Dana (00:16) Welcome everybody to episode six of the Future Proof PT podcast. I'm here with my wonderful co-host, Alex Bendersky, DPT. we're here to talk today about healthcare economics and specifically understanding the direct and the indirect costs of managing low back pain and musculoskeletal disorders.

And then we're going to talk a little bit about breaking down the challenges, exploring solutions to those challenges, and then how all of this relates to workforce productivity, workforce health, and where there's overlap of those topics. We're going to talk about why we think it's so important to cover the topic.

Who besides our PT/OT audience would really benefit from learning about this? it's wonderful to share information with the PT/OT, rehab community, but everything that lives in a vacuum stays in a vacuum. So how do we think about sharing that information, you know, beyond this?

And don't we hear about it more in healthcare economic circles? Why isn't this something we read about more often? And then how can we amplify this message? And we'll talk about how do we use this information? So is it for career development? Is it to help our day-to-day actual work?

is it to think about developing our own business or success for our employer's business or our own business?

Alex (01:40) Thank you, Dana. And once again, excited to have this another week of conversations and really looking forward to see how this turns out. I think first and foremost, as you were mentioning, I think it is so important to create a focus on proactive, actionable insight. And there's so much of our professional community that is being reactive or just contemplating what has already happened without being proactive about the action

change. And so hopefully these episodes lead more consumers, more of our colleagues to actually reference some of the points mentioned and apply them into their work, apply them into their industry, apply them into their daily life. And so each episode hopefully has a theme and today's episode theme is to actually

accurately label some of these concepts that have to do with healthcare economics that provide more objectivity when you're discussing impact of your intervention on healthcare consumption, but also on healthcare outcomes. And these are a little different than what we are traditionally used to, which is patient reported outcome measures, which are like.

familiar with it, about their sensitivity, about their specificity, and their detectable change. These have to do with a more global impact of healthcare economics and how they impact an individual consumer of healthcare, both in regards to extending their life, also potentially reducing the impact of the disease burden, and then also looking into a productivity matrix, which is how does an intervention

and

help an employer offset some of their reduced.

output from an individual, an employer, from this intervention. So hopefully this will be constructive and this will be informative. I think it's really great for our listeners to see how we are growing every episode and we're trying to develop. And so much thanks to you, Dana, where you are just innovating and you are exploring all of the benefits of this.

Dana (03:44) Okay, so then let's talk a little bit more about that, about why is it so important to cover this and maybe move into a little bit of the economic burden of musculoskeletal disorders.

I'll just say from, there's a lot of attention paid to certain specialty conditions, because they encompass so much of healthcare spend.

Alex and I agree, to the impact of musculoskeletal disorders in different populations when it comes to the burden of the working population. It's a great time to cover that. Alex has done some really good research about this that we thought we could dive into a

bit more today.

Alex (04:22) Awesome, yeah, definitely. And if you look into it, the first, let's discuss two concepts, the QALY and DALY. So QALY is quality adjusted life years, and then DALY is disability adjusted life years. And those are two not completely dichotomized economic concepts that have to do with the overall impact of disease burden, as well as wellness, right? So the application of any specific intervention. So defining quality, and I'll read this

to be accurate. So QALY is a measure used to evaluate the value of health intervention by considering both quantity and quality of life generated by healthcare treatment. One QALY equals one year of life in perfect health. If a person lives one year with a health condition that reduces their quality of life, now by 50 % this is equivalent to 0.5 QALY. So the formula is QALY is years of life gained times quality of life weight. So how do we look into that QALY?

think of a treatment that reduces the burden and allows someone to have a qualitatively better life.

by a certain component can be provided against the offset of the traditional life expectancy, which is a statistics that is readily available. So as a clinician, as a musculoskeletal provider, it's hard to conceptualize a QALY because a lot of time, like, and we'll review DALY, which is disability of life years, but how does my intervention, how does my episode of care actually help this specific consumer downstream?

someone

who has a lesser burden of mobility or improved mobility associated with my intervention, you are impacting QALY because mobility is going to lead to higher purposeful participation of that individual in their life even when they're away from your intervention. think of that as a downstream effect. And then I think it's so important to think of it more than just an episode of care.

Dana (06:10) I think we hurt ourselves when we think of care that we provide just in terms of that local episode. The impact that therapists can have when it comes to musculoskeletal care is far beyond that episode. But again, this is part of us being, you know.

in our own silos a bit and not necessarily thinking about the full healthcare ecosystem and how they think about healthcare spend and managing conditions and what that looks like. Right, so.

The impact of our care in the short term is only one component of what the impact of that's going to be over the course of not just that year, but future years. And I'll pinpoint that specifically to what you said about mobility.

in the value-based community when we look at risk, right? What is the risk of a population? We look at all medical factors. There's very little to nothing other than ICD-10 codes, specific ICD-10 diagnostic codes that impact how payers think about risk. And it's a fault in the way risk is looked at right now. And I predict that will change, not just because I think it will change, but there are a lot of

signs pointing to why it'll change. So important for therapists to understand where we need to come in here As payers look at risk differently as they think about, well maybe we should be thinking about things like psychosocial factors and mobility movement functional factors. And any therapist listening that's worked either in the home setting or providing PT in the home under an outpatient billing system knows that when we go in

of the home and we see the impacts of their environment, we see the risks in just their daily living and the changes that we can make and the impacts we can make by changing specific ways that someone functions, developing different habits, but also learning to consistently and correctly, as simple as using the right assistive device or finding and practicing a much safer way of getting up from a chair and modifying the

environment to make that more doable. These impacts have nothing to do with an episode and if we think of them as being episodic in nature we're missing the point of the impact potential of our professions which is on mobility and safety and you know function in general the ability to live home all of these things have a massive impact

and we should be leaning into the risk of mobility limitations and the impact that only therapists can have a demonstrable impact and change to.

