(created by Riverside after editing the show)

Dana (00:01)
Alex and I are so excited to be back for episode three of the Future Proof PT podcast. we're so happy to hear many of you reaching out to us and letting us know how and why what you're hearing about is resonating with you. And we're happy to be bringing a little bit different perspective than maybe a lot of what we're hearing, lots of great content out there. We're nerding out on some

things that we think are great to hear about in a dialogue fashion and really welcome the feedback. Please reach out any time to us. Sign up for our newsletter. It has the email address. You can reach out to us. Any kind of feedback or recommendations, we'd love to have them. We're still obviously very new and building in public, as you all know. Today, we're gonna talk about examining the physical therapy supply chain and we're gonna look really deeply

into the physical therapy referral continuum. And we're going to talk about a journal article that Alex flagged. He's excellent at flagging articles. I comment to him all the time, how do you find something so relevant every day and post about it in such a smart way? So he flagged this article in PTJ from 2023 by Scott Peterson and John Heike called Optimizing Patient Outcomes While Maintaining Healthcare Efficiency.

outcomes, not patient outcomes. And so again, we're going to look at that referral continuum. And I thought we'd start by just having a quick summary of why this resonated with you, what you think is great for physical therapists to take away from it, and what it's maybe sparked in you to think about in a different way.

Alex (01:20)
Thank

I think things

Dana you're absolutely right it is very exciting to speak to a brilliant mind and it's really wonderful to have a bias for you or hopefully minimal bias minimal noise message just speaking about the industry and sharing insight and I think you are such a wealth of knowledge that

Dana (01:59)
Ditto.

Alex (02:00)
anything that comes out of you, like hopefully permeates and I'm so happy that we're  being discovered and is being received well by our community. So signing up for the newsletter and following the podcast and ultimately reaching out to us because I know you and I are both relatively accessible and giving us ideas. I think that the objective is for this to value to the end user and to the listener. And it provides some insight

regardless of even our conversation, that will spark an idea and that will be seeding these thoughts into people's minds that will get them to become more actionable and to start advocating for our

industry So yes, the supply chain methodology and economics of the supply chain in the PT world, right, that ever mentioned referral source and how dependent we are as a at least outpatient PT community on referrals. like especially in January, February, March, there's a shortage of referrals and so there's the

that most PT clinics experience and they panic. And then by the time it's June, July, August, there's an overflow, overflows and PT clinics then don't know where to find extra staff to supervise additional patients. And so this, I guess, imbalanced referral cycle. So going deeper into the mechanism of the referral cycle and actually understanding all of the steps of the processes into the patient being advised.

to seek physical therapy care, to a patient actually being at the door, to patient actually going through the entire plan of care to maximize on the clinical efficacy of this clinical encounter. So I think to me this article by Seth Peterson and John Heike has been...

instrumental in explaining the two main paradigms in a referral service and the perspective of a physical therapist and then also a perspective of a peer because both perspectives need to be appreciated to understand this path dependence of, again, that individual being told this is the service, this is the industry that has the highest probability of helping your clinical problem and then the peer finding the optimal way of both delivering care

and providing access to care to physical therapy services without and reducing barriers to that care being received. So yeah, let's talk about this.

Dana (04:17)
So tell me a little bit about what they studied and what their findings were.

Alex (04:22)
Yeah, so

the main findings were that there was a vast challenge in inconsistency in referral parity and referral continuity. I'm just going to read to be accurate, but the decision making in referral process was flawed. Best practices in high value referrals were not standardized. And so there is always an opportunity to enhance care delivery. There was a key finding of

Dana (04:32)
Yeah.

Alex (04:44)
really have to ensure the referrals are based on clinical reasoning and urgency to avoid the necessary delays and overuse of specialty services. was advocacy for clear guidelines and standardization of a referral framework, like the actual step-by-step process, right? And potentially, like, changing the paradigm and actually being the referral sources, starting to refer out, which we'll discuss a little bit later in this episode. And then addressing administrative challenges with the referral source. I think that, like, the boogeyman work

of prior authorization, right? We can spend probably a couple of hours just speaking about that and how that creates a real sludge, in the referral network that deters people from pursuing further care because it creates a time constraint And one of two things happen. People either become indifferent or people find care elsewhere that's not PT related. So there's a lot of opportunity, I think, to both improve the understanding

of this referral cycle, but also improve the process. And then also looking into that payer insurance company, there is a payer-based need to understand what is an evidence-based referral pathway looks like. Like what, and how do you actually...

