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Medicare Accountable Care Organizations are challenging every healthcare provider to deliver better, safer
healthcare at lower costs Ȃ physical therapists in independent practice are rising to meet this challenge.

The dominant model confronting small, independent practices in any medical specialty is the Dzvertically
integrateddz ACO concept that requires large organizations with sophisticated management and scale
efficiencies to effectively deliver care. Yet, the lowest cost healthcare in America is delivered by small,
outpatient practices.10

This proposal will lay out the case for using a regional network of physical therapist practices in West Central
Florida to assist a hospital or physiciansǯ practice in fulfilling Medicare ACO criteria for cost and quality.

The Florida Physical Therapist in Private Practice group (FPTPP) is a non-profit organization of 72
independent physical therapist clinics from Port Charlotte to Safety Harbor, Florida.

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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Physical therapists can improve healthcare costs and improve quality by reducing unnecessary surgery,
reducing hospital re-admissions and preventing future falls in older patients at risk.

Physical therapists can also screen for common conditions, like deep vein thrombi, pneumonia and stroke,
before the need for hospitalization or emergency room visit.

Finally, physical therapists can provide decision support, including validated clinical prediction rules, for
high-volume musculoskeletal conditions like lower back pain, arthritic conditions and geriatric patients at
risk for falling down. Physical therapists are efficient providers of musculoskeletal care:
ÿ        
      
  
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The following Quality Measures can efficiently be delivered by physical therapists in the outpatient setting
using existing practice patterns. This setting should save money over having these processes of care
performed in the hospital or physiciansǯ office.
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Patient/Care Giver Experience #7 Health Status/ Functional Status (described below)
Care Coordination #21 % of Primary Care Physicians Using Clinical Decision Support
Patient Safety #2¢ Health Care Acquired Conditions Composite

Falls and Trauma

Postoperative DVT or PE
Preventative Health #31 Adult Weight Screening and Follow-up
#32 Blood Pressure Measurement
#3¢ Depression Screening
At-Risk Population/Frail Elderly #63 Falls: Screening for Falls Risk

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The burden of lower back pain and chronic arthritic conditions is not well managed in acute-care oriented
hospitals and busy primary care physicians offices:
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The volume-driven fee-for-service model has patients with musculoskeletal pain, such as lower back pain, get
an x-ray, a NSAID prescription and, after a week or more, a referral for an MRI. A referral to specialty surgery,

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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like orthopedics or neurosurgery, is often provided before the patient gets into physical therapy - which is the
outcome in 90% of these cases.

Physician initiated episodes-of-care are more expensive than those initiated by non-physicians in health
plans with direct access to both physicians and non-physicians. A study of 102,¢3Ä patients with lower back
pain seen in a direct access setting in Tennessee 2006 to 200Ä showed that non-physician care was ¢0% less
expensive than physician care.6

%. %/
A specific example is shown in the following diagram which models a successful cost-saving program
implemented at the behest of Starbucks Coffee, Inc. and Aetna Insurance in cooperation with the Virginia
Mason Medical Center in Seattle, Washington in 2006.13

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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The Starbucks Coffee Company and Aetna Insurance Company complained to the Virginia Mason hospital
system about steadily rising healthcare costs. An analysis of these costs found that lower back pain was one of
the highest drivers of the cost inflation. Looking further into the problem, company executives found that the
Dztraditionaldz path patients with lower back pain travelled was inefficient and wasteful.

The traditional path was costing the


      - 
insurance company (and Starbucks) 
j    Less than 10% of chronic $2,200 per lower back pain patient. j    10 new patients/week
spinal pain patients require 50% chronic spinal pain
complex, instrumented spinal = 5 Starbucks model PT
fusion. patients/ wk
These costs were being spent on
Assume 1 surgery per week
magnetic resonance imaging (MRI)  &No adverse events.
 & 660% increase in opioid 50% in functional status
medications.11 and X-rays early in the course of care. measures
 7.7%   in functional Also, doctors were prescribing Ä0% reduction in pain
status.11 No long-term narcotics or
5.6% risk of serious multiple, powerful pain medications pharmacologics.
complication.12 "   
0.¢% risk of mortality in 30
and follow-up neurosurgical and  
days. primary care visits. Ultimately, most (
13% risk of rehospitalization  $6Ä0 x 5 = $3,¢00 per week
in 30 days.12 of these patients were being referred ¢Ä weeks/ year
$3,¢00 x ¢Ä = $163,200 annual
to physical therapy.
( cost per clinic
 $ÄÄ,0ÄÄ per week per
surgery11,12 ? 
¢Ä weeks/ year The hospital executive redesigned  FPTPP has 72 private clinics in
$ÄÄ,0ÄÄ x ¢Ä = $¢,22Ä,22¢ the care path as described in the the West Central Florida region.
annual cost per surgeon.
 preceding diagram. The costs per
?  $163,000 x 72 =
 Assuming similar disease
physical therapy patient were $900
prevalence and uniform per episode. 1234244
neurosurgical practice
decisions:


Virginia Mason hospital realized


$¢,22Ä,22¢ x 72 =
improved patient satisfaction,
14252444 Starbucks saw fewer days lost from
work and patients had improved
functional status compared to the
Dztraditionaldz option.13

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The following data from a single FPTPP clinic can illustrate the cost savings from including a network of
physical therapist clinics in a Medicare ACO:

Eight (Ä) visits average across a range of diagnoses, ages and specialty referrals.

