Alex Bendersky (00:01)
So we are live to our inaugural podcast episode-information schedule-

effort to bring our community and enlighten them with the latest and the greatest. So just a quick introduction. This will be our first of hopefully many podcast episodes. It's Day 9i and we are really hoping that beyond this podcast episode we'll also have other points in the media including a newsletter, a website and everything else and hope to substantiate some of the

basic baseline foundational science and evidence in physical therapy but also the latest and greatest news to break it down in terms of healthcare economics so that people in a trenches sort of can...

get value from that hour spent with us. So I'm Alex Bendersky. I have been a physical therapy geek for over 20 years and I have really enjoyed every second of the last 20 plus years. And I've met Dana I think probably maybe two years ago, but I think I have not met a more complex, sophisticated, erudite person.

Dana (00:51)
You

Alex Bendersky (01:04)
before with the depth of knowledge of just the economic and the ecosystem just in general healthcare. So I think that they're just a true vital resource to our Moscow Skeletal Community and a true asset beyond that has the deepest foundational knowledge of all of this. So hopefully our gap will be resonating with the audience. So, Dana?

Dana (01:26)
Thanks, that's perfect introduction Alex. And like Alex said, met on LinkedIn, of all places, like I guess a lot of us meet, and started kind of geeking out a little bit on some interesting policy concepts and some of Alex's great posts that he puts on LinkedIn on the latest research. And I haven't seen anybody doing what Alex does, really bringing research.

simply and yet profoundly on a day-to-day basis to the larger ecosystem. And when I really started digesting some of this thinking, there's gotta be another way that we can take all this great work that Alex puts out that's applicable to therapists, but also can be broadened to the larger healthcare industry space and kind of connect the dots. Alex is, and we're both doctors of physical therapy.

We've both practiced for many, years and are both doing some ancillary things in the healthcare industry space. And we just thought it would be very interesting to take our two perspectives and bring them to each other and to our audience and challenge each other, bring concepts that we can discuss and then hopefully bring on guests also that would like to bring articles, books, concepts that they would like to talk about.

I'm just for my quick background, I've a PT since 1998. So longer than probably a lot of the listeners that we hope will be interested in the podcast. I spend my days now working in public policy and health policy. And my focus is on value-based care policy and Medicare policy. And that's across fee for service Medicare and Medicare Advantage. And what I was hoping to bring my perspective as we

as we discuss it, you know, between ourselves and as we bring content to talk about is making sure therapists have, you know, a bigger picture understanding of the healthcare ecosystem so that as they, you know, as you grow in your careers and you think about opportunities and, you know, you kind of have a, decide on some of the directions you might want to go in your career.

You also have some background in other really important aspects of the healthcare delivery system, the care continuum and payer policy in a really approachable way. I nerded in out, both of us are kind of self-proclaimed nerds and really nerded out on policy for many years and found it to be very helpful in career building and also just finding ways to take our profession and sort of expand.

expand what that means to the rest of the healthcare community, but also to therapists themselves. So why don't I kick it back to you, Alex, now to take our next step in our inaugural episode. Last thing I'll say before I'll kick it back is our intention here is truly to build in public. We are going to have outlines, but it's going to be relatively unscripted because we want the dialogue between us to be what you hope, you know, hopefully you're interested in tuning into.

Alex Bendersky (04:01)
Thank

Dana (04:24)
And kind of as one of us brings a concept to the other and talks about it, we hope you're thinking about how you might answer some of these questions too.

Alex Bendersky (04:32)
Yeah, awesome. Thanks, Dana. Absolutely. think that the more conversational and the more uniquely involving it is, the better, right? I think you see this all like the podcast ecosystem is almost a form for information exchange. And I love that, like, if you go into the fundamentals, language is nothing more than a passage of data. And so we're providing hopefully a data that can substantiate and resonate with receptors, which

to

other humans that are going to be listening to this. it's important. the fact that we have access to this medium is wonderful. The fact that we have access to...

say, evidence that we can substantiate what we say is also great, right? And then creating this bridge between empiricism and just conversation as a way of building a bridge to a listener to start questioning and to start actually exploring themselves. think that's, hopefully this will be a source of knowledge and source of information that will only spark a note of curiosity with everyone else and will lead them on

journey of exploration further and that would be terrific. again, thank you Dana for your time. I think this is a great idea and hopefully, like I'm confident that at least two people will be interested, which is you and I for the next hour.

Dana (05:42)
Thanks.

That's all

we need, at least to start. And hopefully, again, continue this and just kind of take it where it goes along its journey. I am in the spirit of kind of asking interesting questions to each other that we haven't planned, maybe necessarily nothing tricky. What is it, Alex, that

you of the things that we've talked about as important to share potentially with an audience and what we want to kind of excite the other therapists about. What is sort of one thing that just jumps out at you at first that you hope for us to be able to discuss and maybe sort of how that maybe lead to something that you might want to share. We're going to share an article today, maybe sort of how that leads to the article that you want to discuss.