pay for the service being received. Like we discussed , promoting value-based reimbursement

models and rewarding physical therapists for managing conditions conservatively before escalating care. in the first two episodes we touched base on the fact that we are this unrefined gem that fails to recognize itself. And so the payers are perfectly fine with us not knowing our true value because it only adds to their value. And then the payers care about reducing

administrative burdens and necessary referrals and ensuring oversight of high cost versus low value care pathways. Essentially that very large range of care provision and how some referrals essentially wind up in a setting where you just never leave versus others that have a very quick episode of care that is insufficient to actually receive anything of value. And then these are the falloffs, right? But these are the people that will continue to pursue medical care through

more expensive, less advantageous clinical services and clinical modalities that are not ours. So I think that this read itself sets a very good foundation with PT being in the middle of this referral cycle and then looking into that top layer of referrals, which is the providers, the physicians and other providers, that states they have direct access to patients just pursue care based in availability of resources. And one of the resources that's starting to emerge is that physical therapists referring to other physical therapists, PT is recognizing that there is a niche

service that they can't provide, but somebody else can. And so I think that's where we have probably an untapped opportunity to continue to specialize, continue to refine our niche care provision so that we don't have to be jacks of all trades. can have a primary care physical therapist, we can have a specialist physical therapist, we can have a...

unilateral niche provision physical therapist and beyond, right? And then lastly, I think, and this is more of my insight, I think in the states in what, 26 full direct access and 40 some form of direct access states, physical therapists that receives patients from the street, from direct access, like there's an incredibly low rate of cross referrals or PTs referring out to other professionals. And how much of that is an untapped potential of building a

clinical network with physical therapists being in the middle, your primary care provider of musculoskeletal services. And then you are the one that's triaging services to the specialist that may be needed. So we have both lack of a utilization of such services and we also have lack of understanding of what are the triggers for somebody being referred out, right? Is it a time-based trigger? Is it a complexity-based trigger? Is it an individual-based trigger that like, I don't think this is working for me, so who should I go?

next. And so PT's I don't think are both well versed and also recognize these triggers as existing and there are there is guidance towards us being this value-based factor. So that's my spiel.

Dana (08:42)
I've drawn it down five different directions to take the conversation. I may work my way up backwards from in my notes here, because that's fabulous. I can picture the therapist in the middle of the referral cycle. So that was really helpful. Thank you.

we can be primary care and specialty care just like...

physicians can be primary care and specialty care. And just like behavioral health providers, which I always see these as the triad of primary care, they can be generalists and they can be specialists. You know, your specialist who focuses on ADHD and children, behavioral health, or they focus on substance abuse, right? You need generalists and specialists. But what I worry we don't need, and we talk a lot about, I see a lot of this online is,

you can just come to me for your primary care. And I'm an independent primary care provider and that language gets dicey. I worry about us leaning too far into that and embracing the nuance, meaning we don't like when physicians, primary care docs, think that they can manage someone's low back pain alone or when they don't refer out for falls, you know, someone with balance who needs to work on gait training.

or whatever it may be, because we're the right primary care provider to be providing those services, the range of services that fit into where we're the highest value provider. So why do we then, for those who are kind of starting to think this way, I'm hoping to question that thinking. Don't mimic what we already don't like. We can be the primary care generalist physical therapist as part of a primary care team, but we cannot

under our licenses, you know, give vaccines and give the flu shot and perform an annual wellness visit and bill for it. We're all part of a health care team. Awareness is the problem. We don't have enough physician awareness that we can help them And then I go right into my value, based spiel

as soon as you know you're paid on the outcomes you care about bringing the PT into your team to manage those conditions because you're not transacting dollars you're being paid for how well you do your job. So there's those and then let me let you comment on or any thoughts on that before I a couple other things I

Alex (10:56)
 think that's very

well articulated and spot on with all of your points. I think there's an interesting thought experiment that we can play and hopefully the audience can play along with us. And that is, when was the last time when you received a patient, a referral for physical therapy, that you denied care and actually sent the patient elsewhere? When you said, thought this is not the right discipline for you, right? And I'm not talking about the extreme like rat flag

medical crisis needs to be in an emergency room or someone who has those blue flags that there's a potential abuse of industrial injury or work-related injury. I'm talking about people with yellow flags that have a much larger psychosocial involvement, but

We all know that pain tends to be this blanket term. Like you have pain, well, go see a physical therapist. So you do receive a referral. These are the patients that are much more appropriate to receive behavioral health services for their...

quote unquote, persistent pain or pain. And there are other disciplines that do really much better job than we do managing some of these cases. And yet, historically, we as PT's take everyone on. We provide care. We focus on things that may be classified as not the highest value care, because we can always find something, right? And having been, I guess, having a privilege of being a dinosaur physical therapist.

Dana (12:15)
two of them.