Alex (08:43) absolutely. I think that's very well articulated. Think of that concept as far as when you evaluate cost effectiveness of your intervention. And so the cost effectiveness of passive care versus active care. Someone who receives predominantly passive intervention, it's not cost effective because there's obviously a price for the care itself that does not lead to enhanced function of that specific individual. So someone who's only getting, just as an example, dry

Dana (08:51) You

Alex (09:09) needling and cupping and soft tissue work. There may be a positive impact towards a suffering of that specific individual, but it may not lead to higher level mobility, better strength, better functionality, arguably, right? Because maybe it does, but these are passive modalities versus active modalities. Somebody who has a improved six-minute walk test is able to walk a longer distance, which then reflects the

Dana (09:22) Mm-hmm.

Alex (09:35) ability to navigate their environment. Someone who has improved five times the extent matrix, or time, same, like improved fluency of transfers results in a better interaction with their environment. So that active intervention has a better quality because there's a much higher cost effectiveness scale associated with these active treatments versus passive treatments. Not to knock passive treatments, but it's as an old formula where substantiating your care or care

has to be active and actionable with a little sprinkle of passive things that are customer service oriented that people like. So I think that as a clinician, when you're looking into a value of your intervention, that value and the quality of life years adjusted is that active.

treatment that results in higher level of mobility, higher functional participation, improved fitness for your environment. yeah. And then second term then is DALY, which is a disability adjusted life years. So think of it as the opposite. And again, I'll read the definition, which is a disability adjusted life year is a matrix used to quantify the overall disease burden expressed as a number of years lost due to ill health, disability or premature death. Like QALY, DALY focuses on health loss.

rather than health gained. So the formula is, Dolly is years of life lost plus years of life lived with disability.

And that you think of in terms of someone who has a natural life expectancy of 79 years, but who is a smoker, right? So then there is gonna be a dolly from that passive habit. Years of life are gonna be lost due to that habit because we know smokers will just have a shortened life expectancy. In context of...

Musculoskeletal services, DALY is the biggest matrix. So the biggest cost to healthcare consumer in United States is actually musculoskeletal disorders. The biggest DALY is your back pain, neck pain, shoulder pain. If you look into the breakdown of the cost, people have a higher loss attrition due to musculoskeletal problems. And as a provider, you may not think of it this way, but someone who has a burden of disease has a lower level

productivity has lower level functionality, and then ultimately it does result in a shortened quality of life. So how your intervention reduces DALY. So you wanna elevate quality and reduce DALY. So I'll throw it back to you.

Dana (11:56) Mm-mm.

First of all, that we need to put the word out there that physical therapy is an investment. And I mean, we have to be able to stand by it as high quality, person centered, high value interventions. If that is how we define physical therapy and we can live up to that across the board as, you know, doing the right thing at the right time and not think about the specific

fee-for-service reimbursement. It is an investment in an individual's total health and in

and in our, you know, how our payers should be valuing our care. We don't do this right now on fee for service, but we should be thinking about this as we communicate with payers or we want to get into partnerships potentially with at-risk providers. What is the return on investment, the inherent value in the highest quality evidence-based care? What do our impacts lead to? And you've already touched on some of this, but it's not just

that they can potentially live home longer and they have less pain, pain mobility being two of the very big impacts that we know we have function. But how is their mental health impacted? How does increased mobility reduce loneliness and then look at the impacts, the negative impacts of loneliness and what changes to environmental factors can dramatically reduce symptoms of loneliness? And anyone with any behavioral health disorder,

or symptoms has a higher morbidity rate. We know it's harder to help them manage their medical chronic conditions if they're lonely, if they're immobile, if they're depressed, right? So when we think about the impact and the value and the investment in high quality physical therapy, occupational therapy, we think about that. What other spend categories

Are we impacting? What are we changing about quality of life? how much are we potentially reducing and what do we have the potential to reduce to individuals living home longer? baby boomers want to age in place. Certainly Gen X wants to age in place, right? So how are our interventions?

Palatable and desirable for a public that doesn't want to live in nursing homes and assisted livings they can avoid it They have their place, but we know there is so much more that we can do to manage individuals in their homes But only if they have enough mobility Right if their pain is is managed and they feel confident that there's a system around them in place That can address needs as they come up. We are integral to that and therapists think about how you can amplify that message

think big about who would be the right receivers of that message and how, we can all brainstorm about this down the line, how do we get that message out there at a critical time when we're looking at the value of each investment made in patients under any of the third-party payer sources?

Alex (14:52) Absolutely. Think of the burden, Just the global burden of the disease, not just when it comes to suffering and pain, but also the impact on that individual, that unit. It sounds insensitive to call a human a unit, right? But that unit fitting into a larger ecosystem. we are, whether we want to believe in it or not, social units that belong to larger microcosm that we're surrounded by. And so our

fitness for that environment is reflected by the amount of energy that it takes to consumed to be part of that larger ecosystem. burden of disease, burden of musculoskeletal disorders that you're taking care of is greater than just aches and pains and discomfort and dissatisfaction with life. It affects people in our surroundings. It affects our families. It affects our employers.

It affects there's externalities, right? It's trickle-down. that now it layman's terms the butterfly effect that the complex system is has a lot of codependencies and so Dolly is that? Complexity so how does your intervention actually impact that individuals fitness for their environment or does it not? So when focusing on a value allocation now Do you want to do things that elevate somebody's quality of life or reduce the burden of disease and both are valuable?

investments of your time and energy, right? So.

Dana (16:17) elevate

quality of life, reduce burden of disease.

Love it. Those are things to really stick on. Should we move into days away from work? So I was talking a bit there about aging in place and the right, downstream spend. Some of these things are still applicable when it comes to the impact on mental health and loneliness and, or, and, know, comp, the feeling of competence and doing your job days away from work, very specific to obviously the working population, but it could also be occupations. And this is where it'd be great to bring an OT to discuss this with us.

Alex (16:23) Mm-hmm.

Let's do it.

Dana (16:49) in more depth, but why don't you, if you don't mind Alex, talk a little bit about that days away from work concept. You know, we'll talk in another upcoming episode about some of the different players in this space that are trying to impact through employer sponsored plans, trying to impact days away from work metrics and, you know, offer these services through human resources, but.

