4 Things We Must Do to Save PT From Certain Death (as Told at the 2019 Graham Sessions)

In one of the last talks at the 2019 Graham Sessions, a young physical therapist boldly stated that in focusing solely on survival, we are actually killing the PT profession. We are clinging to a reactive—rather than proactive—mode of operation, and in doing so, we are surrendering the millions of patients we could be helping to other, less-skilled professionals. And that means we are failing them. In essence, we are standing idle, content with the status quo and blind to the winds of change, as our collective livelihood silently slips through our fingers—and our profession slowly dies. Well, consider this your alarm, because it’s time to wake up.

This was my fifth consecutive Graham Sessions, and each year, it seems like I come home with increasingly more passion and conviction. Of course, this year was especially memorable, as I had the distinct honor of delivering a “What I Believe” speech—basically, the Graham Sessions equivalent of a TED Talk. In it, I focused on solving a problem I’ve been talking about a lot in the last couple of years: only 10% of the patients who could benefit from seeing a physical therapist actually end up seeking our care. The other 90%, as I said during my speech, “have been left out in the cold to fend for themselves in a healthcare system that has been relentlessly pushing dangerous drugs and unnecessary procedures for far too long.”

With a national spotlight being cast on the opioid crisis, I believe this is our moment to step up and not only prevent millions of patients from going down a risky—and potentially deadly—treatment path, but also save our own profession from a similarly perilous fate. This is our moment, and based on the dialogue that unfolded over the course of a day and a half of insightful presentations and panels, I believe these are the steps we must take to ensure that our profession not only survives, but thrives:

1. Remove barriers to access.

This isn’t just about direct access.

We’ve fought long and hard for direct access, and I’m not trying to downplay our achievements on that front. I—like many PTs—am proud to say that some form of direct access exists in all 50 states. And I believe we should continue to push for universal unrestricted direct access to physical therapy services. The problem, though, is that even if patients can legally access physical therapists without first obtaining a physician referral, it doesn’t mean our care is accessible in every sense of the word.

The system isn’t built to support first-line PT.

In fact, I would argue that the American healthcare system—and the majority of the insurance plans that exist within that system—actually deter patients from accessing physical therapy as a first-resort treatment option. In the words of one of this year’s featured speakers, “I think physical therapy is a part of the American healthcare system that works. The problem is, you’re working in a system that’s no good.”

With high-deductible health plans becoming more prevalent, many patients face out-of-pocket costs in excess of $50, $60, or even $70 per appointment. And with most PT plans of care requiring two or more visits per week, it’s no wonder that the vast majority of physical therapy patients—anywhere from 70% to 90%—fail to complete their courses of care. There aren’t too many people out there who can comfortably afford hundreds of dollars a month in unbudgeted expenses—no matter how good the care is. So, accessibility isn’t simply a matter of law; it’s a matter of payer coverage.

How to Do It

Develop relationships with stakeholders outside of PT—and turn them into ambassadors.

So, why is the system constructed this way? How did we get to a point where patients with neuromusculoskeletal conditions are deterred from seeking out the practitioners who are the most qualified and best equipped to help them? Well, a big part of the problem is that the PT community has, for years, been too inwardly focused. We’ve painted our colleagues in other healthcare disciplines as “the enemy,” lamenting that they will never understand who we are and what we do. As a result, we’ve isolated ourselves and created a self-fulfilling prophecy: many healthcare practitioners outside of PT don’t understand our value and thus, don’t refer patients to us in the appropriate cases. Consequently, as I already mentioned, about 90% of patients who could benefit from seeing a physical therapist never do—and instead of venturing outside of our silo to potentially reach those patients, we’ve continued fighting with each other over the 10% of patients who actually do seek out our services.

To change that, we have to change our mindset around non-PT providers. Physicians, surgeons, and yes, even chiropractors aren’t necessarily our enemies. If we can build positive relationships with practitioners across the medical community—and provide them with objective proof of the results we are capable of achieving—then we can empower them to be our ambassadors. That means they’ll not only refer more patients to us—patients who, based on the conversations they have with those providers, will walk through our doors with a positive perception of PT—but also promote our value to other providers in their networks.

