Ortho Primary Care-NEXT-FINAL - 2016

CREATING VALUE AS MEMBERS OF THE PRIMARY CARE TEAM IN ORTHOPEDICS: COLLABORATION,

BENEFITS, BARRIERS, & UTILIZATION Steven B. Ambler, PT, DPT, MPH, CPH, OCS Assistant Professor, University of South Florida

[email protected] @docambler

Andwele Jolly, PT, DPT, MBA, MHA, OCS

Business Director, Washington University School of Medicine [email protected]

mailto:[email protected]

mailto:[email protected]

Disclosures None

• Except…. We: • Are Nervous • Never thought this would get accepted • Would much rather have a discussion

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Objectives 1. Describe the physical therapists role in management of the

movement system and how this places therapists in a primary care role for many common health conditions.

2. Describe primary care roles for physical therapists related to conditions that may require orthopedic surgical intervention.

3. Compare and contrast the potential benefits and barriers to developing collaborative models of primary care across various practice structures.

4. Analyze potential positive and negative consequences of changes of physical therapy utilization patterns in a primary care role for patients that may require orthopedic surgery.

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The Human Movement System • The human movement system comprises the anatomic structures and

physiologic functions that interact to move the body or its component parts.

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Washington University in St. Louis, Program in Physical Therapy

APTA, BOD November, 2014

Practitioners of the Movement System • Human movement is a complex behavior within a specific context.

– Physical therapists provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based upon the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.

– Physical therapists examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.

– Physical therapists maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance

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APTA, BOD November, 2014

Practitioners of the Movement System

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General management Referral

Examination

Evaluation

Intervention

Outcome

Diagnosis

ICF

ICF ICF

PCM PCM

ICF

Prognosis

Movement System

Severity & Intensity

Severity & Intensity

Primary Care & The Movement System • RC19-15: That the American Physical Therapy Association

investigate and identify: – The roles of physical therapists in primary care teams; – The services of physical therapists which may qualify as components of

primary care delivery; and, – The current and future opportunities for physical therapists to integrate

these roles and services into practice, education, and research.

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APTA, HOD Documents, 2015

Why Physical Therapists?

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Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197-2223.

Why Physical Therapists?

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Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743-800.

Why Physical Therapists? • Continuing shift away from communicable diseases to non-

communicable diseases and from premature death to years lived with disability

People are not dying as fast…. A good, but costly problem?

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Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743-800.

Why Physical Therapists? • National Health Interview Survey (NHIS) - 2012

• A musculoskeletal health condition was associated with having an activity or participation limitation linked to a musculoskeletal condition

• A non-musculoskeletal health condition (Heart, Diabetes, Cancer) was associated with having an activity or participation limitation linked to a musculoskeletal problem

If we have shifted away from a biomedical model focused only on the health condition… Why then are the biomedical experts still managing the patient?

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Primary Care • The Institute of Medicine has defined primary care as ‘‘the

provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing within the context of family and community.’’

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Patient Centered Medical Home

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Primary Care • 53.9 million with 1 or more musculoskeletal disorders

• Per capita medical expenditure averaging $3,578

• In 2007, 164 million receive PT

• All 50 states now have some form of Direct Access

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APTA. Direct access at the state level. 2016; http://www.apta.org/StateIssues/DirectAccess/. Accessed June 1st 2016.

Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30.

http://www.apta.org/StateIssues/DirectAccess/

Primary Care Models EMERGENCY ROOM • Increasing numbers of physical therapists work in emergency

departments (EDs), because musculoskeletal complaints account for 25% to 28% of ED visits annually.

• Several hospitals have reported that utilizing PTs for musculoskeletal screenings in EDs results in reductions in unnecessary imaging, shorter wait times for referrals to orthopedic or neurological specialists, and improved patient education.

• Decreased length of stay • Increased patient satisfaction and referrals to outpatient

Peranich L, Reynolds KB, O'Brien S, Bosch J, Cranfill T. The Roles of Occupational Therapy, Physical Therapy, and Speech/Language Pathology in Primary Care. The Journal for Nurse Practitioners. 2010;6(1):36-43.

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Fleming-McDonnell D, Czuppon S, Deusinger SS, Deusinger RH. Physical therapy in the emergency department: development of a novel practice venue. Physical therapy. 2010;90(3):420-426.