Alex Bendersky (06:42)
And I think that, you know, so the biggest question that I have kind of been pondering for the last couple of months is that the entire notion of value and value in an amnestase space, but really overall value in healthcare and considering that it's an often used term, there are very few, I think, individuals that can clearly label the term value and what it stands for. So I think today we should really go deeper into that value-based care as a foundation, hopefully create a

just a clarity behind the definition of what value is and then what care is. Those are two important parts of that three word system that needs to be clearly aligned and benchmarked. So getting to the deeper source of value-based care, but also then hopefully a call to action would be for a typical provider, typical clinician to start understanding that there are two ways of seeing value in self and the care you provide, which you can build

value through self-investment or you can extract value from...

once the value is built from that consumption and introduction of your talent into that larger healthcare ecosystem. So today we really should look into that value-based care and we will use a resource that one of my favorite papers of all time, which is a 2021 paper by Chet Cook and Jeremy Lewis and the team, that I think does the best job aligning to the pillars of value as well as aligning to the value in MSK deliveries

way that can resonate with almost anyone and will probably unite the fringes of our community into

better reception to how do we build value. And the deeper level is I think that there is a self-efficacy behind value proposition, which is you are worth what you think you're worth. I think that there's a quote from Carl Jung that if you don't know your true value, the world will tell you. So I think in the PT space, like PT's don't really know their true value. And so the world is telling them, and unfortunately the world is telling them

finished value and so here we are thinking Dana you and I have done this long enough to see that it's like physical therapy is a lot of self-perpetuating cycles down not up so what do we do to go up so how do we actually once we've benchmarked value how do we build it into something that's greater and how do we build on this so

Dana (09:00)
I, that is the perfect introduction. Before we go into the article, I just will inject kind of this, something to listen out for, for our audience and for ourselves as we think about the word value. And Alex started that off perfectly. Value in healthcare versus value-based care versus value-based contracts. They sound very similar.

There's nuances that are really important that are relatively simple but important to understand as you think about the applicability and kind of question your own ways that you've been thinking about what value-based care means. And just for fun, I will share, I talk a little bit about knowledge management in my newsletter that I've been writing for over a year now actually.

And I use a couple of tools to capture knowledge as I'm going about my day to day. And I've played around with a couple tools, shared about this in a recent newsletter. I use two things, Notion, which Alex and I are building our kind of how we communicate to prep for the podcast using Notion. Super versatile tool, great to store and organize information and capture information. But I've been using this other tool, Capacities. And the reason I'm sharing this is

Capacities is, I'm just still learning it. I think it's really cool. It's free. It works really well. It's for me a great way to kind of map out knowledge. But again, I'm bringing it up because they use something called the global tag system. They actually don't call it a global tag, but I see it as a global tag system. And what that means is when you input information, you can tag it in a bunch of different ways. People use different systems.

I have two different tags for value. maybe it's a PDF. I'll upload a PDF using the app or my Chrome extension. And I can tag the two value tags I have are value-based care, which to me really is a Brown value-based care models, payer policy, et cetera. And then the other tag, and a lot of times it's both but not always, is value in health care. And I separate those because in our

in payers' minds and in those who've created the term and the concept and how to use it and how it relates to data and all of those fun things that we'll talk about over the course of our episodes. Value in healthcare is the way I would describe services to friends, to my partner, to my kids, to my coworkers, to anybody at the grocery store, meaning, and this is still a foundational concept in value-based care.

What is the value, like I think about this, if I'm going to do something or I'm going to get a service or I'm going to take a vitamin or whatever it is, what is the value of doing that or spending that time or money or energy or, you know, brain power? What is the value in that to my health and to my engagement in healthcare? So is there, you know, is this a valuable encounter with my provider, for example, if I go for a physical and it's...

done in two minutes and we didn't have a chance to dialogue. Just simple, but it is a foundational concept in building the movement between fee for service and value-based care. But it doesn't mean we always think about that if we're in the value-based care policy community. We're talking about accountable care organizations or episodes of care. That's different from just our gut reaction to something. Is this a valuable way to spend a health care dollar by anybody? By me? By the taxpayer, right?

So anyway, I just think that that's an interesting place to take that, like the concept of value and realize it means a lot of different things to different people. And one of the things that we can point out, starting with this first article that Alex is gonna talk through, is what are the different ways we can use the term value and why is that important? Just to realize that there's very different ways that other people are using it than we're using it, and that it's a great way to teach the basics. So, I'll stop.

Alex Bendersky (12:49)
Yeah.

No, that's terrific and I think that's awesome. We can even take a step back and actually look into the subjective value versus objective value. probably the best example is the subjective value of a life vest when you're walking in a desert is minimal, but subjective value of a life vest when you're drowning in the water is pretty high. And then there's the objective value, which is life vest has its own objective value because of the material

it's built, its durability and how it will function. So the life vest itself is objective and as long as it's operational, it is what it is, but the subjective value of the life vest is very different based on the context and the situation. So you have the same notion in healthcare that the value of the care delivery and the value of health is subjective based on the mechanism of delivery, based on a person delivering it and based on the receiver. And that subjective

perception is based on both priors, your prior experiences. But there are absolutes, I think, the objective value of the sense that the Kierkon coordinates is objective because it's absolute. You can either follow best practices or you can not follow best practices. The empirical evidence and the evidence guided practice is absolute too, because now evidence always evolves and evidence always changes and shifts. But there is best

available evidence and I think that bringing best available evidence to your practice is important and part of it is then going into deeper layers of complexity is do you have access to materials that help you deliver best available practice? Do you have resources in the clinic to deliver best available practice? Do you have resources in terms of time economics to deliver best available practice? And so that's where we go back into that value

defined as cost over outcome. So what is the cost of value and what are the outcomes that we're looking into? So I think that going into that simple mathematical equation is value equals cost over outcome. We can always see the cost of delivery versus the outcomes that we're tracking or are we even tracking them? So what do think of that?