Alex (12:16)
Right haven't been doing this for a couple of decades now and you realize that there's companies that are actually indoctrinating these young clinicians myself was included to Look for these problems where the problems may not exist where like they coach you well look for Postural discrepancy ask what else should we be managing and to me? I think that's actually a low-value care because you are that creating a Nasir big engagement you were cutting you're helping someone

catastrophize about their state, and that does not create need, that actually creates catastrophization. again, I'm not talking about someone who potentially has three or four or five comorbidities, each one needing to be managed through physical therapy services. I'm talking about someone who has this sub-threshold

issue that they're managing and coping well with and yet we're still trying to pile on and keep them in our clinic in our industry indefinitely instead of sending them out or giving them the liberty to leave to complete the opposite of care ensuring them that we are your physical therapy resource when you need a physical therapist for your physical therapy need please come back to us because we are trying to generate revenue we are trying to provide service for fee or for for reimbursement right the taboo term so that that's a

interesting thought experiment, hopefully that resonates, is that since we're talking about referrals, how many times do you actually receive a referral that you know will be better served receiving social behavioral health services or something else that you still retain in your clinic because, you know, it's February, that your patient roster is low, you have all these openings in your schedule, so why don't we just keep you in for six weeks and we'll just work on whatever? Like, and that's, I think, how we build self-efficacies. That's how we build

self-reliance as an industry by actually acknowledging that this is not the right candidate for my care or my service or this patient will do much better with someone who has better training who's also a physical therapist but who understands this diagnosis, this treatment better than I do. But they're across the street and they work for a competitor. Should I really refer them to a competitor? Absolutely not, right? These walls, like that's a steel wall. There's a moat and there's an alligator swimming in it because that patient stays in. So that's, to me that's

Dana (14:22)
Yeah.

Alex (14:26)
has always been a disappointment but what do think about it?

Dana (14:30)
I couldn't agree more. I have a really good patient example, if you can imagine. I haven't treated full time or more than 1 % in the last five years, but I have a patient example from, this really dates me. This is from the year 2000 or 1999.

And I was treating, and I was just a couple years out of school. was treating, I had left Kessler Institute for Rehabilitation's inpatient site and I went to open one of their outpatient sports medicine clinics with, I was the staff therapist and there was a manager. It was really an awesome experience. I had a wonderful experience at Kessler altogether, And this particular therapist that I went with to the satellite was the

favorite physical therapist of a prominent orthopedic surgeon who specialized in shoulders, did a ton of rotator cuff repairs. So I had a new one of his rotator

repair patients came in, it was first day, and I went to greet them and he had classic shuffling gait, flat affect.

my license does not allow me to diagnose Parkinson's disease, but I would have bet my new home that I just bought that this patient had Parkinson's disease. So as I was doing the history and asking them about the medications they were on, and we were kind of going and having this conversation before we began the examination, it was clear to me that there was no awareness that there was some kind of a neurological disorder going on. Remember, this person just had a a rotator cuff repair.

And that orthopedic surgeon, as I got to know them a little bit, a couple weeks, and spoke to the wife and I flagged that I was concerned of some of the presentation that they should see a neurologist. And then when I was, you know, they had never heard this before. The orthopedic surgeon who was a physician had to have watched his affect and watched him ambulating and no

one had said a word to them living in these silos, right? Where you're a physician and this person clearly has some neurological condition pointing towards potentially Parkinson's disease and no one is going to pick up the phone and call their primary care or refer them to a neurologist. So remember I'm just doing things based on logic. I asked if I could reach out to their primary care doc. Of course they hadn't seen them in a long time and

you know, mentioned what I was seeing and of course extremely grateful they went to see their primary care doc and were very quickly put on treatment for Parkinson's. Again, clear, I'm not a diagnostician of Parkinson's but you know when they're signs and symptoms that you should be making a referral

putting that person within the reach of the right provider and working to help coordinate that care because it was the right thing to do. And that right thing to do should sound so obvious, but we watch it not happen in physician specialties all the time. That was one stark example, but we all know this happens regularly. It's our job, I think. I wholeheartedly agree. Whether it's to another therapist, it could be to another physician, it could be to behavioral

health, but where it's appropriate because a different provider needs to be the one to provide a service, how could we not be doing it? And I will add here as I've brought up a little bit in our first two episodes about trying to connect with primary care docs use as a way to build strength in your referrals, but also to demonstrate that you can be a value based partner. Things like, you not having had an annual wellness visit and not having

your flu shot? Have you had a colonoscopy in the last five years knowing their age range, just knowing the guidelines and then suggesting that there are some good practices in the area? Would you like me to connect you with them? That builds a natural camaraderie between you and this high performing value based primary care practice where it just becomes a natural and partner together and get into these alternative

agreements So let me stop there

Alex (18:27)
I think,

so good job on flagging that, right? And how wonderful it was for you to actually learn it early in your career. I think there's a clear dichotomy of physical therapists that have a job and physical therapists that have a career. And someone who has a job just shows up, takes care of their patients and goes home. Someone who has a career is gonna be invested enough to understand that there are limitations to your practice and there are limitations to your capacity.