Empower payers to be our allies.

Historically speaking, insurance companies have not been kind to physical therapists. Reimbursement rates have fallen steadily over the last several years, and—as I already mentioned—high out-of-pocket costs have led to high dropout rates (or deterred patients from seeing a PT in the first place). And while it would be easy to blame payers for all of our financial woes, the truth is, it’s not all their fault. In fact, I’d argue that we are equally to blame.

At the end of the day, payers make decisions based on data. And most of the time, that means they’re making decisions about PT based on claims data alone—because that’s all they have. (While some payers do collect patient satisfaction data, that doesn’t necessarily correlate to clinical results.) So in their eyes, we are nothing more than a cost. They don’t have visibility into the other side of the equation—the side that justifies that cost. In other words, they don’t always have data showing the patient outcomes we achieved as a result of those expenditures, which makes it impossible for them to calculate their return on investment (ROI). And it’s our fault they don’t have that data, because we’ve not only failed to establish a standardized set of measures to collect it, but also shied away from sharing it—largely out of fear that it would be used against us.

The good news is that things are changing—albeit slowly. Payers are starting to explore the benefits of alternative care paths as a means of not only reducing long-term costs, but also limiting patient exposure to risky surgeries and painkiller prescriptions. And that effort has only intensified in light of the opioid crisis. Suddenly, insurance companies are launching their own studies to explore the benefits of so-called “conservative” therapies—including the soon-to-be-released study conducted by Boston University (and jointly sponsored by United HealthCare and the APTA) finding that UHC is spending more money on prescription pain medication for musculoskeletal episodes than it is spending on cancer treatment.

In response to that study, as validated by a panel speaker, UHC adjusted its benefits packages to waive the copay and/or deductibles for each beneficiary’s first three physical therapy visits. While that might not sound like much, it’s a start—and if we play our cards right, it could give us the momentum we need to effect other, similar changes across the entire payer landscape. But, that will require us to collaborate with—rather than combat against—our payers. It will require us to willingly track and share our data. It will require us to get outside of our comfort zones—our silos. If we are successful, though, we could reach a whole new population of patients who need us—and receive payments commensurate to the value we provide those patients.

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2. Establish a clear value prop—and band together to uphold and promote it universally.

American patient-consumers are tired of paying too much for sub-par care.

Of course, value means different things to different people, but I think we can all agree on one thing: Americans are tired of getting less out of the nation’s healthcare system than what they put into it. As one Graham Sessions speaker so succinctly put it, “We’re paying more, and getting less.” He went on to note that more than 50% of American households spend more on healthcare than they do on their mortgages, and according to some estimates, as many as 800,000 Americans go bankrupt every year due to medical expenses.

Value goes beyond cost.

Unfortunately, as noted in the previous section, PT comes across as a fairly expensive option from the patient’s perspective. Furthermore, it often takes several weeks—and multiple visits—for patients to experience substantial gains in function as a result of therapy intervention. Combine all of that with the fact that we, as humans, aren’t wired to prioritize long-term value as part of our decision-making process, and you’ve got a recipe for disaster (or at least a recipe for a system that favors costly, short-term fixes over long-term value and sustainability). But despite the cost barrier, our patients still recognize and appreciate the value we deliver—not in every single case, but often enough that receiving homemade baked goods and holiday gifts from patients is fairly commonplace in the PT world. And as one attendee pointed out, that’s pretty much unheard of in other care settings: “No one is baking a cake for their dentist for a successful root canal,” he said.

Big data is our greatest opportunity.

Now, imagine for a moment that during every single initial evaluation, you were able to present the patient with data showing exactly the kind of results that patient could expect to achieve under your care—provided that the he or she adhered to the plan. And imagine that you could confidently take that same data into your payer contract negotiations—and possibly even compare it to similar data for other care routes (e.g, surgery). I’m betting you’d be able to paint a pretty clear picture of your value to both parties: patients who want to know what they will get in exchange for the money they’re spending at every visit, and payers who what to know how much they are saving by routing their beneficiaries to PT. Suddenly, the long-term nature of our value becomes less of a barrier, because the payoff is tangible. Plus, with a big enough data pool, we can start to demonstrate our impact at the population level—something payers and legislators are very interested in right now.

