By Michael Weinper, PT, DPT, MPH, President, PTPN
With research showing that early and appropriate physical therapy can prevent unnecessary surgeries and lead to faster recovery, workers’ compensation care managers may ask “Goldilocks” questions about what’s “just right” when it comes to PT: “How do I determine the correct amount, the best providers, and the right timing of PT services for my injured workers?”
These five guidelines will help workers’ compensation managers make the right decisions for the best use of PT:
- Selecting providers who measure and report treatment outcomes.
- Getting a functional assessment at the outset of the case.
- Developing individualized treatment plans.
- Selecting providers so as to avoid conflicts of interest that lead to overtreatment.
- Getting a quick and appropriate referral.
1. Choose the “A Team.” In workers’ compensation, there is agreement that high-performing clinicians are the key to achieving better outcomes. In recent years, data mining and technology have enabled workers’ compensation companies to measure the actual outcomes of cases managed by individual physicians so that payers can identify and channel patients to those high performing doctors. Now outcomes measurement has come to ancillary services, starting with physical therapy.
PTPN, the nation’s first network of rehabilitation professionals in private practice, pioneered the measurement of treatment outcomes in PT, becoming the first organization of its kind with a mandatory third-party outcomes measurement system. PTPN also developed the first “Pay for Outcomes” program in physical therapy. Therapists are evaluated on several quality measures collected through PTPN’s Outcomes Program, Quality Assurance Program and Credentialing Program. Providers qualify for bonus reimbursements from payers by meeting criteria that demonstrate excellent patient outcomes and lower-than-predicted visits. Rewarding the providers who rank highest in these categories –the most efficient providers – saves insurers money on a per patient basis even when higher reimbursement is paid per visit.
And, pay-for-performance systems utilizing these outcomes management programs are working. Of PT offices participating in such programs, more are qualifying for incentives as the programs move from year one to year two – indicating that therapists are working harder to achieve better results to earn the incentive payments.
2. Start treatment with functional status measurements such as injured workers’ ability to perform their job duties and other daily functions. PT providers should measure and report functional status at the beginning of treatment, during treatment and at discharge, to track progress and identify when the employee’s level of function is right for a return to work. The best measurement systems use scientifically validated tools comparing progress to national benchmarks, and are analyzed by a third party – i.e., the providers aren’t measuring it themselves.
3. Provide individualized treatment plans. Rand Corporation researchers have found that factors such as age, gender and severity of injury effect return to work, so the best medical care takes an individual rather than a global approach to what treatment is best for each patient1. High-performing providers use treatment goals and outcomes measurement tools that are risk-adjusted for the specific condition of each employee, rather than one-size-fits-most treatment guidelines or diagnostic categories.
4. Avoid over-utilization stemming from conflicts of interest in office ownership. In addition to overall performance of the PT provider, another factor to consider is the ownership of the PT office. Research shows that physician-owned therapy offices have more visits than those that are independently owned by the PTs themselves2. It seems that physicians who own the PT offices providing services tend to refer to them more often, perhaps even when PT is not needed. Also, the therapy visits may continue beyond the point where they are clinically needed in physician-owned settings3.
A study by the Florida Health Care Cost Containment Board found that the mean number of physical therapy visits per patient was 43 percent higher in physical therapy facilities owned by physicians than in independent facilities4. Another study in the Journal of the American Medical Association revealed that visits per patient were 39 percent to 45 percent higher in physician-owned clinics when compared to therapist-owned clinics. Both growth and net revenue per patient were 30 to 40 percent higher in facilities owned by referring facilities5.
Finally, a William Mercer study for workers’ compensation patients in California revealed that patients seen by physicians with ownership interest in physical therapy services received referrals for physical therapy 66 percent of the time while patients seen by physicians without ownership interest in PT services were referred 32 percent of the time. The difference in volume of referrals resulted in $233 million in services per year for economic rather than clinical reasons6.
Another difference in practice patterns associated with ownership is the amount of time spent with patients, and the level of training of the individuals who treat the patients. The Florida study found that providers in physician-owned offices spent less time with each patient, and that assistants are substituted for licensed therapists more often in physician-owned facilities. Lest these facts be interpreted to mean that there is a cost savings with this approach, consider that provider profiling data shows that using more lower-level staff in correlation with more visits which replaces any short-term financial gains an employer or payer may experience with higher costs in the long term.
In the face of this evidence, the office owned by the physical therapists proves to be the best choice for PT referrals. Such offices have no conflict of interest in ownership that may drive up utilization and reduce quality of care. They are not incentivized to create additional income for physicians or increase physician revenues. Also, PT-owned offices deliver 62 percent more functional improvement for each dollar spent than the national average, according to an independent outcomes management company.
5. Streamline appointment setting for fast and appropriate referrals. For expedited return to work, medical care must be provided promptly. Since early therapy intervention is linked to lower medical costs and better outcomes, look for a free appointment-setting service for the initial appointment to facilitate immediate intervention, as well as requirements for scheduling new patient visits within a few days of referral.
Resolving the Goldilocks syndrome for appropriate physical therapy services is possible in workers’ compensation. The key to achieving superior outcomes is bringing in physical therapy early in cases with musculoskeletal components for faster recovery, fewer interventions, and lower costs. Performance and results are optimized by the selection of PT providers who measure outcomes, are therapist-owned, can facilitate fast referrals and appointment setting, and perform early functional assessment and individualized treatment plans.
By following these guidelines, workers’ compensation payers will realize the true value that physical therapy services can bring to the recovery of an injured worker –in both earlier return to work and lower costs per case.
About Michael Weinper
Michael Weinper, PT, DPT, MPH, is president and founder of PTPN, the nation’s premier network of independently owned physical therapy offices, and is a nationally recognized leader in the physical therapy profession. He is also the owner of Progressive Physical Therapy, an independent outpatient physical therapy practice with four locations in Southern California.
PTPN is the nation’s premier specialty network of rehabilitation therapists in independent practice. It has led the rehabilitation industry in pioneering national contracting and quality assurance programs since 1985. The network has nearly 1,000 provider offices (including physical, occupational and speech therapists) in 23 states. PTPN contracts with most major managed care organizations in the nation, including insurers, workers’ compensation companies, PPOs, HMOs, medical groups, and IPAs. All members of PTPN must be independent practitioners who own their own practices. For more information on PTPN, contact Stephen Moore at 818-737-0246 or [email protected], or visit ptpn.com.
1 Seabury, S, Reville, R., Williamson, S., McLaren, C., Gailey, A., Wilke, E. & Neuhauser, F. (2011). Workers’ Compensation Reform and Return to Work. California: RAND Corporation.
2Mitchell, J., Scott, E., “Physician Ownership of Physical Therapy Services: Effects on Charges, Utilization, Profits, and Service Characteristics,” Journal of the American Medical Association, 1992
3Swedlow, A., Johnson, G., Smithline, N. & Milstein, A. (1992). Increased Costs and Rates of Use in the California Workers’ Compensation System as a Result of Self-Referral by Physicians [Abstract]. New England Journal of Medicine, 327(21), 1502-1506.
4State of Florida Health Care Cost Containment Board
5Mitchell, J., Scott, E.
6Johnson, G., Swedlow, A., “Medical Referral-for-Profit in California Workers’ Compensation,” unpublished addendum to the authors’ 1992 article, based on course notes from their presentation of findings at a physical therapy symposium, January 1992