I'll let you talk a little bit about that, how it's used in healthcare economics, and then if you want to give an example, that would be awesome.

Alex (17:18) Of so think of days away from work as a total number of days an employee is unable to work due to injury, illness, or other health condition. So it reflects a productivity loss. So someone who sustains an injury and is no longer able to fulfill their primary responsibility at work, but I think for our purpose, also think of it as days away from sports, days away from...

family, days away from recreation. It's days away from anything that would normally be a part of your everyday function that you're no longer able to partake in, right? And so that goes into your absolute loss of that desired engagement. And so when somebody has an injury that is more of work-related injury, days away from work is a way of an employer calculating

an overall price of care for an individual with days away from work. There's a very interesting economic perspective of body type and body part where the injury is sustained with days away from work, as well as the second matrix, which I'll even introduce us to that, which is DART. These are way restricted or transferred, which is these are the...

Dana (18:16) Mmm.

Alex (18:26) An injury that is days away from work, but when we employ is able to perform duties that are restricted or transferred to a different role. So I guess the lamest terms is one is absenteeism and the other one is presenteeism. So days away from work versus days restricted where somebody comes in and they're walking with it. And I think the dart.

Dana (18:40) Mm.

Alex (18:48) as a matrix. It's so much more interesting to us because dark is someone who is underperforming. Either they're underperforming because their injury is being actively managed or they're underperforming because their injury is not being actively managed. That to me the reference or the parallel here is these are all the

individuals that are not consuming healthcare at the rate that they should be consuming it. So these are under consumers that are walking wounded, but if they show up to work, they may only work at 50 % of their normative productivity. Now, this is a person that only has the ability to maintain attention span for 50 % of the normal attention span because of that burden of their musculoskeletal disorder and their functionality. and this is an underreported statistics because while somebody who's

away from work because they're injured is easy to quantify. You either have someone working or not. But these with restricted or transferred, unless they are actively restricted because it's a work-related injury, for non-work-related injury, these are individuals that are not living their life to the fullest, right? So think of how other systems can impact access and accessibility to healthcare.

so that these individuals can actually reduce the burden of restricted or transferred ability from their life. someone who is an active runner, who hasn't run in a month because they have a musculoskeletal injury, but they choose to just not return to running, that's days restricted, right? Because their normal baseline is not being met. And I think the impact there is exponentially higher because these are all the people that wait for the things to become critical where they convert from DART, from days

restricted to days away, right? When the injury finally meets the threshold where I cannot do this anymore, I just have to be absent, we can calculate that. But until they get to that threshold of being unable to perform work, there's potential months, if not years, of this walking wounded phenomenon, which we are underserving, or at least under-representing, because these are the people that we can help to reduce the burden, to not have them come to the threshold where they're finally broken.

But how do we meet that? How do we advertise that to the consumer that don't wait for their problem to become so severe that you are broken, you're no longer able to engage? Come and pursue care at the medium that you are comfortable in so that your days restricted is diminished. So you are functioning at a 100 % battery life, right? Your iPhone is not at 50%, it's at 100%. And so for me, days away from work is the battery is dead, like the little red signal and then the phone shuts off.

Now, these away restricted and transfer dart is your iPhone battery depleting, but you continue to look at your TikTok videos because you're just a little bit more oblivious to the battery going to zero, right? So you just continue to engage. And that's, I think that is like something for us to pay attention to.

Dana (21:39) I love that, I love giving it these simple terms too, even though, okay, I've heard of it before, but we're not talking enough about this. The more we can figure out how to quantify the impact of not just days away from work, because like you said, more has been studied about that, but how and can we quantify days away restricted or transferred?

And if it's hard to quantify, how can we speak about it and look for ways as a community of therapists who stand to gain a lot as a profession, if we can quantify this appropriately and thoroughly and then get that message to those who care about hearing it, how much that can potentially benefit the profession and all of us working in it. I also think...

this has a lot to do with a lot of the point solutions and why employers are so interested in, you know, creating a free, you know, supplemental benefit for lack of a better word, something used in Medicare Advantage a lot is that term, but a benefit to without a copay for individuals working for an organization to tap into whenever they need to, they have found a way to sell this to by quantifying the potential benefit through data, I'm assuming.

quantifying something similar to DART and days away from work altogether and understanding that this, right, this is working. We're seeing this work through multiple different vendors, which again, we'll cover this in an upcoming episode further, but this is kind of a nice lead-in. And I just, you know, wanna say, this is really an access thing. There's so much that can be done through a point solution, but true, what is needed for a physical therapist or an occupational therapist?

to be involved in with the patient and what needs to be supported through technology. And as technology is becoming more sophisticated, it's simpler to have those either asynchronous connections or supported technology, supported treatment. What is the right combination between the various apps available and technology available?

That has not been figured out yet. Well, I'll add this link to our resources from the Peterson Health Tech Institute where they did an evaluation of not all of the various available vendors, but a handful of them. And just kind of looking, I think for therapists to just keep an eye on this and understand how third parties that are not in the PT world are evaluating the effectiveness and what many questions are still out there is...

is very helpful to, think, and I'm sure you'd agree, Alex, really great to know about so that as this potentially impact us or our profession, we can start thinking about what does this mean? How do we get this message out differently? And how do we think about, or is it worth bringing it to our professional organization to lean into more? Is I think, and you've brought this up a few times, Alex, that there is, we think of,

Well, what is it? must be our impacts directly that have improved this patient and reduced their pain or improved their function or both. what, how much was us, how much was them, you know, just getting better over time with some interventions? And what is the ideal combination of synchronous in-person remote asynchronous technology assisted set of solutions that can and should be offered, you know, at some future time it will be.

But if we acknowledge that these solutions are better in a lot of ways than what we're doing now, if we look at return on investment and try to get as pure as we can about the data and quality of life impacts, then what do we need to know about That's what's coming to my mind as I'm thinking about this through the, I don't wanna say value-based care lens, but value in healthcare spend, value in quality, return on investment, all of those things.

that are top of mind for payers and providers. And I'd love for the therapy professions to lean into more.