Dana (14:59)
I know we're going to have a fantastic time and I hope our audience does too because I'm finding already as we're building in public here that the way the two of us think is complimentary and so as you're bringing up topics I'm thinking about what how that relates to something that I would like to share so I'm so glad you brought up that life vest example before I don't want to go down a giant rabbit hole but I will say when you talk about the use of a life vest and the value of it that's

That's parallel or very similar to essentially insurance risk, right? You don't use a life vest because you think it's going to improve your health. You use it to save your life or as an insurance policy, essentially. I could be an expert swimmer, but if the boom hits me when I'm out on my lake on the sailboat, I'm going to be dead without that life vest. The value of it only comes if it's needed. And I think we...

you know we forget that sometimes when we think about like the evils of payers you know i'm not i'm agnostic and this is not ever going to be where i proclaimed the wonders and greatness of payers i think there's a lot of misunderstanding about the role of payers and what they were meant to do versus what we think they do versus what they actually do and when it comes to something that's not like a clear subjective versus objective is one way to think about it another way to think about it is

Is something that's being done or that you seek out for care or that you do for yourself? Is it something that's obvious value? You just know or recognize? Is it perceived value? I think this is going to be good for me. So I go about it. So I make that appointment. Or what's true value? And one of the things that we were talking about before we started, the Relentless Health Value podcast, I...

I don't know if Alex has ever listened to it. I personally highly recommend it. Stacey Richter is a genius and a wonderful podcast host. And one of the things that she said recently was that I think she may have been quoting someone else. So, but I think her words were patients are really bad at understanding what valuable care is or what is what is a high value service. So, right. Most patients don't understand that getting an MRI will go to let's PTA example.

that getting an MRI when you have simple low back pain without red flags is not a valuable way to spend anybody's dollars. If it's your dollars, if it's the payer's dollars, whose ever dollars it is. anyway, that's just kind of a simple example. Value is subjective, it is objective. Sometimes it's based upon a risk-based assumption because the risk of something happening.

Or sometimes it's that, you know, there's just a real true understanding that if we do X and, you know, work at X or receive X, we're going to get Y and it's very well understood between the two. So, and the other thing that I was just going to say based upon what you had brought up was there's absolute value, there's care concordance, there's using evidence-based practice.

And then there's the reality that I think so many therapists really struggle with, which is we can only do what we are incentivized to do. And so if we work for, we're in an outpatient clinic and we work on a system where we have to see so many patients per day and equal X number of units per day, we may want to spend 30 and feel that and understand and believe and understand the evidence that spending more time on this.

whatever it is, is going to be what's most valuable to the patient. But that inherently does not always mean that that is the highest value to our employer. And this is where a lot of the tension has come up. And so I'm just putting words to it. It is really the fault of the way we decided to pay for care that has put us in the position that we are now. And hopefully when therapists can realize that, they can start thinking about what are the other

What are other solutions that are either out there or that they can create because we're in a time where payment has become a more flexible term than just a transactional service? anyway.

Alex Bendersky (18:59)
there.

That's a perfect, I think, leeway into the priors and the futures. And so I really like that you mentioned the payer system and how we're the of our circumstance. So the providers, a lot of times, are victims or products of the circumstance where they are placed. There's a really interesting phenomena of imprinting, right? So arguably, once you have an experience, no one of us can ever forget

get an experience once we have been part of it. Positive experiences and negative experiences imprint forever into our cortex.

we can become victimized, right, and then we can become products of those experiences that actually lead us to a bad path, or we can use these experiences as resources for growth. just pondering on how this imprinting based on your location as a practitioner leads you to appreciate your own value and your own fitness in a clinical space. So if you are a new grad who is placed in this assembly line operation that forces you to see 25

patients today. And based on this, your personal growth is diminished, your personal value is diminished, and you feel like you're surviving because just the volume of patient is overwhelming. So that you get imprinted, the feeling that this is the only, this is the normal, right? And so certainly there is that evolution of...

some some survive in that system and some thrive in that system and some don't and the ones that survive into that system fortunately or unfortunately take the system to the next organization and the next organization and ultimately a lot of times the understanding of this value based on the peer is

is skewed based on the imprinted value of us from our foundation, like that our founding fathers in the MSK space were, they were surviving because they were just generating revenue off like this volume, not value. The other part I think that's really important that you've mentioned is the payer, like we tend to in healthcare to,

payer blame everyone like it's like and it's such a I think a lowest hanging fruit to just blame everything on a payer and to victimize ourselves because the pay it's payers fault the payer doesn't want to pay for our care the payers rejecting and creating these nudges for us to not want to provide care which in a way it's true to a point but there's a reason for it there's a reason why payers choose to create these nudges and these friction points

in care delivery and these friction points serve a purpose which is to discourage people from providing chronic care. Now, as a provider, if I take pride in my care delivery, I'm gonna say the payer is an enemy. I'm the victim, the payer is a villain. The reality is, we're both victims and we're both villains because even if I provide good care, everyone around me may not provide as good of a care. And for a payer, we have a very different true north that we're oriented on.