Dana (18:32)
you

Alex (18:55)
And so that one size fits all just simply doesn't work And I think we also are looking at things from a slightly solid perspective because I'm in Chicago So I have this best luxury of having 300 professionals within two mile radius for me but think about the PT clinics in more rural areas we potentially you are the only health care provider in a 50 hundred mile radius, so you are going to see that overcast of

patients with questionable diagnoses, with questionable clinical presentations, I think that's where it becomes ever so important for you to build a clinical community where you become a resource, right? You are a physical therapist, but you are a professional that has a healthcare community that surrounds you, that you know that you can use. And if something is questionable, you are advocating for the patient. You are the resource for the patient and for the community because you know

Dana (19:30)
Love that phrase.

Alex (19:47)
when things just don't feel right or the things need to be looked at by someone else. In turn, being in Chicago with two PT clinics in every corner pretty much,

Every clinician has their strengths and certainly there's enough of a patients that fit the general model But there's enough brilliant physical therapists in Chicago that really practice on top of their license And are sub specialized and I know that they do a wonderful job Taking care of these very difficult cases that would be much better than I ever could but there's always a barrier there's always a constraint that if I refer out outside of my

brand towards another brand, right? That becomes a major constraint and a cause for almost a disciplinary action because how dare you chase away a revenue source? Which I think when that becomes the case, then you have to question whether that is the discipline or that is that employer you want to work for. But that's a different conversation altogether. But it is again, like your job as a professional to understand your limitations

understand how to use your community around you to be the resource to your patient and to that community.

Dana (20:53)
that's being a great physical therapist and what the DPT that elevated degree was supposed to in my mind put the profession in a different place and we have to amplify that message because a lot of the assumptions that we make are not necessarily

for the reasons that we think they are. It's more of a lack of awareness. Generous assumptions about why things are or aren't happening can be tremendously helpful. And I love your point about, well, we shouldn't refer out to anyone else, even another therapy clinic. But the way human behavior works, and I'm no psychologist, but when you give value, you see it in social media all the time, when you give value to people,

there is a sense of they want to be able to give back because you didn't ask for something were just doing the right thing that goes a long way therapists who've worked outside of traditional clinical care maybe you recognize that once you get into the business world be really

open to thinking about what's best for the patient and a lot of times it's as simple as they don't have a primary care doc and they're not getting their mammogram along the correct schedule. We should be identifying those things and helping those patients I'm gonna tell you one more I was at a conference

and a very, very tiny conference. And someone from, Kaiser Permanente was speaking. And he said something that blew so many folks' minds, but it makes complete sense, right? In a value-based system. He said, he's an orthopedic surgeon. And he said, what we're required to do by Kaiser doesn't matter who you are. If you are a provider and you are seeing a patient in Kaiser's system,

and you pull up their chart, the first thing you do is look at all of their quality measures and see if they've had all of their tests what gaps they have for the year, and it's your job to schedule them. I'm an orthopedic surgeon who specializes in, let's say it was, I don't remember, let's say it was shoulders, My first job is to schedule their mammogram in the room face to face with the patient. You know the likelihood of that patient actually going for that mammogram, how high it is when the doctor told them to do it right in there, right?

what they studied was when they changed this system and required this the time to get diagnosed with breast cancer dropped of course precipitously but then it dropped even the time frame between when they had the mammogram and when they found out the results and when they had the next biopsy and it actually saved lives and of course it saves costs because you're catching things earlier when

more treatable and it reduces suffering and it reduces the spend that's incurred when you try to manage end-stage cancers, right? So again, all aligned. But I can't imagine in the fee-for-service world where any orthopedic surgeon's manager would say, first thing you're going to do is look at their quality gaps and make sure they've had their preventative tests. But that should be the norm.

Alex (23:44)
No, mean, absolutely, right? I think that's where we start just fitting the label that the world assigns to us. That's like the Carl Jung's quote, right? If you don't know who you are, the world will tell you. It's like the world is telling us that we have to over-provide care or we have to be this one size two for everyone. And ultimately, we just morph into that without being a resource where I think

like a physician has a Hippocratic orphan has a responsibility, a therapist has their responsibility, and each one of us can really act more on patient advocacy care provider. And that does mean taking care of the entire individual, not a body part, not a diagnosis, not a CD10 code, but taking care of an individual. And that means

asking them questions that are pertinent to their well-being and sending them where they need to go. guess another good experiment would be if an ACO, if they're trying to provide a value-based contract with a therapist, they can ask them, how many patients have you cross-referred? And if they say zero then I wouldn't give them a value-based contract because that shows that they're less likely to understand

constraints of providing just high-value musculoskeletal care and constraints of your own profession. So, yeah.