Marketing is not a dirty word.

Marketing, at its essence, is all about communicating your value to the people who would benefit from your product or services the most. It’s not necessarily about manipulating people into paying for something that won’t benefit them. In fact, I would argue that that type of “marketing” is actually damaging to the marketer, because if you attract clients who won’t actually receive value from you, you’re putting your reputation at risk. But if, on the other hand, you can more effectively reach the people who will find value in what you have to offer, you’ll gain more than just the revenue you generate from treating them; you’ll raise the brand equity of your organization as well as physical therapy in general. And this isn’t an effort specific to private practice owners and therapists. To effectively promote our value at scale—to change existing perceptions around who we are and what we’re capable of—we must all get comfortable with marketing ourselves and our services every day and in every setting.

How to Do It

Collect and share data that unequivocally proves our impact.

It’s impossible to prove value without data, and it’s on all of us to contribute to the data cause. So, if you’re not collecting outcomes and patient satisfaction (or better yet, patient loyalty) data in your organization today, it’s time to start. And be mindful of the type of data collection tools you are using, because those that are proprietary to physical therapy—rather than widely used and recognized across the entire medical community—don’t pack as much of a punch (especially in conversations with payers and referring providers). Also, it’s important to share that data as much as possible, rather than holding it to your chest. Only then will we be able to draw large-scale conclusions about the positive impact we are having.

Own our role as primary care providers.

Aside from data, how can we show our peers in other healthcare disciplines that we can effectively function in a primary care role—as a patient’s point of entry into the care continuum? Easy: By using our clinical reasoning to determine which patients actually aren’t a good fit for PT—and referring them to other providers accordingly. By stepping up and owning our ability to practice wholly independently, we will usher in legislation and payer policies that support that independence. Of course, this will require some research and relationship-building on your part, but in the end, it will be totally worth it. You’ll not only contribute to fostering a better care experience for the patient, but also establish yourself as an expert. And if that patient ever is in need of your services—or if the provider you recommended ever comes across a patient who could benefit from PT—there’s a good chance you’ll add one more patient to your clinic’s schedule.

Deliver high-quality care experiences to the patients we are best suited to treat.

For those patients who are good candidates for our care, it’s up to each one of us to provide high-quality care experiences. That means using every available tool to not only select the right course of treatment and match patients with the right therapists, but also monitor the efficacy of that treatment as well as the patient’s satisfaction. The unfortunate truth is that there are a lot of therapists out there providing sub-par care—and that’s often the product of volume-driven practice models that prioritize productivity over quality (more on that in a bit). And as the old saying goes, one bad apple can spoil the bunch. In other words, when a patient has a negative experience with a single PT, it damages the entire PT brand, because at some point that patient is going to relay his or her experience to a friend or family member—or possibly even write a negative online review. When that happens, it creates a negative perception around physical therapy in general, which not only turns prospective patients away from exploring PT as an option, but also influences the attitudes of the patients who—for one reason or another—end up in our clinics.

Create raving fans.

I’ve already talked about empowering payers to advocate on our behalf, and the same goes for patients. As I alluded to above, word-of-mouth matters—the traditional variety as well as the online equivalent. The more you can get patients singing your—and your profession’s—praises to friends, family members, and online review readers, the greater visibility and respect we will all garner. So, when you identify a pleased patient—through the use of a patient satisfaction or Net Promoter Score® (NPS®) survey, for example—ask that patient to review you online or recommend you to someone in his or her personal network. Patient by patient, we can build the brand presence we’ve always wanted—and as a result, tap into the aforementioned 90%.

3. Make sure we’re ready to meet the demands of a vast and diverse patient population.

To capitalize on increased demand, we must increase supply.