Dana (21:18)
Mm-hmm.

Alex Bendersky (21:44)
And

unless we align in the true north what the payer wants, which is efficiency, which is outcome based, which is objectivity, versus what we want, our true north, is camaraderie, patient centeredness, patient experience. There's a way to unite it, I think, to create a larger level.

appreciation and that's where we go deeper into these alternative payment models potentially and explore them as we go probably later too to see how what else can we do to participate in this value-based care where we get reimbursed fairly and adequately for the value providing not for the volume.

Dana (22:20)
I think we'll end up talking about in upcoming episodes how we can and how we can persuade others to think about the inherent value of evidence-based, patient-specific physical therapy services, not the standard of, I don't mean standard in the good way, mean not the average care, but we could put a little bookmark here to talk in a future episode upcoming about

what is and can be the true value if we all were to practice evidence-based care, giving every patient specifically what they need, agnostic of what we would think about billing for an individual service, X equals Y, but really what can we bring to the total, because this is how payers are thinking now, if despite what people may or may not understand, and this is what we'll convey over time.

How can we present a different value because our interactions with patients in an evidence-based, standardized way lead to a lower total cost of care? So our value goes up. More dollars should, and I predict will be given if therapists can get on this track, given to the therapy professionals because the value of what they bring to the healthcare industry ecosystem.

is so much higher than the way we're reimbursed traditionally. And we have a chance to make a big wedge between where we are now and where we can and should be, but it's going to have to be based on presenting the evidence in a way that payers and other providers and the community views this. So again, we'll put a little check mark there for a future episode, but I'm glad that this has come up in our inaugural conversation, because I think it's kind of one of those foundational pieces of

foundational piece of information that if we can share it would be really beneficial to our audience.

Alex Bendersky (24:14)
Yeah, for sure. then let's dig a little bit into that article so that we have something to talk about, right? So, again, the article which is titled, Providing Value-Based Care as Physiotherapist by Chet Cook.

Dana (24:20)
Great.

Alex Bendersky (24:29)
Denninger, Lewis, Diener, and Chuck Techpin. The article is from 2021, so still within that threshold of a five-year limit. And again, it's just a wonderful consolidation of...

probably exemplary communication of best opinions and best expertise on paper. to start it off, think that there's, authors mentioned that there are four pillars to value-based care. And then the pillars are patient-centeredness, adherence to clinical guidelines, measurement of patient outcomes and experiences, and cost-effectiveness. So we can really take a couple of minutes to discuss each one of these pillars. We can start off with

patient-centeredness and what does it mean to be patient-centered? It's kind of this polycelepic war that people like, but what does it really mean? Does patient-centeredness mean that we do whatever the patient wants us to do because we want them to be happy? Is patient-centeredness more in a way that I will provide a patient bill of rights to the patient to know that while you are being treated by me, you will receive A, B, and C, and you will receive it based on this evidence, right?

patient-centeredness more of an alignment where it's an active communication between me, the provider, and patient, the consumer, and this complete clarity and transparency in the transaction that is about to occur. I'm centered because I'm going to give you this, and in return, I expect this from you. So what do you think, Dana, on patient-centeredness?

Dana (25:52)
think those are important pillars and emphasizing one or the other, one versus the other. I won't get into necessarily an argument for one or the other, but I will say patient centeredness in the way we think about it in the bigger healthcare delivery space. And again, just I talk too much about this, but in my work, I'm...

and my day-to-day job, I'm thinking a lot about and working a lot on policy that impacts the full healthcare experience and it really is not specific in any way to physical therapy. I inject that because my knowledge, inject that, I inject the possibilities of what PT can bring. So let me start with that. Patient centeredness as we think about the healthcare industry just in a bigger space.

has a lot to do with things like access to care. So just if we look at that one thing that I don't know that therapists think about a lot of times when we think about what patient centered is, access to care, if we don't think about access, we don't think about whether a patient is actually going to make it to our office, whether or not they have the hours available that our clinic makes available, whether they can trust that we will

be connecting with their other providers that are integral to their full health care experience and how they care for themselves and how they view their health. So anyway, to add something that if I was thinking about patient centeredness, patient centeredness thinks about what a patient needs to do and be to be successful. Some of it.

is going to be things that they're aware of and others are going to be things that they don't think about as being patient centered but when they don't exist they're going to impact their outcomes. if a patient can only come at 7 a.m. or 7 p.m. and my hours are 9 to 5 or 9 to 6, well we can't even get to the next step of patient centeredness because we can't even give them access to our services.

And anyway, yes, I mean, I love those things. And I think that thinking about what patient-centered care is, when we're thinking oftentimes a lot about billable units, because out of necessity for business, we can step away from what is really, truly valuable to patients. And something like access is of high value and patient-centered, even if we don't always think about it that way, our patients do.