Dana (24:57)
What

came up for me there, I love that, Alex. What PCPs really hate.

especially when they enter into value-based contracts where they're responsible for total cost of care. And even your old school doc, what they hate is when they feel that they're the quarterback, they're truly the center of that person's healthcare experience and help to guide them. They hate when they don't know what happened to their patient. There are ways, the more advanced accountable care organizations,

some of them will opt into or connect into their health information exchange or they will adopt an admission discharge transfer feed so they find out some of these things by connecting electronically But a common thing that happens is like patients being admitted to skilled nursing, the skilled nursing facility never lets them know they were there, never lets them know they were discharged. It's in a complete vacuum and no one cares because what's the incentive? The primary care docs don't send us patients, the hospital does. Why should I connect them?

crazy, right? Like the highest risk of readmission on discharge is gonna be in the first 10 days. They're not gonna think to just get in with their doc. You should be scheduling it, but what's the incentive to do that? Right? It doesn't exist. But how about practically speaking, you're a PT, Orthopedics sends you patient went around their PCP, went directly to an orthopedist, the orthopedist sent them for therapy. Shoulder, let's stick with the shoulder today. You know what builds amazing trust between you

and the primary care doc that you wanna work with more, you're hoping to get more referrals from, with consent from the patient, letting that physician know you have a referral, you're managing this patient for rotator cuff tendonitis, Dr. So-and-so sent the patient, you wanna let them know how they're doing, and by the way, they mentioned they haven't been there this year, you're happy to help them book for their annual wellness visit. You'll become the MVP of a primary care doc's office

in no time because you are helping connect the dots. And connecting the dots is what accountable care, a lot of it is about. Be a coordinator of care. I know we're not loaded with time, but we're moving in a different direction. doesn't, yes, it costs time, but a well-enabled front desk can help with that scheduling, right? A well-enabled technology solution can help you dictate that note quickly and get it off.

We have to be doing these things even if we're not paid yet, even if not in a value-based contract. Spend the next year doing some of this prep work. Maybe we can put together like a one pager for our listeners where we share just some actionable tips for what you can do to build trust and strengthen your referral relationship with providers in your area Behavioral health providers, primary care docs, right? Does that

resonate with you.

Alex (27:44)
I think

that's actually spot on. there's a lot to unpack there, right? Like building trust and becoming a resource, becoming a solution instead of just a care provider. That's one. The other really important factor is probably a slightly different chain of thought.

a patient that does not complete their course of care. So all of the drop-offs, right? The attrition in some of the practices is like 50%. So 50 % of patients that slowly fade away don't complete their assigned course of care. And how many therapists take an initiative of actually informing a referral source that this individual failed to complete the course of care? Usually these patients just drop away, and then in three months in order to complete the course, you just dictate

Dana (28:16)
Right?

Alex (28:25)
a very shallow note that closes this specific episode of care, but that like...

I think you can create specific triggers that if an individual has not been seen in more than a week, that you really need to contact the individual and you need to contact the primary care provider or whoever the referral source is because that referral source is under the assumption that this individual is still continuing to receive care. And I think that's just good communication, right? That is a good customer service outside of care provision that like I, this individual failed

Dana (28:55)
That's right.

Alex (29:00)
to complete the assigned course of care, I just need you to know this. And we've made these efforts to account the patient and whatever the reason is, it's just good communication. That is you being part of the entire ecosystem instead of you just seeing yourself from the silo that I'm just going to give my course of care, right?

Dana (29:17)
I might even go a step further than that than saying that they didn't complete their course of care, which I think is brilliant and it should be done in all cases. If someone sent you a referral because they believe you're the right person to treat their patient And could be that if it's the PCP, it's their medical home. I would maybe phrase it just a little bit differently and say that they have achievable goals.

that we've worked carefully on that are individualized and they haven't continued to show up to achieve those goals. Here's what I see might be the barriers. Can we partner in trying to help them get to that stage? And here's what I think will happen or could happen if they don't achieve those goals. And maybe you know that that primary care doc has community health workers. This is much more commonplace now than we imagine.