Of course, increasing the demand for physical therapists won’t do much good if there aren’t enough of us to meet that demand. As I mentioned during my Graham Sessions speech, even if we were able to capture an additional 10% of the patients who need us, that would increase our collective patient load by about 11 million per year—or approximately 335 patients per practice, according to my calculations. And the more we chip away at the 90%, the more diverse our overall patient population will become—and the more diverse we must become to ensure that we are always able to provide each individual patient with the best possible care experience.

The exorbitant cost of a PT education is threatening the diversity of our profession.

Unfortunately, as one attendee so astutely noted (and as I discussed in last year’s Graham Sessions recap post), “There is no mistaking the lack of diversity in our profession.” And physical therapy’s diversity problem starts at the educational level. Why aren’t PT programs attracting students from a variety of cultural, geographic, and socioeconomic backgrounds? I could probably write a whole separate blog post on all the factors contributing to the lack of PT student diversity, but one of the biggest—as noted by several attendees of this year’s event—is the rapidly rising cost of obtaining a DPT. To put that cost into perspective, consider this stat cited by one of this year’s attendees: “PT students represent 5% of all healthcare education students. But they hold 42% of all debt. That tells you something about what is happening in our profession today.” A handful of Graham Sessions participants disclosed their own debt figures, which ranged from $100,000 to $400,000—yes, that’s with five zeros. And while some students are able to stomach that kind of price tag, many—especially those who come from disadvantaged backgrounds—simply cannot bring themselves to take on that level of financial risk.

Burnout is pushing talented therapists out of patient care.

On top of that, many new grads find themselves in employment situations where performance is assessed based on productivity—not care quality. As one young speaker told the audience, the burden of her loan debt didn’t start to affect her until she got into a clinical care situation where she was valued based on the number of units she billed—because in that type of compensation structure, she said, “If a patient doesn’t show up, I don’t get paid.” Furthermore, it disincentivizes therapists from spending “unbillable” time with their patients—even if those patients need that extra time in order to achieve the best possible results and have the best possible experience. And all of that takes away from the reason so many therapists got into the profession—and took on such massive student loans—in the first place: to help their patients live better, fuller, more functional lives.

How to Do It

Push CAPTE to require greater financial scrutiny as part of the accreditation process.

This is a big one. In fact, the APTA’s Private Practice Section actually sent a follow-up email to all attendees with instructions on how to submit a formal request to the Commission on Accreditation in Physical Therapy Education (CAPTE) to revise the PT and PTA accreditation standards in a way that would place greater emphasis on each program’s financial breakdown. As one attendee noted, “hundreds of millions of dollars” aren’t going into the actual programs, and CAPTE should be more involved in policing the allocation of tuition revenue. I would urge anyone reading this post to submit feedback here before March 13, 2019—and to continue pushing for greater financial transparency and efficiency in our PT education programs.

Introduce debt paydown incentives for staff therapists.

Another avenue to explore—especially for PT employers—is the introduction of debt paydown incentives. As one attendee noted, even putting $10,000 to $15,000 toward the principle of a loan now could exponentially reduce its overall cost. So, why not develop employee incentive programs that reward high-performing therapists with employer contributions toward student loan repayment? It’s a great way to foster employee engagement and loyalty—not to mention promote the delivery of exceptional patient care.

Continue to explore alternative educational models.

Beyond capping tuition—something that, though ideal, probably isn’t very realistic at this point—therapy leaders and educators can continue to push the envelope on the traditional physical therapy education model. Thanks to advancements in technology, it’s no longer necessary for students to complete all of their coursework in a brick-and-mortar learning environment, and by “cutting the fluff”—as one attendee so eloquently described it—PT schools can drastically reduce their program duration. In fact, as one attendee noted, “The game has actually already changed.” In other words, we’re already starting to see hybrid and alternative DPT programs, and their popularity will only grow with the cost of their traditional counterparts. According to that same attendee, “The landscape of education is going to radically shift.” And if the discussion around student debt at this year’s Graham Sessions—and across the entire PT community over the last couple of years—is any indication, that shift will be welcomed with open arms.

4. Get out of our silos—and off of our high horses.

There is strength in numbers.

Our profession is growing, and with it, so should our power—our power to advocate for ourselves at the state and national levels, and to effect the positive change we want. But that’s not necessarily happening. And a big part of the problem—according to multiple commenters at this year’s Graham Sessions—is the lack of inclusivity in PT.