Primary Care Models THE UNITED STATES ARMY MODEL • Since 1970 PTs served in a primary care role for neuromuscular conditions

(due to shortage of orthopedic surgeons during the Vietnam War) Primary Care

Physician Orthopedic

Surgeon Physical Therapist

Physical Therapist

Orthopedic Surgeon or Appropriate Specialist

OLD

NEW Murphy BP, Greathouse D, Matsui I. Primary care physical therapy practice models. J Orthop Sport Phys. 2005;35(11):699-707.

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Primary Care – Army Model • Refer patients to radiology for appropriate imaging evaluations

(radiographs, MRIs, CT scans, and bone scans) • Restrict patients to their living quarters for up to 72 hours • Restrict work and training for up to 30 days • Refer patients to all medical specialty clinics • In some cases, order certain analgesic and nonsteroidal anti-

inflammatory medications

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Murphy BP, Greathouse D, Matsui I. Primary care physical therapy practice models. J Orthop Sport Phys. 2005;35(11):699-707.

Primary Care – Army Model • Prompt evaluation and treatment for patients with neuromusculoskeletal

complaints • Promotion of quality health care • Decrease in sick call visits • More appropriate use of physicians • More appropriate use of physical therapist education, training, and

experience

↑ Efficiency ↑ Effectiveness ↑ Acceptability

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Primary Care Models KAISER PERMANENTE MODEL

Referral

Algorithm

PT

Behavioral Health

Pharmacist

Clinical Educator

NP

MD MISSION

Quality

Accessibility

Affordability

Patient

Satisfaction

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Primary Care Models – Kaiser Model

• Referral Algorithm – 18 – 65 years – Nonindustrial injury – Non-third-party liability – Afebrile – Denies chest pain – Denies abdominal pain – No seeking medication intervention – Willing to see a PT vs. MD or NP

30% seen via algorithm in

PT

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• PT Evaluation – in Primary Care Setting – Screen for refer out – PHI and examination of problem area – Consult with MD – Manual therapy if indicated – HEP instruction/ self-management – Discussion with specialist if indicated

Patient interview supplemented by self-

questionnaire

Patients tend to be younger, acute, 1st time

referred to PT, & previous episodes

resolved with first line intervention by MD or

NP

Patients w/ chronic sx’s seen in traditional

PT setting

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REQUIREMENTS

• Minimum 4 years of experience • Demonstrate working with a team • Kaiser written exam

– Differential diagnoses – Acute musculoskeletal injuries of peripheral joints – Radiological review of plain films & MRI – Laboratory values relevant to primary care – Pharmacology

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Primary Care Models DEPARTMENT OF VETERANS AFFAIRS SALT LAKECITY HEALTH CARE SYSTEM (VASLCHCS) MODEL • Duplicate the US Army Model but with broader approach

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Chr

onic

Dis

ease

Pharmacology

Dietary Modification

Exercise/Mobility

Prevention


Primary Care Models – VASLCHCS

Triage RN PT Another

Provider

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PT is paged by RN either in PCP or ED setting for neuromusculoskeletal complaint

Collaborative evaluations (team-based approach) encouraged when appropriate


Primary Care Models – VASLCHCS

OUTCOMES • Holistic Treatment • Integrated Team-based Approach • Reduced backlog of orthopedic and neurosurgery from 90days to less than

30 • ↑ Job Satisfaction • 23% ↑’d Referrals

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Primary Care Models ARMY – KAISER – VASLCHCS • Summary

– Additional competencies required beyond entry-level education – ↑ Efficiency – ↑ Delivery of Patient Care – ↓Costs – Challenges in exportability (Army & VA due to payment models)

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Benefits & Barriers: Physical Therapy PCP

Benefits Direct Access • ↓ Healthcare resource utilization • ↓ Invasive interventions • ↑ Efficiencies • ↑ Patient outcomes & satisfaction • ↑ Appropriate diagnostic

strategies

Barriers Direct Access • Reimbursement • Certification Requirements • Diagnostic Classification System

Deyle GD. Direct access physical therapy and diagnostic responsibility: the risk-to-benefit ratio. J Orthop Sport Phys. 2006;36(9):632-634.