Alex (25:27) For sure, for sure. And I think like I'll get on my chariot a little bit, but I think if we're referencing these digital health solutions, I think the biggest disservice to healthcare industry is to actually label something as digital health versus traditional health. Nobody understands what the label means. And it's very easy to dismiss it as something I don't need digital health. I need an in-person provider. The truth of the matter is they're perfectly complimentary to each other. And so it's part of the large

Dana (25:40) Yes.

Alex (25:54) ecosystem of healthcare where you the way you consume healthcare it contains multitude of different interventions and different platforms and so these platforms need to be respected utilized efficiently and it's almost having a digital provider digital health platform that is being offered to employers and we'll probably discuss a little bit further but there's a large digital health provider that is about to go IPO so

by their own published papers, they're very proud that 3.5 % of eligible consumers are using their technology. Now, 3.5 % is beyond low for a product that is offered to you being consumed. So being proud that you were able to elevate something from 2.7 to 3.5%, it's great, except that I don't know any other service provider that is proud at 3.5 % engagement rate. That's ridiculous, right?

But part of the problem here is that in the United States at least we have very low understanding of what the threshold of failure is when it comes to musculoskeletal problems because we have no baseline testing. We have no benchmarks. Our benchmark is the presence of injury, not absence of disease. Right. So while we have a benchmark general health, we get our annual physicals. We have a benchmark for dental health. We go for dental check-ins and so we know more

more

or less year after year, whether it's been a nutrition of general health, an elevation of general health, or we're maintaining. Now, for musculoskeletal health, those benchmarks don't exist. So, musculoskeletal health now is being offered only as a point solution when tissues actually break down, when we actually need to consume care. And so, here we are. We're discussing these really impactful economic data, but how does a consumer even know? What is my threshold for consuming musculoskeletal provider services?

regardless of the medium, digital or not, they don't because we don't have, even as our professional community, a read-upon baseline threshold for these issues to be addressed. So not calling for physical therapy to have once or twice a year check-ins, although that would be nice, but more from a standpoint of as an individual, as a consumer, to understand that you have one or two or three nagging problems.

and you're managing them through over-the-counter medication, or you're managing them, or just limping along, there is a point where, on a societal level, we should have a threshold that that's when I start consuming healthcare. And that threshold is not established. So unless you know of something.

Dana (28:26) No, and what is very aligned with what first got me interested in value-based care. was this difference between needs and wants, right? Like how...

patients themselves think about needs and wants, how providers think about needs and wants, and how we try to justify what they're doing is what's medically necessary if we agree that third party payers are generally paying for what's medically necessary And you know, a simple, like you said before, a simple example, the sprinkle piece, like are we doing eSTIM and cold packs and right, the massage, the things that are kind of like add-ons that we do because we know or we think at least that it

It

helps with compliance and it helps with getting patients to show up for the next visit if they know there's something that they're going to enjoy about it, all of those things. this also needs and wants are not just in the therapy space, they're in the medical space. Are we giving people things because they ask for them? I want an MRI, but do you need an MRI and what are we using to determine that need?

And again, not a tangent, but that's why we have prior authorization that everyone hates. We caused prior authorization by doing and ordering whatever we want and not thinking about what's medically necessary. It's evolved and turned into having plenty of problems we're all aware of, but that's why we're there, because we're not good at...

understanding our role, at least for third-party payers, that we have to provide what's medically necessary and because we don't always do that, we have been subject to things like prior authorization. So anyway, roundabout way of saying...

We are not great at identifying what the needs are, not the needs that therapists should be addressing, the needs that the population should be prioritizing, the public doesn't know what they need. There's this like semi-medical, you know, kind of snake oil stuff too that tends to overlap a lot of the same symptoms of patients that therapists are ideal at treating, at least science says so and evidence says so. So it's not just that needs and wants are a challenge.

that people don't know what they really need. They know what they want a lot of times. Sometimes they don't, but a lot of times they know what they need They don't know what's going to be the best care for them. And again, where do we come in then as stewards of, you know, of payers, but of just of taxpayers, of the payer systems, where are we stewards? Because we're providing care that's needed. But it's not so simple because the public doesn't know all the time what's needed.

there are barriers like expensive co-pays and co-insurance and deductibles. It doesn't even matter if they know for sure what they need. If they think, know, again, general, if they, if a person thinks that, well, I probably need that but maybe I can put it off. That's again where we end up with problems like, well, you know, you need to get a colonoscopy every five years, whatever it is up to a certain age. Well, but can I put it off?

Alex (31:18) that it goes directly into that like creating a friction points like but I think there's there's a positive way of creating friction points so there was a

and I don't want to lie, either a Canadian or a British study that looked into that positive friction points of creating a nine month wait hold period for an individual eligible for total joint arthroplasty. And so what they found was that there was like a 50 % attrition. Musculoskeletal problems tend to be cyclical. And so somebody has a flare up, but they're like, fine, I'm ready to have my knee or hip replaced. But then you create this purposeful friction point that you're eligible for a knee replacement.

Dana (31:39) Mm.

Alex (31:56) It will run into a schedule for something that's in January 2026 and we'll see you in January. And what they found is that 50 % of people that just didn't show up for that scheduled appointment because they no longer needed.

or they no longer pursue that type of intervention. this is where behavioral economics and choice architecture actually plays a positive role where with the United States being a consumer industry and consumer nation, we provide unlimited access to some points of healthcare and that unlimited access results in high level of consumption of these low value modalities and low rates of consumption of high value modalities.