Alex Bendersky (28:09)
Yeah, I

love that you said access and accessibility, that we put ourselves out there a lot of times, but then we tend to attract the people that will come in, and like the analogy of a pie, right? We're eating from the same pie, but we really build a bigger pie. And I think I have been extensively involved in different digital health startups and digital health.

processes and I think that's that we see the system of care provision and patient centeredness as something that is much more a traditional face to face encounter. We don't see patient centeredness as a way of creating an ecosystem that provides resources and care through the platform that's most convenient for the patient which could be digital, hybrid, could be all of the above, but that is patient centeredness when you can actually create a communication tool that allows a patient access and accessibility to you beyond the

Dana (28:44)
And then mom left this in my car

Alex Bendersky (28:57)
your

clinic walls or when you provide a health...

Dana (29:00)
It's a nice old bin.

Alex Bendersky (29:02)
data health information to the patient that goes away from just our like face-to-face encounter, right? So let's go to then the second pinnacle, which is the adherence to clinical guidelines. So I think there was a brilliant paper by Josh Zadro in British Journal of Sports Medicine like maybe last year about the physical nervous adherence to clinical guidelines. And without kind of alluding data, essentially we're just not very good about

following clinical guidelines as a professional community and not just in United States. We're just not good at following clinical guidelines in Australia, in England, pretty much anywhere. we tend to...

Dana (29:32)
You

Alex Bendersky (29:40)
choose our sages, choose our philosophers and follow our philosophers blindly without examining what else is out there. I think the other part of the clinical guidelines is they tend to evolve and we have to co-evolve with them. As humans, we evolve with the environment that we're proud of. And so as new technology emerges, as new resources emerge, we evolve with that as well. But as professionals, we tend to stagnate.

Dana (30:02)
You

Alex Bendersky (30:06)
if we're following clinical guidelines in 2012, we tend to continue to follow 2012 clinical guidelines, even if it's 2025. And not always to our own fault, but because there's limited access to clinical guidelines, there's limited opportunity, there's certainly very little reward in staying current with clinical guidelines. A therapist practicing like it's 2012 gets paid the same amount of money that therapists practicing like it's 2025. So

Dana (30:23)
You

Alex Bendersky (30:33)
I guess Dana, what do you think? Well, how do we structure a system that actually rewards adherence to clinical guidelines in our space?

Dana (30:41)
Well, how do we structure it is a complex question. So I'm going to take the easy way out and answer it this way and say we can't adhere to clinical guidelines in fee for service as therapists, right? Certain professions, it's much easier in health care. It's much easier to adhere to clinical guidelines and do your best work and still be reimbursed well. So a good example would be surgeons.

Right. So if I'm a brain surgeon, I have to follow the most up-to-date advanced clinical guidelines and be at the cutting edge of research if I'm going to be perceived and be and get the best outcomes for my patients. And that's not going to it. It's it's both going to impact my my billing if I don't do it and it's going to impact my outcomes and mortality rates going to be higher. Right. So

There's a simple, you know, paying a high value for that most evidence-based best practice is much easier to adhere to something like this. But if we're, you know, as therapists, similar to primary care physicians, if we are to follow what the best clinical guidelines are, many of what's included in that is going to include less, potentially less frequent visits or things like telephonic check-ins.

less dependence on being in the clinic and more dependence on patient empowerment and patient engagement. Those things don't translate always as well in fee for service physical therapy. It may mean spending more time on patient education and dialogue and encouragement and behavior change. Hard to come up with the billing codes in transactional medicine. So for physical therapists like

Like for primary care, I make that analogy because it's just such a simple one for us to all conceptualize. We don't have enough billing codes in fee for service to do and follow evidence-based guidelines and make a living and keep our employers in business. So there must be, we have to find, right, I think this profession, because of the inability to adhere to clinical guidelines and be reimbursed sufficiently.

We have to find a different way to be paid and different ways to partner with other providers and with payers to just change this trajectory.

Alex Bendersky (32:58)
For sure, maybe a payment multiplier, if you show that objectivity or if you show or, you're right. mean, we're being constrained by the fee-for-service because it's four codes that have been interpreted to the best of our ability. But...

I think even as simple as a clinic owner or as an administrator, create an availability of these resources, provide just the lowest threshold incentive for these resources to be accessible to clinicians providing care. Not saying that everyone will, but I've been doing this long enough and I've kind of grown in

in a traditional sense where you grow your clinic, you grow your territory, you grow your region, and you have enough clinicians that you are working with together, enough of your colleagues that you see the entire ecosystem of clinical efficacy. And there's one specific example of this really highly trained clinician, so someone with advanced training, all the right alphabet soup after the last name, that was a sacroiliac joint specialist, that the entire world

worldview

became centered around the one specific anatomical description. like, clinical guidelines would be that a selection criteria became much more skewed towards what was convenient for her worldview without expanding into a larger worldview. So, I think, in a way, almost zooming out and seeing the bigger picture, but also creating the resources that are available to them. So.

Dana (34:11)
Mm-hmm.

So if

you're a hammer, everything's a nail in that example.

Alex Bendersky (34:25)
Absolutely.

