Start-Up of You”
• Outdoor plants
• Roasting large loins of meat
  • Beef
  • Pork
  • Lamb

So here we go – follow this space!

Are you psyched for surgery?

This is a video of a 27 year-old woman who underwent an L4-5 total disc replacement using the Maverick disc prosthesis.

This video is awesome, right? You can see the stability of the prosthesis as well as its mobility. The patient moves above and below the implant. All is good. Unfortunately, all is not so good. This marvel of modern medicine may be the appropriate treatment of choice for some patients, but it is being severely overutilized and the results are far from stellar.

According to Trang, et al in Spine, “This Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a WC setting is associated with significant increase in disabil­ity, opiate use, prolonged work loss, and poor return to work status. The article goes on to say that “If we do this surgery you have a 1 in 4 chance of a repeat surgery, a 1 in 3 chance of a complication, and 3 in 4 chance of never working again.”

Dr Timothy Flynn, a Fellow of the American Academy of Orthopaedic Manual Physical Therapists, points out that the surgical decision-making process is often heavily influenced by the enthusiasm of the performing surgeon – Redirecting Our Enthusiasm. This is much like a mechanic telling you that you need your transmission replaced and you have no idea if that’s the best solution to get your car back on the road. Flynn suggests that patients need a more objective resource they can depend upon to inform them of the most effective, least risky, and least expensive solutions to their problems of back pain. This can certainly be extrapolated into other elective orthopedic surgeries, as well.

Before you make any rash decisions, speak to your primary physician and consult your physical therapist. They may have some information that you need to hear……….

Fear the Triathlon Swim

When I was 16 my family went skiing in the Alps. At Mont Blanc in Chamonix we took a gondola over a chasm that must have been over 300 feet below. I had an uneasy feeling in my stomach. I was a little scared, uncomfortable. My mother, on the other hand, was horrified. She was hyperventilating, crying, unable to control her emotions. There really was very little to fear. The situation was very controlled, but those thoughts were the furthest from her mind. Fear had taken over. My brother and I laughed at her and she laughed a little too, then she took a few deep breaths and she was able to convince herself that all would be OK.

A few years ago a friend of mine was participating in local triathlons with his father and brother. He repeatedly asked me to get involved. “You would love them. They’re so much fun. You’d be great at triathlons.” At the time I was just running. I could barely swim and I didn’t own a bike. It all sounded like a lot of fun, but i was horrified of the idea of swimming more than the length of a pool. The thought made me uncomfortable and I’d just block it from my mind. I wasn’t doing a triathlon – not possible. As I neared 40 years old, my body had broken down some. Injuries had taken their toll. Competitive soccer became too risky and I’d lost a couple of steps from my not-so-fleet feet. Running marathons, particularly training, was a brutal endeavor, wearing on my joints; the same ones repeatedly. I needed a new challenge.

Another friend of mine tried to coax me into triathlons 2 years ago, but once again that fear of the water reared it’s ugly head. I attempted to register for the 2009 NYC Tri, but didn’t exactly give it my all. I took my time with the forms and ended up getting shut out. It took another year for me to get motivated, but in 2010 I made sure I got my paperwork in and I was entered in the 2010 NYC Tri. I had no idea how I was going to do it, but I knew I would.

I was confident in my cycling and running, but I knew swimming would be my bugaboo. Now fear is a powerful force, perhaps stronger than any other of our emotions. It makes us do irrational things, things we would never consider otherwise. I had this idea that I was going to just wing it and complete the swim without any training. Instead of facing my fear head-on, I was shying away from it, perhaps hoping it would go away. My brother in-law questioned me on my thinking and suggested that I would regret ruining my entire event if I wasn’t prepared for the swim and he actually had no idea how pitiful my swimming was.

He was right, though, and when I first got in the pool, I could barely do 50 meters. My swimming, and my survival techniques gradually improved in the last 2 months leading up to NYC. I could manage about 1000 meters in the pool with a combination of freestyle, breaststroke, and backstroke. That barely prepared me for the big dance. On July 18, 2010 I got into the Hudson River at 100th Street with about 100 men in my age group and I steadily fell behind the pack. I looked up, completely breathless after 100 meters. I was alone in the river. No swimmers around me, a 25 foot wall to my left, and about a mile of river between me and New Jersey to the right. All of my fears were now my reality. I was frozen in place with no escape. I couldn’t scale the retaining wall, I couldn’t go back – the next pack of swimmers was already descending on me, and I couldn’t see the end of the swim. It could have been 25 miles away. New Jersey might have been closer. I did the only sensible thing – I panicked.