That's where you and I are both on the same page of making physical therapy a primary care profession allow a PCP PCP-behavioral health-physical therapist to be a part of the same unit to be screened and to be Let them consume resources. We're dirt cheap compared to everything else So we should probably discuss for

a couple of minutes of indirect societal cost of some of these things. So we know that there is like the same quality of life years and disability impact and the direct cost has to do with consumption of these expensive health care components. But what is the indirect cost on the global social spectrum of someone walking around with an injury that's being under managed or underserved? How does it impact

their social spectrum, their societal spectrum, their responsibilities. And can we quantify this indirect cost, right? With one interesting component, like, and this is also from, they did a study of a rate of consumption of anti-anxiety, anti-depression medications in United Kingdom. And what they found is in United Kingdom, or at least in London, I think there's a pharmacy attached to each neighborhood. And so they can really see the rate of consumption based on these

pharmacies like to obviously with none as granular as you would want but

neighborhoods that had a open body of water attached to it, like a river, a creek, or a pond, had lower rates of consumption of these antidepressant medication. And this is me getting this from one of the podcasts I listened to. I think it was Freakonomics. But if you look at it, that's the indirect cost. You have an environmental exposure to a body of water that actually has an indirect cost on your healthcare consumption, because your ability to see a open

body

and water indirectly impacts your behavioral health. I think that the reference here being musculoskeletal, there's a lot of indirect costs and benefits that we're not protecting or we're not counting into this because they're harder to quantify, right? But what do think of this?

Dana (34:32) But, you know, when I have a friend say, well, orthopedist said I needed a total joint replacement.

I'm gonna bring up someone because it's timely the fact that the new FDA, assuming Marty Makary will be confirmed as the new FDA commissioner.

You know, don't hear docs talking too much about things like variability of specialists and the different returns on investment of certain surgeons versus other surgeons. But Marty Makary, has written a couple of books. And the one that I really love, the price we pay, he talks a lot about quality variability and...

Alex (35:07) you

Dana (35:11) the various factors that impact the spend by a particular surgeon and then what their outcomes are. you know this

is a great example, right? So you can look at a hundred different orthopedic surgeons, you can look at their surgical rates, you know, for total hip, total shoulder, total knee, total ankle, and then look at the, for a similar patient with similar risk factors, then look at the spend over that year, the coming years, other factors related to morbidity and mortality, and you get a really good idea of what the big outliers are. And one way to reduce

impact of some of these outliers is to just have it be more standard that you see a physical therapist and consult with them because they're your primary care physical therapist

they help you make some of these decisions. Hopefully therapists know the data about the surgeons in the area so that if they think they may need an orthopedist to do a consult for a potential surgical candidate, you're sending them to the one that has the great data. This is happening in accountable care organizations right now.

providers at risk, they know the data and where the surgeon's around and they're trying to direct their patients to where they think they're gonna get the best consultation and the right interventions. So again, I would like to say just another positive for bringing therapists more into the primary care space, we want...

patients to have a more standardized experience where they have someone they can trust that's a provider who can help be the quarterback for that MSK care. I didn't really mean to go back to the primary care and quarterback thing, but it fits really well here, right? How do we reduce variability in surgeons? Well, don't go to the surgeons that are beyond one or two standard deviations from the mean of surgical rates. Start there. And if you have someone you can trust or a primary

care team you can work with, then you're more likely to end up in the right surgeon's office if you do need a consult. What do you think about that?

Alex (37:12) I think that fits perfectly into the saying, don't ask a barber if you need a haircut, right?

Dana (37:16) hahaha

Alex (37:16) It's inevitable that you're going to have a path dependence based on your discipline. And so there's definitely, I would say, to be optimistic, a larger contingency of medical professionals are ethical and will advocate in line of a patient. They will provide the best quality care and best opinion. But at the same time, if you're looking at a surgeon that has availability in the OR on Tuesday and Wednesday, that may skew that recommendation a little bit when you know

you still have some overhead that you have to cover from your OR time. It's the same as to steer back into our discipline. What is the likelihood of a patient being turned away from physical therapy services when they come in with a script? Just because as a professional, I have yet to see a physical therapist that readily turns away patients when they don't deem that these patients will benefit from their care. Or the same if there's a

large pressure and rightfully so just evaluate so that plan of care needs to be fulfilled. So someone has a three times a week for four weeks plan of care that someone's gonna receive 12 visits. When was the last time a therapist after four or five visits to say that I think based on your now current trajectory you're gonna do pretty well so why don't I see you again in a month but why don't you just take off the other visits. The plan of care for completion is unfortunately one of the matrix that we use to justify and to assess

quality of care we provide, but is it really qualitative when we are working to the number, not working to patient advocacy, I guess patient centeredness? So it's a tricky subject, right? Because when is somebody actually ready to receive a surgical intervention? When is somebody actually ready to complete their course of care? There's a lot of ambiguity there, unless you create a standardization, which is what the value-based care

is trying to do, which is create these achievable benchmarks based on prior cohorts or based on prior rates of utilization. I think at least it gives you some granularity because now you have some kind of essential source of truth. When you have a source of truth, it's easier to align your care to. Where if you assign that an average, a patient with this diagnosis who fits into this demographic marker consumes 7.8

visits, you are less likely to provide 26 visits, right? At the same time, if you say that someone who has a X amount of distance walked in six-minute walk test...

is less likely to benefit from joint arthroplasty because your mobility is not being compromised. That's an objective measure. If you can walk a mile in 18 minutes just because you have radiographic evidence of hip or knee osteoarthritis, it is much less likely that you need that radical surgical intervention. At the same time, then, how many surgeons are aware of these objective markers that are closely aligned with a disability and the success of procedures? And then you reference literature that shows

like and if we're just going to be on a joint arthroplasty bandwagon, 50 % of patients who go through joint arthroplasty continue to experience symptoms a year after a procedure. Not to say that it's not a successful procedure, but how do you evaluate success? A surgeon will say, prosthesis is in right place, surgery has healed, everybody's doing great. Patients continue to have complaints because not all complaints are musculoskeletal that are coming from musculoskeletal system. So how do you create that dissonance or how do you manage that dissonance?

Dana (40:32) Mm-hmm.