And you see that in PT world, right? So part of it is that if you are a manual therapy hammer, or if you're an exercise-based hammer, or if you believe that your investment of didactics in the last three years to become a dry-needler, becomes, you're gonna use that indiscriminately. that's, unfortunately, that is part of the downfall of the economic model too, is when you are diluting the clinical efficacy of these resources because of an indiscriminate application.

brain surgeon that does...

these complex procedures when the smaller procedure would do just because they become master of that one procedure. Now, I'm certain that there is some heuristic that will govern that clinician to still apply that procedure, but they're gonna be discriminant towards the spectrum. Like, should I do A, B, or C? For clinicians, we just become more A, B, or C, but never between them, right? So, I guess being more agnostic towards philosophies and being more inclusive towards best available clinical evidence and clinical guidelines, right?

Dana (35:20)
Mm-hmm.

Love that.

Alex Bendersky (35:21)
So let's

move to that in the third pillar, which is the measurement of patient outcomes and experiences. So I think this is where we as a community probably.

suffer the most were like I know as payers they want to see objectivity and they want to see measurements and they want to see data and for clinicians of patient reported outcomes and patient experience outcome data has become much more of an afterthought. It's just a compliance issue that you have to go through in order to finalize your notes. So you just rush through it. If you look at the how we collect patient reported outcomes, so the method of collection, the mechanism of collection and the processing of patient reported outcome data is absolutely

inferior to what it was intended to do. It's just again more of a compliance issue than a true patient specific resource that gives you the foundational data about what this individual is going through based on their own self-perception, both objective measures but also experiential measures. So these tools have been developed for one purpose. We're using them for something completely different and we're interpreting in a completely different way too. So you have a hammer

that is being used to fix a crystal vase because we're trying to get a brand new car. And there's three completely different domains with very little relationship, but here we are, right? So what is a way for us as a community to kind of huddle around these objective measures and to operationalize them in a point where they become a meaningful part of our clinical performance, clinical output?

Dana (36:51)
I can best, I think, answer that from my perspective in trying to dispel some common misunderstanding I hear from therapists when they talk about things like, well, we showed them how valuable this was, or we showed them how this got better outcomes. That payers and other providers who want it, if we just think about partnering, how do we get close?

you know, a closer partnership so we have better referrals. Let's just start that simply. Just to, we want more referrals from this group, they're using another group. Let's not even talk about, you know, value necessarily. But this is the biggest group in the area. 80 % of the referrals go to clinic A, we're clinic B. How do we get more referrals? When therapists think about, well, this is the, you know, this is the data that I'm showing.

It's great to be thinking about the data that we think is important and know is important, but to convince other people of things, other folks that are not therapists, but those who we want something from, we want to strengthen our referral relationship. You know, we want to build, it could be, we want to build some kind of a partnership with them, whether it's to get into specific contract or whatever. We have to think about the data in the way that they're thinking about the data.

not the way that we think about specific interventions on a specific person. the way that just to give high level kind of what does measurement look like, I will go to just an accountable care organization measurement. What do they look at? And I'm gonna go right to a value-based care example because we're at the point where about 50 % of primary care practices are in an accountable care organization, at least in Medicare, but many times in Medicare Advantage and other payers.

And this is what the way they're looking at data. get all of the claims, they and their actuaries, they get all of the claims data for all of their patients. They then look to stratify that data based upon where there's outliers first. So where are we seeing patterns where we're making specific referrals and not getting anything good out of it, like poor outcomes for certain providers.

like poor morbidity and mortality rates for patients with heart failure, for example, or high use of the ER for certain patient population types. If you're in an accountable care organization, you're trying to use dollars to a higher value and you change who your partners are in the community so that you're using the ones that will help bring value to patients and keep them from going to places like the hospital and for unnecessary surgeries.

So if you're a therapist and you're trying to get more patients referred for low back pain versus sending them to the orthopedist, you want to know what the referral patterns, traditional referral patterns look like, what those dollars are getting for their patients over time, how it's impacting the total spend and the total outcomes of those patients. And...

what can you offer, what can you show them you can do, and what can you offer to help them get something better for their dollars, right? So if that looks like, you know, simple, patients with low back pain being referred to therapy, you will give them really good access to care and a simple onboarding, and you're going to show them that within a year, you're going to reduce those patients, their low back pain patients use of MRIs by 20%, let's say.

Those are the kinds of dialogues that providers that you want referrals from want to have. They're eager to find levers that don't cost them anything, that get their patients a better outcome and spend less money, and that makes them successful. I don't know if that's too granular, but is that making sense or where Alex asked me questions to help it?

Alex Bendersky (40:44)
I mean,

that's perfect, right? So you actually did a terrific job breaking it down into an opportunity. Like there's an opportunity to communicate exactly how you're gonna reduce cost, reduce risk. And the levers for that are to have this communication as a provider that...

rather than just maintaining these patients indefinitely and driving cost through the volume of provision, you have to start having a conversation that the cost per episode of care equivalence compared to the downstream cost of alternatives is X, Y, and Z. And so if you're a provider and you're managing this non-complex back pain patient, you can have an actuary that runs down the exact cost of

care

based on the discipline that the patient is receiving care from. There's been a number of good studies that just really evaluate the downstream effects. So as a provider to say that, I'm a physical therapist, if you trust me with this patient, the result is going to be, as you were mentioning, 20 % reduction in imaging, 30 % reduction in hospitalization, 10 % reduction in likelihood of opioid addiction. You just have these available data.