We know they have some, concerns about their safety at home. If they have a community health worker or they have a medical social worker that makes home visits as part of the practice, they want to know that this is your concern and are grateful because they're responsible for these patients if they're in a value-based arrangement. And assume that primary care was going to all move to advanced primary.

care. I can't predict the future, but if if I was forced to say I would say 75 % in the next five years, primary care will be in advanced primary care. It's the way they make more revenue and that is driving the adoption and then they love it and they stay in it rather than leave the medical profession. I've got a little tangent here, but I think therapists can take a little lesson from

Lesson sounds patronizing, I don't mean it that way. But when I've spoken to physicians working in advanced primary care practices

when they get into that new team based approach and patients feel that their services are being wrapped around them and they are their go to source, physicians who are on the brink of leaving the profession are now committed for lifetime to staying in the profession because they have such satisfaction every day. I have heard this story from physicians saying I was ready to leave. mean, this was my dream.

to be an internist I had no idea that primary care could be practiced like this right where you have there's behavioral health and social work and physicians and NPs and nurses and they're all working together and they all know each other and they're all coordinating care this is beautiful this is what we should want and if we can

get pts as part of this and I would say ot's too

We will have such higher patient satisfaction rates and retention of therapists, right? It's totally great and fine for any clinician who wants to leave clinical care. No shackles on us. But I, suspect that there would be many more happy PTs and OTs if you were functioning in this team based approach to care when you're a primary care therapist, providing more generalized services, which can be pretty broad. There's a, there's a whole

lot more reason to be committed and attached to that work

Alex (32:16)
Well, I think that there are definitely some therapists that are already practicing this model that you were describing, where if you have a specialty or niche practice and you have your own specialty community, you become the go-to resource. There was a brilliant clinic in Chicago called Entropy Physical Therapy. So Sarah Haig and Sandy Hilton were...

Dana (32:30)
Mm-hmm.

Alex (32:37)
were two therapists that were there and I think to give them the shout out that they provided exemplary service to their community and it was their community. They were the resources. they had specialties and they did a great job expanding knowledge so they welcomed these scholars from all over the world to come and speak in Chicago so I had a privilege of listening to Laura Mosley and

and other brilliant clinicians from all over the world, but they also were a resource to their community. So I think that there was a significant amount of patient cross-referral because that was, like, they weren't in an effort to keep the patient indefinitely. They were trying to advocate for the patient's needs, and so essentially, they were outliers because 10 years ago, 15 years ago, they were already primary care providers in their own right, and there's a lot we can borrow.

from that specific model of one clinic being a resource in the middle of downtown Chicago, giving this exemplary service. Yeah, there's a lot we can do and going back to that article, I think that the article is

Dana (33:32)
Mm.

Alex (33:39)
physical therapist can become a resource to the community because we have a common goal with the community, with the providers, with the referrals. We want to optimize patient outcomes and maintain healthcare efficiency. So we're all kind of working on the same problem, but from different angle, and we can only do better when we act like a resource, when we act like a provider that actually takes the patient's interest as a primary source of attention.

Dana (33:55)
Mm-hmm.

of that.

Alex (34:09)
would be

really good to see if more therapists, if more listeners take this model and then go to the clinic tomorrow or whatever and start to reconsider what I'm doing. Maybe I can be that resource. Maybe I can start establishing this PCP community around me where I become their MSK resource. And in return, once I have their MSK resource, I get the PCPs that I can cross-reference with, right? So then I think you are then becoming a physical

therapist with a capital P and a capital T, right? You're not just a physical therapist, but you are a physical therapist who is doing what they can to provide exemplary care

Dana (34:48)
we're talking about actionable insights and how to be a resource to primary care. And I'll bring up the Medicare Shared Savings Program because it's such a large program that encompasses now almost half of Medicare beneficiaries that are in fee for service. When a practice enters for the first time and they're a new participant, so this is an Accountable Care

organization, so it's a group of providers that come together, sign a contract with the Center for Medicare and agree to certain measures that they're going to follow and agree to a benchmarking of spending. So looking at what expected spend should be for their population and data helps to inform that. And in the beginning when you participate in the MSSP, the Medicare Shared Savings Program,

The first track, track A, B, is upside only. so what that means is if you save money from prior years again, because you're providing the right care at the right time with the right provider, and you save money, you earn back a percentage of the dollar saved. But I bring up the beginning part where you're having a first sign

of a Medicare Shared Savings Program contract. And therapists who just learn the basics of the Shared Savings Program and the levers can come in to these new practices as a resource to share. how we can provide early access to high quality musculoskeletal care to help address some of the high variability

unpredictable downstream spend show you how we can help you be successful in this program And when there's no downside risk, and you have someone coming to you with a solution and you're in something brand new, it's really appealing to a brand new group that just is trying to figure everything out to say, someone knows about this program

