Integrating PT First CSM 2017

1. 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

2. Disclosure No relevant financial relationship exists

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? 5.7% 5.7% 20% 20% Of GDP Of Medical Expenditures $865 $865 Billion Billion Estimated Value of the National MSK Estimated Value of the National MSK Market Market

6. MSK Overview – Patient Demand by Body Part 75% 75% Of all MSK cases are Spine, Knee & Shoulder National MSK analysis via commercial claims data February 20, 2017

7. Does Therapy Matter? % of MSK Touches 50% Therapy Therapy Clinic Visits Standard Imaging Office Procedure Advanced Imaging ED/Urgent Visits SG2 2012 Report Specialist Procedure Home Health

8. What Health Systems See 1 Emerging value-based reimbursement Chronic conditions account for of healthcare costs 75% 2 In the U.S. Growing Growing U.S. and Increasing pressure to improve while decreasing costs 1 1 Medicare patients is readmitted readmitted within 30 30 days

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

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. Hospital System vs. Healthcare Delivery System Full Service Health System Integrated Delivery System Payers Payers Medical Staff PT Post Acute Services Employed Diagnostic Center ASC Faculty Post Acute Services Employed Physicians and Outpatient Services

12. What If?? (1) Identify appropriate patient population… (5) Evaluation of current practices High volume cases/admissions  (6) Establish outcomes measures/indicators Variations in clinical practices  (7) Sequential event mapping with outcomes triggers (2) Obtain commitment from Leadership/Clinicians (8) Staff & Patient education (3) Assemble interdisciplinary team (9) Implementation of pathway (4) Data review & Benchmarking

13. PT First, A New Concept?

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

21. Perspective

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

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. “PT First” and Payers  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

25. Perspective

26. Revolutions

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 As above with 10 item questionnaire $20 copayment regardless of deductible status 8 hours training for neck and back management 12 clinics with 40 participating therapists  Screening:  Payment:  Training:  Scope:

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

35. Reload v2.0  Encouragement of Direct Access  No MD Blessing and 2ndcopayment  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

36. Just Wasn't Sexy

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

38. Medical Screening  Previous Criteria

39. Medical Screening  Opportunity

40. GHS Musculoskeletal GHS Musculoskeletal (MSK (MSK) Program ) Program Back Neck Back • 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

41. GHS Musculoskeletal GHS Musculoskeletal (MSK) Program (MSK) Program Spine (Neck/Back) Shoulder Knee • 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

42. MSK Program MSK Program For Spine, Shoulder, Hip, and Knee Pain Hip/Knee • 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 Shoulder Neck/Back

44. PCP Urgent Care Ortho Center Follow-ups @ 6 visits/30 days IF> 25-50% better Then… Refer back < 25% improvement Non MSK symptoms 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

46. 2016 “Report” Card 2016 “Report” Card Spine (Neck/Back) Shoulder Knee

48. Patient Demographics CY16 Jan 1 – Dec 31 Diagnostic Diversity: Percentage of total patients by body region 403 403 509 discharged from PT Average age = 47.4 years 79.5% are female • • • Body Region 15% 15% 34% 34% 106 106 Lumbar Cervical Shoulder Knee 31% 31% Female Male 20% 20% 36% 6% 25% 31% 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.

49. Patient Patient Outcomes Outcomes CY16 Jan 1 – Dec 31 50 ATI OrthoPath Patients 100% 60% direct to PT 85% without further medical referral 7.8 visits/patient • • Pre 13% Improvement 12% 28% 21% 90% 80% 70% • P ercent Function 60% 50% 40% 30% 20% 10% 96% Patient satisfaction 0% Neck Low Back Shoulder Knee

50. How am I doing? Total DC Patients # # of Patients with completed outcomes Avg STD Initial Avg STD Final Avg PT Visits 100.0% 250 Operational & Patient Outcomes 90.0% BUT, BUT, BUT….. . 80.1% 77.1% 80.0% 200 75.0% 74.0% 73.8% 72.6% 71.0% 70.8% 70.8% 67.7% 66.8% 70.0% 60.0% 150 59.0% 54.3% 50.0% 51.5% 49.5% 49.2% 48.6% 46.4% 44.8% 40.0% 100 43.5% 41.9% 37.7% 30.0% 15.3 20.0% 50 15.0 14.9 13.9 11.0 10.0% 10.6 9.4 8.9 8.8 8.5 96 74 86 63 71 6.9 43 26 22 15 12 9 2 8 7 6 6 5 5 4 3 1 1 0.0% 0 Benchmark - top 10% Clinician 1 Clinician 3 Clinician 5 Clinician 7 Clinician 9