Alex (40:36) That's that's my sorry got away a little bit there, but that's my two cents

Dana (40:39) No,

So smart.

and needs to be called out more, I'm gonna pose a question to the audience. It's a somewhat rhetorical question. But how much do therapists really want to be considered by the full healthcare ecosystem and by patients and providers and the community at large? How many of them really wanna be autonomous if we're just filling prescriptions written by physicians as they're written as if we're a pharmacy

They're completely against one another. And then we say, I wonder why patients don't think to come to us first. Because you're filling prescriptions. yes, we need to have good relationships with our referral sources. Yes, we want to be part of a health care community and part of teams, whether they're within or around us. But to blindly accept prescriptions written by any referral source that doesn't even have a correct diagnosis on it.

Diagnosis of low back pain does not mean that they have done the clinical reasoning to determine that this is what this individual needs. It's crazy. We can't have it both ways. We can't just do whatever is written on a prescription and think that the public or physicians are going to think of us as primary providers. It's just...

Silly when you talk about what doesn't make sense you can't have it both ways do you want to have closer relationships a foundation to build from by having? Meaningful dialogues with referral sources

If we don't do that, just scrap the idea that the public or that anybody else or payers are going to think of us any differently. If we just blindly fill prescriptions, why would payers keep giving us additional if they're having to do prior off and they're basing it on just a historical filling of prescription?

We're like a vendor of physical therapy care rather than being a professional doctor of physical therapy providing one-on-one care to a patient. And there's my rant.

Alex (42:30) No, you're right on. I had the whole spiel of the difference between physical therapy as a discipline and physical therapist as a provider and how people get referred to physical therapy as a discipline. It is a complete fallacy versus people getting referred to a physical therapist.

Dana (42:37) Mm-hmm.

Yeah.

Alex (42:47) to receive services related to their musculoskeletal needs. We are the only discipline that gets referred to as the global discipline label, which like how many times do you see someone being referred, go get some cardiology. Like I think something's wrong with your heart, go get some cardiology. Or like you just don't, we're the only discipline that has a prescription that says go get some physical therapy and then we fill it. And then so few of us have enough autonomy and agency.

Dana (42:59) I know.

Alex (43:12) to question or to actually communicate because you're a professional. So you are a doctor of your profession or you are a physical therapist who is a tenured clinician with a lot of experience. Your job, your professional responsibility is to advocate for the patient and to actually provide the best available care in the time. And if there is some kind of a conflict, your responsibility is to be part of the larger healthcare system.

communicate, right? Like pick up the phone and communicate, address that other professional. A lot of times, and I will actually ask you to discuss that one of our listeners, like Cody, right? Who was actually a testament to agency in a qualified form as a professional who is acting on his professional responsibilities. But as a clinician, it is your responsibility to engage with other healthcare providers.

because it's part of the same parallel. We shouldn't treat healthcare professionals as a hierarchical system where we are physician extenders, we're physical therapists, then there's the next step, then there's the next step, and then there is a physician. That is wonderful, but that paternalistic model is one of the reasons why the healthcare consumption is so high, because there is that like a worship of a pinnacle of description, and we are just fulfilled, we fill scripts. We are physical therapists that are...

discipline, right? So maybe you want to mention a little bit about what a true agency looks like in the field from your recent experience.

Dana (44:39) You

It's just the paradox of what we say we want and what we want our professional organization to argue for. But we can't get out of the fee-for-service cycle and be treated differently and be valued by other providers in caring for patients in a way that they can trust is going to be the best thing and develop that relationship if we're just going to fill prescriptions.

I want to believe that it's changed to some degree, but frankly that's why one of the many reasons why I couldn't function in the fee-for-service system in an outpatient setting is that wasn't supported

We're going to optimize and maximize whatever we can get and well the doctor wrote the prescription and then we say why don't doctors think of us as equals and why don't patients think of us as equals? It's comical honestly and it's still happening. So you know like there's a lot of things could be true right at the same time but we can't have what we want as a profession if we keep feeding the fee-for-service cycle. We have to find

a different way and there will be prediction, there will be practices that do a much better job and providers may be individual providers that do the better job at

developing a collaborative relationship where once you start having these conversations with your close referral sources, they'll start calling you to ask you what you think about things, right? And ask for your opinion and you start to develop an organic change to how at least that one individual referral source thinks about the possibility of physical therapy. Now, if it's the only physical therapist or OT or whatever that they're interacting with that does that, they could just think, well, that's just a good

physical therapist. I never fit in the fee-for-service model. I had to find a different way to try to impact health care.

So anyway, all that to say this is a fundamental issue that you and I have both really, really resonates with us. And I think a lot of the younger therapists, you know, we'd love to hear from more of you, but starting to like, you know, catch on to this, that there's gotta be a better way to do things. And if we can consistently somehow all agree, we're going to act like the degree that we have and realize

referral is just a prescription written for therapy is just a historical way that referrals have worked but that that's separate from our professional decision making or clinical responsibility or moral and ethical. We take ethics every year, right? I laugh. Maybe this is a good topic for the states to be adding to their ethics course for next year or the next license. What is our responsibility to our referral sources and to the community at large?

Alex (47:06) Mm-hmm.

Dana (47:17) for thinking independently and communicating with our referral sources and our payers about what's best for patients

Alex (47:25) Being at the CSM, like just a little bit more than a month ago and being on a panel of these non-clinical PTs, I'm a little bit of an imposter because I'm still seeing patients one day a week. But like the panel. love it. like at this point you will have to prime me with my cold hands from that. it's

Dana (47:35) That's perfect, because you're still right in it and seeing it and getting that feedback. I'm glad you do.

Alex (47:45) The panel of therapists that attended to hear the panel, there's a simple question to ask. You're looking to leave the profession because you're dissatisfied. You've been out of school for three to five years and you just see that physical therapy may not be what you desired or what you envisioned. You have to question yourself one of two things. Are you unhappy with your job or are you unhappy in your job?

