How to Improve Patient Adherence for Physical Therapy

In my first blog post, “Patient Adherence: Understanding Why We’re All Bad at It,” I discussed the main reasons why patient adherence remains such a difficult challenge for the majority of clinicians. Here’s a list of the most commonly used patient excuses to recap:

• I forgot.
• I don’t have time.
• I don’t know why I need to do it.
• Exercise hurts.
• I’m not in pain right now.
• I don’t trust doctors.

Sound familiar? While each of these reasons is most certainly amenable to change through regular methods of patient and behavioral management, these solutions require extra work, time, and energy on the healthcare providers’ part—resources that most don’t have in today’s business climate.

So, what can we do to increase adherence?

After previously introducing the unfortunate reality that adherence to medical care is not amazing regardless of the context in which it’s observed, what is the obverse of that? Answer: In literally every facet of health care, one of the most effective and best-studied interventions that change the nature of medical care is (drumroll please)… 

Text message reminders.

Yes, really. It’s not particularly exciting, but it has substantial and broad evidence of benefit. 

Reducing Non-Compliance with Text Reminders

SMS reminders for appointments or medication usage have been studied in a marvelous constellation of contexts—one review included more than 160 separate studies of text message interventions, and the strong majority of them indicate the simple truth that reminders are effective (and sometimes, more reminders are more effective than fewer).

Reminders for vaccine appointments, follow-up appointments, prescribed exercises, medication usage, and refill reminders—they all seemed to work because people forget irregularly scheduled events. 

If you’d like to see PT-specific studies:

• This one by Chen et al. (2017) produced a fairly robust increase in functional outcomes for treating adhesive capsulitis (i.e. better range of motion at the shoulder), and 
• This one by Taylor et al. (2012) managed to reduce PT clinic non-attendance rates from 16% to 11% using single text message reminders.

Building Trust With Patients

Slightly more abstract, but just as important to patient compliance is trust. Now, trust is difficult to study, but there are well-established elements to understanding it. One is reducing information asymmetry, presenting a healthcare professional as a handy conduit of all relevant information until a mutual understanding of a treatment state is achieved. Another is person-centered care focus, although this is largely done quite well—physical therapists are forced into participative or person-centric treatment in a way that, say, surgeons, are not. 

Both of these are interactive by definition. Trust and its obvious component pieces (relationship-building, communication, etc.) come from more contact with patients.

Solving Adherence Problems with RTM

So, we have established:

• Reminders work; and
• Trust development comes through interaction.

Maybe with these in mind, CMS revised the CPT code schedule beginning in 2022, and made remote therapeutic monitoring (RTM) codes available for billing.

In 2016, Sakallaris et al. wrote:

Payment for most services is authorized only when the patient's problem exceeds a diagnostic threshold; preventive or self-care is not highly reimbursed if at all.

It seems this environment is changing somewhat. After unbundling CPT code 99091 in 2018, doctors were allowed to bill for “the collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver.” And while this may not qualify as “preventative care,” it is certainly available for physicians to help build the skills that directly lead to it, like self-efficacy. In 2022, PTs were accorded the same ability.

It is now possible for PTs to bill for:

1. Setting a patient up with a remote therapeutic management platform that allows them to record therapeutic data from home (98975),
2. Retrieving data from patients if that data is returned for 16 or more of every 30 continuous days during an episode of care (98977), and
3. Every 20-minute interval of monitoring and interpreting that data, including mandatory remote patient interaction, within a calendar month (initial 98976, repeat 98977).

Besides this representing a new source of revenue for PTs, this also provides a sterling opportunity to simultaneously remind patients of the parameters of their success and develop trust through an ecosystem of continuous, even daily, investments in self-management.

Now, this is not an admonishment to complete home exercise programs, although RTM and HEP could be directly related (if you could monitor an HEP while it was being performed, and it was correctly reported, it could certainly qualify as RTM). But rather, it incentivizes both patients and providers to participate in mutual information recording and sharing. 

Take the previous study (Chen et al.) of the frozen shoulder, and imagine that rather than just receiving a reminder to participate in an exercise session, the core components of that activity were funnelled in near-real-time back to you. You would know when participation was dropping off, what progress was being made, and have a conduit for communicating the expectations of both. It would also provide you with better information for more accurate goal-setting, and enable you to adjust said goals as treatment progresses.

While this is powerful, there is one more element of patient care it also manages to address.

Beware the False Consensus Effect

If you’re a PT, you train people how to be active every workday. Your colleagues are PTs and many of your friends are probably PTs. Those of you I know are also active people—I know PT powerlifters, PT cyclists, and PT aerobics instructors, and you probably do, too. I don’t think I know any PTs who are big fans of perpetual inactivity.

This can provide a real disconnect for calibrating your empathy with patients. Due to the false consensus effect—the idea that what you believe, do, and think are reasonably well reflected in other people—there can be a substantial disconnect between patient and provider lifestyles. A 68-year-old recently-retired woman with chronic low back pain does not have much in common with a 27-year-old recently-graduated DPT who saved up for a carbon fiber bike.

However, many PTs design exercise therapy plans for their patients that are really for their patients as a reflection of themselves. Beautifully detailed, quite long, eminently sensible, challenging, and often ignored. In truth, you are relying on patient answers (quite unreliable) and in-clinic demonstrations of progress (somewhat unreliable) as evidence that a home care plan is being implemented.

In other words, PTs have an information asymmetry, too. They have no direct evidence of whether home exercise is being performed often, well, or at all. And, albeit perhaps in a limited way, RTM directly addresses that.

Solving Information Asymmetry with RTM

As RTM tools are digital by definition, every product or service that provides it retains some ability to “reach out and touch” someone. Take these examples: A normally reliable client “checks in” with data for three days, then misses two in a row? Cue an instant text message reminder. A new client misses the first three days of measurement? Flag the data, and schedule a quick phone call. An old client never really seems to make the improvements you think would affect their activities of daily living? Send daily automated emails until the data begins to be returned. And so on.

If there are risks to this, two come immediately to mind: first, no one likes the idea of living in Bentham’s panopticon, constantly surveilled for progress and lacking in privacy. But this should be navigable with the correct expectations and the right frame, that a PT and a client exist in a mutual relationship that can be informed by the data drawn from their progress. And while it’s extra work to establish that, remember you are now getting paid for it.

Second, on a macro-level, any revenue-generating mechanism provides an opportunity for some people to do it badly. If these codes are taken advantage of and viewed as “easy money,” they will be modified or even removed. Hopefully, the data-driven requirements of RTM code monitoring will help in making sure that this powerful tool to establish a working mutual care relationship can be accessible by the profession for years to come.

PTs often feel persecuted by the decisions made around CPT codes. But this year, at least, that should really not be the case. The release of RTM codes has produced a mechanism that aligns the incentives of all parties involved in care decisions. In the inevitable march toward the digitization of everything, they feel like an excellent start.