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Benefits – Direct Access (PCP) • ↓ Costs to patients and insurance companies

– Mean allowable per episode: $152 less (PT related costs) – Mean allowable per episode: $102 less (non-PT related costs) – ↓ Ordered images

• 6 – 8% less ordered – ↓ Injections – ↓ Prescribed medications (fewer drug claims)

• 12% less took NSAIDs or analgesics • ↓ # of visits

– Mean difference of 1.1 visits… and as high as 13.4 visits (older study) • ↓ General Practitioner (GP) visits post-PT

– 29% compared to 46% within 3 months – Fewer mean hospital admissions

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Benefits – Direct Access (PCP) • ↑ Patient Satisfaction (5% higher)

– 9% more evaluated management of their condition as average or above average

• ↑ Discharge Outcomes – 2% – 15% more achieved goals – 79% compared to 60% completed course of therapy – Greater pain reduction (3points compared 2.5 points) – ↓ Mean # of days missed from work (17 days less) – No adverse events in either group – No disciplinary action or litigation variance in either group

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Benefits – Direct Access (PCP) PCP Referrals Uncomplicated Low Back Pain (N = 841) – 385 to advanced imaging, 377 to PT, & 79 to specialist or other • ↓ Cost (for PT group)

– $504 (3.8 visits) compared to imaging group $1,306 – Average subsequent costs over the following year were 66% lower

• $1,871 compared to $6,664 • ↑ Chance of surgery, injections, specialist and emergency department visits

within a year (for imaging group)

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Fritz JM, Kim J, Thackeray A, Dorius J. Use of Physical Therapy for Low Back Pain by Medicaid Enrollees. Physical therapy. 2015;95(12):1668-1679.

Benefits – Direct Access (PCP) Musculoskeletal primary care providers • ↓ radiology: 11% compared to 82% for family care practitioners

• ↓ medication: 24% comparted to 90% for family care practitioners

• ↑ return to duty-ratio for military personnel: 50% higher for PT’s

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McGill T. Effectiveness of physical therapists serving as primary care musculoskeletal providers as compared to family practice providers in a deployed combat location: a retrospective medical chart review. Mil Med. 2013;178(10):1115-1120.

Barriers – Direct Access (PCP) Do you treat patient via direct access? Percent

Acute care hospital 11.6

Health system or hospital-based outpatient facility or clinic 34.2

Private outpatient office or group practice 81.3

SNF/ECF/ICF 12.7

Patient's home/Home care 13.2

School system (preschool/primary/secondary) 63.8

Academic institution (postsecondary) 46.7

APTA Direct Access Utilization Survey Executive Summary February 2010

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Barriers – Direct Access (PCP)


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Barriers – Direct Access (PCP)


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Barriers – Direct Access (PCP) • Employer requirements that all patients have a referral appear to impose a

significant barrier to direct access. This requirement exists in all types of practice settings but is especially prevalent in both inpatient and outpatient hospital-based settings. A large percentage of respondents indicated a need for resources to help them remove hospital/institutional restrictions to direct access.

• Although reimbursement is often mentioned as a barrier to direct access, there is an indication that this barrier may be more perceived than real in many situations. The number of respondents who reported claims denials for patients seen without referral was relatively small.

• Certification requirements prior to treating patients via direct access, in those states where it is required, appear to impose a significant barrier to provision of direct access services by physical therapists

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Alternative Payment Models

Athenahealth.org

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Bundle Payment

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Bundle Payment: Comprehensive Care for Joint Replacement Model (CJR)

• The Comprehensive Care for Joint Replacement Model (CJR) is a new payment model being tested for episodes of care related to total knee and total hip replacements under Medicare. The model will be tested in 67 metropolitan statistical areas for 5 years beginning April 1, 2016.

• Programs under the model will be administered by hospitals in the participating areas, and physical therapist practices will be impacted in those areas.

• Hospitals will be at financial risk for the care provided during the initial hospital stay, plus 90 days after discharge from the hospital

APTA. Comprehensive care for joint replacement model (CJR). 2016; http://www.apta.org/CJR/. Accessed June 1st 2016.

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http://www.apta.org/CJR/

Comprehensive Care for Joint Replacement Model (CJR)

• The average Medicare payment for hip and knee procedures ranges from $16,500 to $33,000,according to the CMS

• Medicare estimates a cost savings of $153 million over the 5 years of the model

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• All Collaborators are required to engage with the hospital in its care redesign strategies and to furnish services during a CJR episode

• Collaborators may include: – Skilled nursing facilities – Home health agencies – Long term care hospitals – Inpatient rehabilitation facilities – Physician Group Practices – Physicians, non physician practitioners, and providers and suppliers of

outpatient therapy. 40

Smith H, L.; Drummond-Dye, R. Comprehensive Care Joint Replacement Model: Physical Therapy Perspective. Alexandria, VA: American Physical Therapy Association;2012.