Just like we had laughed at my mother, I laughed at myself. That calmed me a bit and then I took a few deep breaths and talked myself off the ledge. When I looked around again, I realized I was floating down the river without any effort. There was a significant current pulling me downstream. I did a little breaststroke with my head out of the water and struggled like that down to the pier at 80th Street. I never resumed a normal freestyle stroke and never actually got comfortable in the water that day. I did survive, despite having 1 of the slowest times in the field.

I emerged from the Hudson coated in a layer of black silt and completely exhausted. It took me 10 minutes to catch my breath, but I recovered fairly well and performed respectably in the bike and run segments. Overall, I consider my first triathlon a success. I overcame 1 of my biggest fears, I completed 1 of the toughest athletic events my home town has to offer, and I set the stage for my triathlon career. Despite my anxiety, I had a lot of fun that day and I will be back in 2011.

4-Hour Body – Fit or Fail?

Over winter break I spent every spare moment that I wasn’t chasing tennis balls off my kids rackets to dig deep into Tim Ferris’s new lifehack guide, The 4-Hour Body. The book is touted as “An Uncommon Guide to Rapid Fat-Loss, Incredible Sex, and Becoming Superhuman.” I must say that each of these topics is of interest to me and I’ve been doing my best to follow the guidelines that Ferris has outlined. I have not exactly followed every directive to an exact degree, but I’ve used the book as a roadmap for many of my present endeavors.

For example, the chapter entitled “From Swimming to Swinging” includes a section called “How I Learned to Swim Effortlessly in 10 Days.” Now it should be noted that Ferris appears to be a very fast learner. He is a Princeton grad and he mentions earlier that he tied the gym record for single-session improvement of his vertical jump with the NFL Combine coach that he worked with for the book. So it may take the average person 12 or 15 sessions to pick up all of Terry Laughlin’s techniques of Total Immersion swimming that Ferris learned from Chris Sacca. I’ve watched Laughlin’s DVD and I’m currently working on TI so that I have some energy left for the bike and run in my future triathlons. I’ve improved my comfort in the pool every time I’ve swam since, and I’ve decreased my strokes per lap from 25 to 22. Swimming is more fun and relaxing for me already and I can’t wait to work on my technique to continually improve.

On the flip side, I haven’t had as much success with some of the data tracking that Ferris encourages in order to benchmark and track progress. I’ll admit it, I occasionally fudged measurements and results in Chem lab back in high school. I’ve never been a stickler for minutiae and I tend to live by the Schroedinger’s Cat principle that if you are measuring it or tracking it, then you are affecting it. So I got my self a FitBit, a small clip-on device that you put on your belt and it measures your activity, including walking, sports, sleep, etc. Cool, I was a self-quantifier – for about a minute. Sure enough I got home after my 6th day with my FitBit….without my FitBit. It must have fallen off during the day and I never saw it again. Fail.

I continue to follow the word of Mr Timothy Ferris – working on my 4-hour body. Some other products and ideas from the book that I’ve tried and stuck with so far are:
– Slow-Carb Diet – love my binge day
– Reading The Black Swan by Nassim Nicholas Taleb
– Using kettlebells in my strength training workouts
– Regularly taking Athletic Greens
– Pose Method of Running
– Drinking GENr8 Vitargo S2 supplement after workouts

It’s been an awesome journey so far…..

A Pain in the Bronx

If you hurt your back, shoulder, knee, or hip shoveling snow the past few weeks, you are not alone. The volume and weight of the snow from the past few snow storms has put a huge strain on many bodies here in the Bronx. Luckily for you, in New York state you do not need a referral to receive treatment from a physical therapist. If those aches and pains are keeping you down or just won’t go away, contact a PT and get the treatment you need to get you back on your feet.

This winter is not going away fast, there may be more snow to shovel soon and there’s plenty of snow for skiing and sledding. So get to a PT and get yourself back into shape for outdoor winter fun.