They can be surfaced as a negotiating power to negotiate potentially even a higher fee schedule because you are able to reduce risk. You are able to reduce downstream cost. But you have to have understanding, I guess. And I think one of the ways to do this is to go back to the patient-reported outcomes is you have to have that foundation of this data. As a provider, I can go to a negotiation saying, these are all the patients that have managed with back pain. And you can see that significant reduction in

your disability score based on this outcome measure. So you can compare my clinic to the clinic across the street, or you can compare my clinic to global cost, or you can compare my clinic compared to the orthopedic surgeon who's managing patients with lower back pain. And that's the cost of care. So these are important data points to discuss. So no, that was terrific. So let's, for the sake of time conservation, let's move to the last one, which is,

Dana (42:46)
Mm-hmm.

Alex Bendersky (42:54)
think of really we probably mentioned in the last data point too, but that cost effectiveness, where that cost effectiveness is one of those slippery terms that I think we really have to do a good job defining and create benchmarking. What is cost effectiveness in musculoskeletal care? How do we drive cost effectiveness and how do we prove cost effectiveness compared to what, right? Me versus someone else or is cost effectiveness me versus in different discipline or cost effectiveness

effectiveness,

me versus doing nothing at all. And do we see cost effectiveness just in the principle of care delivery? Or do we see cost effectiveness as a much larger quality of life years or determinants of general well-being as a human existing in the United States? So what's cost effectiveness?

Dana (43:42)
Well, before I answer Alex, just tell me a little bit more about what the article says about about cost effectiveness as a value lever. If you can, if you can pull out anything else further, because I could go so many different ways with this that. Yeah. Great.

Alex Bendersky (43:55)
absolutely. So I will even read it from it. So cost effectiveness

are administrative measures which indirectly assess the intensity and complexity of care utilization. face value, lower costs are inherently associated with value care. However, this is not direct individual, but we assume further complicated issues is the fact that reimbursement system differ from country to country, make a direct comparison challenge. Costs are historical measure of value-based care, but require consideration within the context of other

factors, including the care provided, and the patient engagement and experience.

Dana (44:29)
Okay, perfect. So there's a, you know, there's a reason why the equation for value is both quality and cost being considered and a lot of reasons for that. But if we want to, you know, think about the fact that some things are worth spending more on because you have such an exponentially important high value outcome that comes from that spend. So

Right? So let's use brain surgery as a going back to the extreme, right? We're not going to put a dollar amount because I just don't know what it is on what's considered a fair price to pay for a neurosurgeon removing a brain tumor. But we can all agree that that's probably, you know, exponentially more valuable in terms of cost. If you get a good quality outcome, your life is being saved, right? So to the extreme example.

It's cost effective to pay the best, if it's truly the highest quality, best outcome neurosurgeon in the world, top dollar, whatever that is, tens of thousands of dollars maybe, to save your life. It's not valuable to have that done and pay for that if you don't have a brain tumor or if that tumor should have been ablated first with radiation because that was standard of care or if they're...

they're equally as effective in their outcomes as the next best who is 0.000 % different in terms of quality and their cost of their surgeries three times as much. So cost is always relative. I think for therapists, the value, you know, the cost and quality ratio, we don't deserve, let me say this, not everyone's going to agree with this, but.

If we don't provide evidence-based care that gets an outcome, the best possible outcome, then we don't deserve to be paid more than we are now. If we're not going to change the frequency, for example, and achieve the best outcome because that lower frequency but better engagement in long-term commitment is there, right? So if we think about that use of health tech for a combination of in-person and remote.

because that person will comply with that. Maybe that overall cost that we're paid for that should be significantly higher than it is in fee for service because we're getting a better value. But we have to be able to show that that cost effective care, if we're spending less in fee for service, they should be paying us more for because the overall outcome that is achieved for that individual is so significantly higher than if we had done the traditional fee for service more visit payment, right?

So I think of cost effectiveness really in relative terms. Anything where you're achieving a great outcome and it was the best, most efficient way of doing it is going to be worth something more than spending more on something that is less efficacious, but maybe made everybody feel okay about it, right? Like, you know, the person perceived that it was a good way to spend money and they enjoyed it, but was it really cost effective from?

from it being best for the patient, maybe that needs to be communicated to them, best in terms of the contribution that those dollars spent led to a dollar saved down the line. So yes, I believe cost effectiveness is crucial to high value care, but again, lots of nuance here. is cost effective is relative compared to the quality of what you're getting for that, both in the short term.

the quality and the cost for the individual providing the care, for the individual receiving the care and participating in the care, and then for the dollars being spent. You could say wherever those dollars are coming from, whether it's providers at risk or it's a payer, but those inherent, you know, the inherent cost effectiveness of something is a complex equation that has to be looked at in relative terms.