and can share how early physical therapy, how they're going to give us early access to their care, how early physical therapy is going to help us address our low back pain patients. And now we have a partner and it gives that, that sense of stability. I would even be going to practices that are not in an agreement yet. You know, you can look up who's in the Shared Savings Program now. I would be looking to see if all the, you know, primary care docs in your area or any of them not in it. You can

join with them. You can help them get into that contract. They'll be the participating provider physicians and you can actually sign a specific agreement with them. you can get into an agreement with them from the beginning. You know here's what we're going to commit to and this is done commonly with home health agencies, skilled nursing facilities, PTs,

are way more efficient than all of those other sources. So go in and offer to be a partner. Offer to help them with the application to CMS. There's lots of ways that you can become the foundation for practices or communities' entrance into these programs and learn with them. Build together from the ground up and you become part of the program as it's being constructed.

Alex (37:45)
I think

Dana, what's missing here in the words of Fiddler on the Roof and the words of Tavier, we need a Yentel, right? We need a matchmaker to make me a match, find me a find and catch me a catch. That is, I think that there is that middle connector that is missing that can potentially do exponentially positive impact on both communities because it can provide this

Dana (37:51)
you

You

Alex (38:13)
this fine middle ground for the therapist to help them understand and to help them gain access And then in return, get access to these skilled individuals that have been prepped to be able to provide care in this level, which is, I think that is the perfect Beshearit moment. That's the matchmaking moment.

Dana (38:33)
I love that.

Alex (38:34)
Yeah, but but there's like until the matchmaker does that the magic right? think the therapist may even even if they listen to this they may Take this and then they will be on that eternal search for that connection, right? So I think that's that's the opportunity where like someone with your level of knowledge I think it's so good for them to understand and hear that there are opportunities outside of this fee-for-service model that that is just grinding everyone down there is opportunity to expand yourself to other

where you can actually enjoy what you do and not feel like you're just on the similar line trying to convey or get through as many people as you can in a day. So yeah, it's really great. I've just learned that too. So it's really wonderful to hear that there's this opportunity for a therapist to go in and actually offer services

Dana (39:19)
help them apply. I applied for models that I had to teach myself. I attended webinars and I figured out how working in a health system and then working at a startup, how to do these complex applications. We all have the ability to do this. It's just a matter of doing a little research and learning. And there's resources at Center for Medicare to help you be successful in it. The hard part is this administrative work. So if you develop what we talked about

about earlier, right? You start connecting more with the providers in your community because there's still like plenty of opportunity for lots of participation growth in these models, you become part of the structure from the beginning and really think broadly about what our role can be. We all know as therapists that we have this expanded knowledge that

and the generous assumption we can have here is because Everyone's worried about their own cheese. What was that book? Don't steal my cheese or don't move my cheese or something. Yeah That goes back a long time, too But assume that there's just not a good awareness of how you connect with them and how you can support them and build something together you can build a community of Accountable care think how beautiful that word is I am accountable for

Alex (40:17)
with my teeth, right? Yeah.

Dana (40:34)
for the patients I care for. It changes the whole paradigm and allows us to have the impact that I feel even when I graduated with my MPT in 1998, I felt that this was the mission of this profession. And it can be realized if we're aware of what the possibilities are and the fact that there's very good reasons why many are not aware of what we can do to help and be a part of the day-to-day care of their patients.

Alex (41:03)
I think, again, to bring the full cycle in the same journal article, there's an extensive talk about a care continuum. so care continuum is about creating these feedback loops with patients, with community, with referrals.

providing data-oriented approach to this clinical care provision through these feedback loops. So once you establish a community, it becomes a self-perpetuating cycle. So once you establish these feedback loops, they start to feed on itself. And you're building already from an organizational structure that you didn't have before. So there's essentially an unrefined asset that is just waiting to be utilized.

Dana (41:44)
That's right.

Alex (41:46)
But I guess now it's the time. So are we gonna start a movement or is this episode gonna go into that eternal...

Siberia of all episodes and never be discovered it would be wonderful for us to receive feedback and to receive emails or contacts from people that have tried to do something with this or people that are interested in doing something like this. And so then we really can gauge then the volume of interest in our community and also then, I guess, provide some

follow up to this to our community so that there's actionable steps and through the newsletter too. So signing up for the newsletter and actually getting more insight about some of these referral sources.

Dana (42:27)
Once you're

signed up for the newsletter to double plug that, Of course, this could be the first time you're listening. We created a resources database that is a

landing page with a database built into it. And it's only for subscribers of the newsletter. So it's what we're giving you in return for letting us communicate with you. After every episode, we are adding into that resources database, which you can just bookmark.

and it includes whatever we spoke about in the episode. So some of the things like we plan, we know that the article we just spoke about will be in there, but the other topics that we brought up, we'll add those resources so that you can refer back if you want to them. And we would love to bring guests on. Our goal is to have a live session where it's three of us and we can have a dialogue with additional experts.