• Hospitals are given a target cost per episode annually • Providers are still paid under their respective payment systems • Cases are reconciled post episode to determine if they have met the target

cost • Hospitals may have financial relationships with collaborators allowing

them to share risk and savings in the episode to support their efforts to improve quality and reduce costs

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• Hospitals will be placed in one of four quality categories for each performance year: Below Acceptable, Acceptable, Good, and Excellent

• Categories will be determined by quality composite score (scoring methodology on CMS website)

Quality Category Eligible for Reconciliation Payment Eligible for Quality Incentive Payment

Below Acceptable No No

Acceptable Yes No

Good Yes Yes

Excellent Yes Yes

http://www.singletrackanalytics.com/blog/15-12-06/making-sense-your-first-bpci-reconciliation

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Creating Value • Many ways to consider value… • For now: Outcome achieved and cost required • Outcomes questions still linger

• Individual • Population • Experience • Adherence to guidelines • Diagnosis • ICF

Creating Value in the Interim

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Moore JD. Unpacking Payment Bundles. Physical therapy. 2016;96(2):139-141.

One, not so new, example… ACL Injuries • Who should manage this person? • Is a knee injury in need of ongoing management? (is it preventable?) • Is this a movement problem? • What diagnosis would be primary?

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Medical Movement System ACL Tear PROM Impairment secondary

to Tissue Imp. Tibiofemoral Rotation Hip Adduction

Who should manage cont..? Medical Movement Diagnose pathology Diagnose movement syndrome (clinical

dx/screen for pathology) Determine course of care: advice and data linked to other pathology

Determine course of care: advice and data linked to movement response

Fix the tear Fix movement problem Deal with medical complications from fixing the tear

Return to function

Improve performance Prevent Injury (could start with this)

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Hui C, Salmon LJ, Kok A, Maeno S, Linklater J, Pinczewski LA. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for "isolated" anterior cruciate ligament tear. Am J Sports Med. 2011;39(1):89-98.

Stergiou N, Ristanis S, Moraiti C, Georgoulis AD. Tibial rotation in anterior cruciate ligament (ACL)-deficient and ACL-reconstructed knees: a theoretical proposition for the development of osteoarthritis. Sports Med. 2007;37(7):601-613.

What do we do now? • ACL Reconstruction

– PearlDiver Patient Record Database-United Healthcare – 2 visits pre-operatively (3-months pre-op) – 17 visits post-operatively (6-months post-op)

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Zhang JY, Cohen JR, Yeranosian MG, et al. Rehabilitation Charges Associated With Anterior Cruciate Ligament Reconstruction. Sports Health: A Multidisciplinary Approach. 2015;7(6):538-541.

Proposed post-op management at one facility

• Physical therapy should see early and the duration of care should be similar and extended – Must consider when needed the most – ~2 yr follow-up

• Frequency should vary greatly and should be based on – Criteria decided by team – Patient context

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Grindem H, Logerstedt D, Eitzen I, et al. Single-legged hop tests as predictors of self-reported knee function in nonoperatively treated individuals with anterior cruciate ligament injury. Am J Sports Med. 2011;39(11):2347-2354.

Proposed post-op management at one facility

• Improved continuity of care – Outcomes – Satisfaction

• Interdepartmental benefits – Increased revenue – Increased efficiency (less visits/more pts)

Value: Outcome achieved and cost required AND… Increased revenue in the

interim?

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Current proposal

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ACL Surgery

Surgeon f/u determined for medical care

Post-op with PT

Management of Movement

System

Case 1 • ACL reconstruction with hamstring autograft and lateral menisectomy • Started therapy 10 days post-op • 6 months • 6 visits

– 1/wk for 2 wks – 1/month to 3 months – 6 month f/u

Case 2 • ACL reconstruction with hamstring autograft and medial meniscus repair • Started therapy 5 days post-op • 6 months • 12 visits

– 1/wk for 8 weeks – 1/month 4 months

The future?

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Knee Injury

Surgery/Conservative

Management of Movement System

PT Surgeon

Entrance Determination

Barriers to implementing in the interim

• Organizational structure • Organizational environment

– Interprofessionalism • Development of procedures • Scheduling • Volume • Development of outside relationships • Initial patient education and acceptance

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Summary • Physical therapists are practitioners of the movement system and are

positioned to be the primary care providers of that system • Numerous opportunities exist for physical therapists to take the lead in care

of individuals with movement problems and to do so in a way that increases “value”

• What that value means and to whom is still a discussion that we should be participants of

• Physical therapists should be innovative in the interim to determine the multiple ways that they can participate in primary care

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QUESTIONS

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Ortho Primary Care-NEXT-FINAL - 2016

Documents

Transcript of Ortho Primary Care-NEXT-FINAL - 2016