And if you're unhappy in your job, it's probably 90 % of people just aren't unhappy in their current position. Go out there and advocate, go out there and actually build a community of like-minded physicians that can become your community. You don't have to be unhappy in your job, look for a different job, but don't just look to leave the professional together because you are dissatisfied. You don't feel like you have agency. Agency is something that you build as a professional. Agency is the first time

You see a patient that's fit for a different discipline and you question their referral and you actually contact someone from a different discipline and say, I believe this is a fits your model a little bit better than my model. Or the first time you call a surgeon and you actually share your opinion to say that I believe there is some difficulty and it's okay to be yelled at. It's okay to create some conflict. And if your employer is not going to stand by you when you are doing something that's ethical,

if you, when you're doing something that's clinically evidenced, because just because there's a risk of alienating a referral source, that's when you can be unhappy in your job. That's when you can start looking for a different employer, just because you're not fulfilling that 27 patients a day matrix. But that's, I think that's the grassroots movement of a lot of young therapists, hopefully that are gonna be listening to this podcast. They need to start questioning where they are. And if they're not in a perfect fit, find a different fit.

but find something where you can be a advocate of yourself, your profession within a larger healthcare community because you are worth it, you are valuable, you actually make a difference. think, Dana, I've probably referenced you 20 times since you mentioned it, that we were like, payers don't want to see us as a value. Like it's okay for us to be undiscovered. It serves everybody's purpose to know that physical therapy is an undiscovered gem because we can just continue to be used, right? But you as a clinician,

Discover yourself, discover your true potential by creating advocacy and you will see how things start to change. That's what it takes to change. It's a voltage effect. when you have a bulb that's flickering, the more people, the more clinicians that sign on to this process, the higher the voltage, the brighter the light bulb, the more advocacy you create for your community.

Dana (50:21) We wanna create a movement.

And it didn't click when you mentioned it last week, but I know exactly what you're saying by the, are you happy not happy in your job, within your work or with your work? We want maybe our target audience. Part of it is therapists who are starting to...

feel uncomfortable with the dynamic that they did not understand was the actual dynamic when they were in school, right? They're getting their DPT, they're hundreds of thousands in debt, they come out with this doctoral degree, and then they're relegated to filling prescriptions. again, generalizing, but generally, the generalization is still true.

We want you to be part of this movement. And what does a movement look like? It means like thinking about real strategies to apply what we're saying to wherever you're working now. And it'll work better and worse in some places. I will liken it to in my days in...

the health system working in population health. did a lot of work with skilled nursing facilities. Skilled nursing, for those who aren't familiar,

you're paid per day unlike the rest of the inpatient settings. skilled nursing facilities would say, well, why should we discharge patients sooner

we developed partners. But what we were selling to them truthfully was we're looking we as the health system, the referral source to you, the SNF, we're looking for you to think about your role differently. We want you to partner with us on providing the right care.

the right education to the patient, the right transition planning, the right goal setting, the right family training, right? Discharging patients when it's most appropriate, getting them transitioned home to home health. Yes, your days per episode are going to be lower, but as you strengthen your partnership with us and we see the output of, we see how it improves quality and reduces spend

you will get more volume and yes it's hard to change referral patterns but you know as we've talked about in prior episodes you have a primary care provider practice that's in an ACO it's the they don't know to pitch this to you but you should be pitching to them I would like to be your primary physical therapist

practice,

OT practice that you use and here's what I will do for you. Here's how we're going to improve our access. Here's how we are going to make sure we're giving the right patients the right care for the right amount of time. Here's how we're going to follow up. Here's how we're going to make sure they get tucked back in with you so that you can continue your longitudinal management with them.

Physicians don't even know to ask that of therapists. We know we're capable and then we make this assumption that these practices know what we're capable of. But if all we're doing is selling this volume of service that they're not seeing the benefit of, why would they think differently? Nobody wants to work or think about things that aren't in their primary day to day, right? We don't want people to have to think about how we can help them be successful and their patients do better. And by the way, therapists be much happier.

you in their job, But that's the opportunity. Fee for service is not going to sustain us and we're going to be relegated to a smaller and smaller component of care. We have to be the ones to push back and say, here's our value to you, to patients. Here's how we help you avoid unnecessary surgeon visits, all that other stuff that we talk about. And here's how we're going to

partner with you, we're going to offer this to you proactively. therapists that are dissatisfied because what they're doing right now bothers them. It's very possible to do. We just have to build enough excitement about it so that we can kind of help coach you along a bit as you become more interested in the possibilities of this.

Alex (53:59) APTA value paper, right? So the cost benefit analysis is defined as a cost of intervention to its monetary benefit. And the cost effectiveness analysis is a cost per unit of health gained, typically expressed as quality of life years gained. So with this in mind,

Dana (54:01) Awesome.

Alex (54:14) if

we can just look at the statistics of the economic value of physical therapy in the United States, and this is an APTA sponsored paper, so take them with a grain of salt, but we are...

absolutely providing value to the healthcare systems if you look into some of these diagnoses. So the conditions analyzed based on a net benefit per episode of physical therapy care on a global scale, right? So if you look at the knee OA, the encounter, PT encounter through any episode of care, if there's a PT present versus PT absent from the diagnosis, there's a $14,000 saving from when PT is actually involved in a care trajectory. If you look into the carpal tunnel syndrome, which is crazy, the

cost of saving or the benefit per episode of physical therapy care is almost $40,000 compared to. just like someone who has a diagnosis of carpal tunnel syndrome, just exposure to physical therapy services on a global net scale leads to $40,000 in savings.

Lower back pain, the cost benefit is $4,160. Stress urinary incontinence, the cost benefit is $10,129. Vascular cladocation, $24,000. Fall prevention, $2,144. then cancer rehab, $3,500. So this is just what physical therapists is involved in a care trajectory for some of these diagnoses. The health system,

wins because they actually save money downstream. That's what you're providing. So when you're looking into some of these episodes, it's not just the episode of care, it's not just the fees that accumulate from that encounter. There's other externalities, there's other direct and indirect costs to the healthcare provider.

that are being replenished from just your exposure. So think of how valuable you are as an asset when you're taking care of some of these patients, not just from the opposite of care, but from the downstream effect. We are incredibly valuable. So if you need that advocacy, that paper is going to be included in our newsletter for subscribers. They can download this paper and they can use that as a point of reference.

to the physician, the medical community that they're proud of, to their patients in terms of advocacy. that is one of the ways for us to start to advocate is for these APTA papers to become much more readily available to the medical community, for them to be accessible to the medical community. And there's plenty of others. there's five other papers that can be referenced that show that just a significant cost impact of like, if you look at the work of Julie Fritz, if you look at the...

work of travel ends, all of them have done wonderful jobs showing the cost benefit of our work, right, of our exposure to the patient and our patient community. So, yeah.