Alex (43:15)
Absolutely,

absolutely. think it's starting starting from a movement from the ground up and letting our listeners actually be the sources of future episodes and the sources of future continuum.

So I think we're running up on time. Why don't we discuss the book? And I think the book fits into this entire discussion the book that I would want to discuss is called Arriving Today, and it's from Christopher Mims. And the book came out in 2021 that looks into that supply chain of the author who ordered this nominal

gadget from Amazon. And then he traces the entire complexity of the supply chain of this gadget being manufactured somewhere in Asia and then being shipped via like the shipment, the provision, the categorization, and then finally the delivery. So it's just a fascinating understanding and appreciation of this 99 cent Amazon phone cover that goes through so many steps, so many iterations. There's so much

automation but also so much efficiency built into the supply chain and my parallel in a healthcare model is that we as healthcare providers can borrow from some of these efficiencies. We don't have to reinvent the wheel. All we have to do is we just look into that conversion industries and what they have done well. Like if we order something from Amazon, it's right there on your door sometimes the same day. How do we borrow or how do we build a healthcare

community that is also built on efficiency, not necessarily speed, but quality. I know that if I order an item A, item A will arrive in a safe, effective manner at my door and I will be able to use it. If I need healthcare, how do I access a healthcare system through the supply chain, through the entire level of complexity, of all the factors that are involved in the supply chain? There's the system factor, there is

the provider factor, there is the social factor, there is the personal factor, and all of these factors build into the healthcare supply chain so that when I know I need to receive care, there's gonna be care provided, but also when I need to provide care, I'm part of that supply chain. I am a physical therapy supply chain that goes for patients that are equipped for me so that I know that when they arrive through the referral, they will be an appropriate candidate to receive care.

through a structured method and then potentially moved further along the supply chain. So it's definitely a worthwhile read, not a quick read, a worthwhile read to understand this industrial supply chain and then let's borrow some of that into our clinical supply chain.

Dana (45:50)
that you've probably heard this saying that there's no new ideas. We're just recycling them and saying them in different ways. And where we can borrow not just new, you know, think about ideas being represented in different ways, but I think my big takeaway from your explanation is why not just learn about what's worked in the past and tweak it and make it applicable for your own practice, your own career, whatever it is. I love that.

Alex (45:54)
Yeah.

absolutely i

think if you want a completely unrelated caveat of information that ideas and knowledge is it discovered or is it created right so do we create knowledge or do we just discover it along the way and there is enough movement in determinism that there is no knowledge that is ever created it is always discovered it's out there

Dana (46:36)
Love that.

Alex (46:37)
and all we have to do is just look for the right spot and knowledge is going to be there. It's all there. Any point of knowledge, any point of information and data that has ever existed already exists and we just have to find the right resource to bring it to us so that it's available.

Dana (46:52)
That's,

yeah, perfect. Before we end, I'm gonna give one plug.

for something going on next week. It's completely free. It's called Healthcare Value Week. So for anyone who's actually made it all the way through this episode, Healthcare Value Week is once a year in the winter, and it's a week long. There's some in-person events, but what anybody here can do to participate and just to listen to the top thinkers in the value-based care space, just go online, Google Healthcare Value Week.

We'll put a link in our show notes. Have to get that out quickly because it's next week. And you can sign up for free to attend any of the virtual sessions kind of like going to a big event where you pick where you want to listen. And then as long as you sign up, you can always listen to any of the other speakers. It's lot of panels. And some of the great minds in value-based care are going to be speaking to big broad audiences. So it's a great time for true novices who just want to get their feet wet.

to listen especially to some of the early keynotes and if you have to happen to to be in town there's other things that potentially in DC if you wanted to to join are available too so healthcare value week it's a big thing in the value-based care world and some of the people i look up to the very most in this industry will be presenting at this and i hope even one pt listens

Alex (48:11)
Yeah,

well, I know one PT that will listen. That's the other side of your screen. But it sounds like an amazing opportunity. the Healthcare Value Week. It's new to me. It's really interesting and definitely most likely going to be a time well spent because it will only add insightful information. So thank you for sharing that.

Dana (48:13)
You

Hahaha

You're welcome.

And thank you all for listening to us chat. And the brilliant Alex, I have so much fun talking to you. Could do this for three hours, but perfect time to end it and excited for our next episode.

Alex (48:43)
same

day and I appreciate it thank you for all your knowledge again I will be a sponge absorbing it so thank you for this

Dana (48:50)
I am too. I'm

learning from you. I love it. Okay. Have a good night everybody or whatever you're listening to this.