We are alienating our own.

Veteran PTs are dismissive of ideas from those just entering the profession. Therapists working in emerging—though growing—niches like pelvic health still feel like they are practicing on the fringe. And long-held prejudices against physician-owned physical therapy services (POPTS) have cast therapists working in those environments as PT pariah. Furthermore, as one speaker pointed out, non-DPT therapists (i.e., those practicing with a bachelor’s or even master’s degree) and PTAs are often considered “less than” their doctorate-carrying peers. “That’s a huge segment of our profession that feels very excluded,” that attendee noted.

A rising tide raises all boats.

Often, those groups who feel disconnected from the PT community become apathetic toward profession-wide efforts to advance it. In fact, one of this year’s attendees perfectly illustrated this attitude when he asserted that direct access doesn’t matter to him as an inpatient practitioner. This could not be further from the truth. Sure, universal unrestricted direct access might not directly affect the day-to-day work of an inpatient therapy provider, but those therapists who say it really only matters to outpatient private practice PTs are viewing the issue through a very narrow lens. We have to think about the net impact of these initiatives over the long term. Direct access allows us to function as first-line providers, which could allow us to reach and heal more patients before they enter the system elsewhere, which could increase awareness and appreciation of physical therapists throughout the general patient population, which would strengthen our presence across the entire medical community—regardless of setting.

How to Do It

Find your tribe—but don’t isolate yourselves from the others.

Tribalism was a prevalent theme at this year’s Graham Sessions. It’s a concept that, as one attendee pointed out, “is huge in our culture right now”—and it’s especially huge in physical therapy. We’ve always been a fragmented profession, and I think the divisions and subdivisions of the APTA have something to do with that. But now, with the advent of social networking, therapists are gravitating to even more niche groups—which is great. When we engage with peers who work in similar settings with similar types of patients, we can all learn from each other. Unfortunately, though, this phenomenon has, in some cases, further separated and isolated us. When we retreat too far from the general PT community—when we exist on islands—we weaken the power of our profession at large.

Become an APTA member.

There was a lot of debate over the importance of APTA membership at this year’s Graham Sessions. In fact, there was an entire panel devoted to discussing this issue. While I certainly empathize with PTs who feel like the APTA is not representative of them and their interests—there’s no denying that the association’s governing bodies do not adequately or proportionately reflect the diverse makeup of our profession—the fact is, whether you like it or not, the APTA is your association. It holds the greatest advocacy power, and even if you don’t see the direct value of an APTA membership, in failing to contribute to the large-scale efforts the APTA is able to support, you are failing your profession. As one attendee noted, “If you’re out there saying you’re a physical therapist, it’s because of APTA.” Furthermore, apathy does not beget change. In other words, if you want the APTA to better represent you and your interests, you have to get involved. Change will not happen on its own.

Rally behind the causes you care about.

One of the things I appreciate most about the Graham Sessions is the amount of passion the speakers and audience members have for their profession and their individual causes. We need more of that throughout the physical therapy community. So, if there’s something you care about—whether it’s a legislative issue like direct access or a social issue like the general lack of education and awareness around PT—get involved. Seek out others with similar passions, and hold each other accountable for taking action.

Welcome change as opportunity.

Finally—and this is mostly directed at the more, ahem, experienced PTs like myself—be open to change. What worked in the past won’t necessarily serve us in the future. In fact, I’d argue that it’s not even serving us in the present. As one attendee pointed out, our culture as a profession tends to be conservative, and we often mistake valuing history for being forever committed to it. But if we dig our heels into tradition—if we fail to adapt to a rapidly evolving patient base, health and wellness service market, and technology landscape—then we will, in one attendee’s words, “find ourselves becoming extinct.”

The 2019 Graham Sessions may be over, but that doesn’t mean the conversation has to be. In fact, I’d love to keep the discussion going all year long. With that in mind, I invite you to offer your own insight in the comment section below. What are your thoughts on the current state of affairs in PT? What are our greatest opportunities in the months and years ahead?