Average costs are $Ä7 per visit (single case).

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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Episode cost is $6Ä0, collected.

According to the projected options, physical therapy is 97% less expensive than the traditional, volume-based
model! Starbucks, Aetna and Virginia Mason have proved this model works well for patients, payers and
hospitals.

Clearly, physical therapy should be an important component of an Accountable Care Organization attempting
to lower costs and improve quality in healthcare.

·+6#    7


Private and public sources of quality measurement in physical therapy are now abundant and even small
practices are increasingly using sophisticated quality metrics embedded in electronic data collection devices
(EMRs). Further, decision rules that prompt and remind therapists to collect baseline and follow-up quality
data are being developed that will improve the fidelity of this data going forward.

A sample of the quality data includes functional status measures by body region. Percentage improvement is
calculated using the following formula:

ሺ݂‫ ݓ݋݈݈݋‬െ ‫ݏݑݐܽݐݏ݈ܽ݊݋݅ݐܿ݊ݑ݂݌ݑ‬ሻ െ ሺܾܽ‫ݏݑݐܽݐݏ݈ܽ݊݋݅ݐܿ݊ݑ݂݈݁݊݅݁ݏ‬ሻ


ܲ݁‫ ݐ݊݁݉݁ݒ݋ݎ݌݉݅݁݃ܽݐ݊݁ܿݎ‬ൌ
ሺܾܽ‫ݏݑݐܽݐݏ݈ܽ݊݋݅ݐܿ݊ݑ݂݈݁݊݅݁ݏ‬ሻ

The functional status measures are validated standards in the physical therapy industry and are recognizable
to most physical therapists with experience in the outpatient setting. The conditions measured in the
outpatient setting include the following high-volume problems:

Spine dysfunction
a Back
a Neck

Shoulder, arm and hand dysfunction

Lower limb (hip, knee and ankle) dysfunction

Foot and Ankle (sports specific)

Balance and dizziness
a Balance confidence
a Fear of falling down

Psycho-social factors
a Anxiety/Depression
a Fear avoidance beliefs/behaviors

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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Physical therapists who screen chronic pain patients for psychosocial factors and treat these patients using
proven behavioral interventions represent an emerging physical therapist practice pattern. As such, the
previous cost estimates may   the impact of physical therapistsǯ care on costs and outcomes in
the population of patients with chronic lower back pain.

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Positioning physical therapists as triage providers for many common musculoskeletal conditions, like lower
back pain, ankle sprains, shoulder sprains, twisted knees and tennis elbow, could significantly reduce hospital
systemǯs current costs.

Fee-for-service reimbursement provides limited incentives to reduce costs using non-physician providers,
like physical therapists. Medicare ACOs, however, will reward providers with 50% of the shared savings over
the three minimum time frame of the initial program.Ä

The following decision rules are in routine use in many physical therapist practices in states with direct
access and in states without direct access. Additionally, a direct access model is used in the US military
(Army, Navy, Air Force) where physical therapists practice primary triage of injured soldiers using the
following decision rules.5

1. Detection of ankle fracture without x-ray.


2. Detection of foot fracture without x-ray. 2   
 
 
 
    
 
3. Detection of knee fracture without x-ray.   


¢. Detection of spinal fracture without x-ray, MRI
   
     
or CAT-scan. 
  
   
  
 
 
 
5. Detection of pneumonia without x-ray or
laboratory tests. ï 
 
 
6. Detection of blood clot (deep vein thrombosis) v    

without Doppler ultrasound. 


  
  
   
7. Detection of strokes (cerebrovascular events) in
dizzy patient better than diffusion-weighted MRI Propo 
  
r or 
rïrï Pror
within the first ¢Ä hours. 
Ä. Detection of psychosocial factors, such as 
 


   
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depression and anxiety, can identify patients
that may tend to have negative outcomes or who
may end up becoming high cost outliers.

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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As noted in the text box, the use of electronic Clinical Decision Support rules specific to the providersǯ patient
population will qualify a provider under both HITECH Meaningful Use criteria and under the Proposed
Quality Measures for the Medicare Shared Savings Program.7,Ä

Physical therapists can detect prevalent conditions at a higher rate


than physiciansǯ unaided intuition using clinical prediction rules to
 "
screen for common, high-volume conditions like stroke, pneumonia,
Safety is defined as the
DVT, spinal and neck fracture, ankle or leg fracture, and knee fracture.
percentage of patients
with identified
ÿ     #$!     %& '
pathology referred to
"    #%($)* '" 
physicians by the use
(   +      
of the decision rule.