Dana (57:00) And for therapists to think about, know, I've read this paper, probably a lot of therapists have read this paper. But I think for therapists to understand, when you read something like this and it's so clear and obvious, right? Think then about...

Well, if it's so clear and obvious, then who doesn't benefit from this? And who doesn't benefit from this are hospitals, surgical centers, specialists, surgeons. Anyone who's doing those interventions and getting those dollars that you're avoiding has no interest in this message catching on.

that you're squeezing a balloon and we're saving money. We should be taking that message and thinking about who it resonates with. it resonates with payers who are interested in getting into at-risk relationships where there's more upside for the provider that can avoid expensive care and...

There is a benefit to at-risk providers like primary care practices that are in full risk relationships where they are responsible for the dollars. This is a message you want to get to them. This message will be squashed by anyone benefiting in fee for service and who benefits in fee for service right now the most, right?

who benefits the least are specialist surgeons, hospitals and post-acute centers, right? But there's lots of people who it does benefit. It certainly benefits our profession. It benefits the general public. It benefits advanced primary care practices. And it benefits payers. we, but then we have to be able to show why our value is so much lower than it should be based upon how we're being reimbursed.

because we're impacting the avoidance of care so dramatically. But the reason we're this teeny tiny fraction

So we're like 0.5 % of spend or something because we make up so little we're we're a rounding error We're inconsequential in a lot of ways and that's on us. We can't blame payers for that We have to bring to them. Look, here's what we're capable of. Here's what the data shows. It's concrete data

And here's why you will benefit more as a payer if we have better access to these patients going to provide them evidence-based goal concordant care specific to each patient, not based on a prescription So I'm so glad this was the article that you suggested this week.

It's great to consume it and go see. I see a lot of people saying, well, see, told you so we're if we're so high value, won't know people get it because who's motivated to get it? we're not in their minds now. So take that for what it is and see it as opportunity. We're at the ground level. All this opportunity is in front of us. We are starting to get data like this. Now think about who doesn't want that data to get out there because it's not going to help them. It's going to hurt their heads in beds. It's going to hurt their surgical rates, If we

better access to more patients earlier and more commonly but we're providing the right care that we are prescribing then we share a different value and so that the economic value of PT paper was part one. Part two is how are you using it and who are the blockers and what do we need to consider

Alex (1:00:10) right on. think it's a good action statement. So just boasting the value is not enough. Make it actionable start being able to take on risk and be participating in risk and be part of a solution.

Dana (1:00:20) what's actionable? What's the takeaway? Step one is don't take any prescription at face value. Take the prescription as their entry. That's how they got in front of you Now, what does this this patient need? What does your evaluation show? What is their prognosis?

their true rehab prognosis, develop a plan of care, and then go back to that referring prescription, and communicate with your referral source and start developing a partnership. And then start communicating with them more regularly We have to break free of the fee for service cycle before we will be considered for value-based contracts. It is that simple. We have to develop a much better relationship with the

public through how we interact And then through our referral sources, whether it is specialists or primary care providers, we have to change how they think of us. And I think we haven't made much progress because we're not willing to recognize this fundamental problem we have.

if we could gather up momentum, then we can make a big difference and start to really change and have people stay in the profession longer and be more satisfied,

Alex (1:01:30) I think that's at least initially a part of the solution. I would really be interested in some of our audience providing feedback too. It would be so good for them to engage and provide their insight, right? So right now it's just two individuals using their points of view, but there's 270,000 physical therapists. There's a lot of PTs in the United States that are looking at this problem and that are discussing it.

Dana (1:01:38) Mmm.

and OTs.

Alex (1:01:57) absolutely, you're absolutely right. So how do you become a part of the solution? So for the sake of time, I will quickly mention the book recommendation, which has nothing to do with physical therapy, but it's a brief history of intelligence, evolution, AI, and the five breakthroughs that made our brains. And I guess the parallel here is if you look into that...

progress and the progression of intelligence. It's not a linear progression, but it is a progression. The worst place to be, the lowest point of development, professional development, is right now. Because if you are actionable and if you're doing something to change, the next step is going to be better than where you are. So this was just a brilliant read to see how humanity has gotten to this point. And if you zoom out of our discipline and just

into the humanity and the proper fit. There's a lot more we can do with what we have, but we can continue to develop, evolve, and ultimately we'll build a better profession, we'll build a better narrative if we're being proactive than if we're just looking retroactively into where we were. So that's my spiel for this.

Dana (1:03:02) And why should therapists

read that book?

Alex (1:03:04) I think it's important to almost look into the depth of complexity and development of who you are as a human, because that is the baseline, that's the foundation. And if you look into the reason where you are and how you are,

and some of the processes that govern your insight and your intellectual ability. You have to have the rudimentary knowledge foundation. To me, this book lays a foundation of human intelligence. So the therapists are part of the larger health ecosystem. We're the foundation. So think of how the foundation of our intelligence lays and how we got here and where we can go from here. So, and obviously, embrace technology. The book does a really good job summarizing how the next step of human

intellectual evolution is through technological integration. think of it. Using technology, not shining technology.

Dana (1:03:49) That's key. Embracing it, it's key.

I love it. Okay, this has

been terrific as usual. really, I think this is our best episode yet, if I might say so.

Alex (1:04:01) I agree every one has been a work in progress, but yes, it's always wonderful

Dana (1:04:05) it. And don't forget to subscribe to our newsletter. you have access to our resources database that we add to every week. So we're doing this for the benefit of the physical therapy and occupational therapy community and anyone else who's interested in how therapists are evolving