Alex Bendersky (48:24)
Yeah, I think that it's a very good point, like a cost effectiveness from the standpoint of what are you getting in return, right? In a service-based economy, like what's exchange rate, essentially? I really like that. It resonates, I guess, to go to a simpler level. The chatter now that we're in with February 9th is patient retention, right? And so it's an interesting cycle in a physical therapy world that every January we

panic because patients are not in the clinic just to complain about how overwhelmed we are in August when the patients are all in the clinic. But the cost-effectiveness from a standpoint of patient retention that like do you have do you provide the same value for patient visit one versus patient visit 18? Is there a cost-effectiveness when you are providing over providing care or over utilizing or do you provide the same quality of care when somebody can be equally outsourced?

to an automated non in-person visit or do you continue to retain the in-person visits because that's like you feel like it's more cost effective than someone not receiving care at all or is then iatrogenesis where like actually providing care has a negative impact that actually costs more and reduces the value reduces the efficacy so

Dana (49:26)
Mm-hmm.

I'll

give you one example of that before we wrap up. That maybe is not related specifically to outpatient care, but something that I've spent a lot of time on in the past. There's, you know, if any listeners have spent any time either working with or working inside the skilled nursing facility space, that space is unique to inpatient care in general because more pays more. So every day you're in a skilled nursing facility as long as

Documentation can justify that everyone's following Medicare or whoever the payer's guidelines, but in this example we use Medicare because it's paid per day. is, therapists have become, in my many conversations with dozens and dozens of therapists, hundreds working in that setting, there's this deep-seated belief that the longer they keep a patient in their facility, the better the patient is.

But when we actually look at the research, we know that because patients in skilled nursing are sitting in wheelchairs all day, except when they're in therapy, and they're laying in bed the rest of the time, that there is a diminishing return after X number of days. It varies depending obviously on the total characteristics. But generally, big general, about two weeks is about the most anybody's gonna get out of skilled nursing. And beyond that, you start to get

more deterioration, more cognitive impairments, you know, more dependency, all of lots of depression, lots of negative sequelae. But this fundamental belief that more, more, more is better, better, better, and they should be here because I can care for them, but not understanding what negative impacts that's going to have on that person's life down the line, on, again, the cost-effective spending of dollars. A lot of times it makes no sense, but we get stuck.

we as professionals, not just therapists, everyone, we get stuck in what we see in our day to day and what we've been conditioned to believe because of those benefiting from those things and what patients have come to believe that we set ourselves up to not see clearly. So anyway, I know I'm related, I want to, where I can touch on areas of care that therapists practice in that aren't necessarily traditional outpatient, there's so many ways to draw the,

you know, some of what happens, those dynamics into this conversation that are probably valuable.

Alex Bendersky (51:57)
And I think that's perfect actually to finish off with the optics and with a resource like what is your source of truth and where do you get the source of truth. So the optics of a home health provider is that I want to be the hero but the reality is that at a certain point you become more of a villain or a victim than a hero based on over-provision of care which actually has a negative health effect and health impact.

So we should wrap this up with a quick book introduction that will probably help our listeners, which would be Naked Economics Undressing the Dismal Science, which I found to be absolutely the best way of introducing micro, macro, and meso economics to a fifth grader. It's a way to get these really large economic turns to a reader without going too deep into the mathematics, too deep into the formulas, but really understanding that all of these economic levers

And especially thinking about the mess or economics where we like on a larger scale working with a large health systems That's your macro economics and then working in a clinic and just providing care. That's your micro economics and day-to-day minutiae But then the mess economics which is just a network architecture the supply chain resilience the supply chain mechanisms like understanding like your day-to-day operation has dependencies now So this is I think a foundational read for any clinician, especially now that is in a process of self-discipline

Should I stay in a clinical? Should I leave clinical? Understand the foundation of business of healthcare before you choose to cut away and leave clinical care altogether because until you understand it, you are being reactive without having a deeper knowledge of the complexity of the healthcare system. hopefully somebody will be able to read this and then report on this too because it is definitely a very good read.

Dana (53:28)
Mm-hmm.

I'm going to audible

it because that's how I listen to books usually, but I can't wait to read it and then maybe down the line give you my 30 second take on it too. Thank you for the recommendation, Alex.

Alex Bendersky (53:51)
Awesome.

Dana, thank you. This was wonderful foundation, wonderful first. definitely looking forward to more of these in the future.

Dana (54:01)
I love it. I love it. And for anybody who happens to be listening to our very first podcast, I will send this out to my newsletter subscribers and we will post it to our social media. We're going to be putting out, like I mentioned at the beginning, a newsletter specific to our podcast. So it'll share the podcast episodes. It'll share resources. It'll have its own little website.

For now, if you can subscribe, if you don't, to my newsletter, it'll be in the show notes, timelessautonomy.com. It's also in my bio in LinkedIn. And then once we have that newsletter subscription going in the next week or so, then you can sign up for that specifically as well. And again, really welcome any feedback. We'll be asking interested folks to come on, therapists or...

other therapists types or any other healthcare professional that would like to talk about some of these issues with us. So more to come. Please continue to tune in if you tuned in today. If you made it until the, wow, we're at the one hour mark, kudos to you. I figured that we would be able to talk for as long as we wanted and were able to. And thank you, Alex, so much for agreeing to do this with me. We decided on this for everyone one week ago that we were going to set this up and we, by gosh darn it, we actually did it.

Alex Bendersky (55:16)
action.

Dana (55:17)
Have a great weekend, Alex. Thank you. Okay, bye.

Alex Bendersky (55:18)
weekend. Thanks Dana.