   ,   (  
+

       +  + 
  5

Additionally, evidence indicates that patients with more severe or distressing conditions preferentially seek
out physicians over non-physicians. Patient Dzrisk selectiondz can reduce the prevalence of insidious conditions
in non-physician clinics by 50%.6

We recommend non-physician personnel can screen patients for pathology prior to expensive imaging using
evidence-based decision rules that are more safe and less costly than routine diagnostic imaging.

j   %   -  j .   7


Two hundred and six university-level educational institutions in the United States now train clinicians as
Doctors of Physical Therapy (DPT). Their extensive education and training in musculoskeletal medicine is
more comprehensive than the number of educational hours spent on musculoskeletal medicine by most
physicians in medical school.
Dz         
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1. Physical therapistsǯ scope of practice is defined by the Florida Practice Act (FS Chapter ¢Ä6), the
Medicare Benefit Policy manual (Chapter 15) and various commercial policies and individual private
contracts.

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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2. Physical Therapists in Florida have a      that is bound by a 21-day
restriction if the patient has not previously been evaluated by a medical doctor, osteopath, dentist,
podiatrist or a chiropractor.

3. Medicare requires the physician certification of the therapy Plan of Care and subsequent 90-day re-
certifications.

¢. Most commercial plans have administrative caps that limit the   or total number of sessions
to a pre-specified maximum.

5. Independent physical therapists are not categorized as eligible professionals under the 2009
American Recovery and Reinvestment Act (ARRA) Health Information Technology for Economic and
Clinical Health (HITECH) Act.

6. Physician organizations attempt to restrict or limit expanded scope of practice of professional license
holders in state capitols across the county. Recent examples include expanded medication
prescription authority for Nurses in Florida in 2011 and Direct Access to Physical Therapists in
Illinois in 2010.

Tim Richardson, PT, Physical Therapist in Private Practice, Medical Arts Rehabilitation Inc, 506 ¢th Avenue
West, Palmetto, Florida, 3¢221. Please contact: TimRichPT@PhysicalTherapyDiagnosis.com .

C. Jason Richardson, PT, DPT, OCS, COMT, Results Physiotherapy Centers, Vice President of Clinical
Operations, 2001 Mallory Lane, Suite 201, Franklin, TN 37067.

Eric Chaconas PT, DPT, Fellow of the American Academy of Orthopaedic Manual Physical Therapists,
Instructor, University of St. Augustine for Health Sciences, 1 University Blvd, St. Augustine, FL 320Ä6.

Eric Schweitzer, DPT, MTC, Physical Therapist in Private Practice, Premier Physical Therapy Premier Physical
Therapy, 16¢0 Gulf to Bay Blvd, Suite 1, Clearwater, FL 33755.

?"
1. Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of
physical therapy. Phys Ther. 1997;77:10-1Ä.1
2. Matzkin E et al. Adequacy of Education in Musculoskeletal Medicine. J Bone Joint Surg. 2005; Ä7-A(2):pp.310-31¢.
3. Childs, J, Whitman, J, Sizer, P, Pugia, M, Flynn, T and Delitto, A. A description of physical therapists' knowledge in managing
musculoskeletal conditions. BMC Musculoskeletal Disorders 2005, 6:32.
¢. Flook, Nigel. Primary Care Physicians and Musculoskeletal Disorders -The Challenges Increase. J Rheumatology. 2006. 33; 1.

c 

A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
   !"#$
5. Risk Determination for Patients With Direct Access to Physical Therapy in Military Health Care Facilities. Moore, J, McMillian,
D, Rosenthal, M, Weishaar, M. J Orthop Sports Phys Ther 2005;35:67¢-67Ä.
6. Liliedahl RL et al. Cost of Care for Common Back Pain Conditions Initiated with Chiropractic Doctor vs. Medical Doctor /Doctor
of Osteopathy as First Physician: Experience of One Tennessee-based General Health Insurer. J Manipul Physiol Ther.
2010;33:pp.6¢0-6¢3.
7. Zywiak W et al. Meaningful Use for Eligible Professionals: The Top Ten Challenges. Computer Sciences Corporation. August
2010.
Ä. Improving Quality of Care for Medicare Patients: Accountable Care Organizations. Dept. Health Human Services. CMMS. April
2011.
9. Boissonnault WG et al. Pursuit and Implementation of Hospital-based Outpatient Direct Access to Physical Therapy Services:
An Administrative Case Report. Phys Ther. Jan 2010;90(1):pp.100-109.
10. Accounting for the Cost of Healthcare in the United States, 2007. McKinsey & Co. Available at
http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp . Accessed June 2, 2011.
11. Martin BI, Turber JA et al. Trends in Health Care Expenditures, Utilization and Health among US Adults with Spine Problems:
1997-2006. Spine 2009; 3¢(19): 2077-20Ä¢.
12. Deyo RA et al. Trends, Major Medical Complications and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older
Adults. JAMA. 2010; 303(13): 1259-1265.

&" A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. Wall Street Journal. January 12, 2007; Available at
http://online.wsj.com/article/SB116Ä571¢315517¢7Ä6.html . 

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A Value Prospect: Physical Therapists in Medicare Accountable Care Organizations (ACOs)
   
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