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REP 26 - We are not a commodity: the value of physical therapists vs. physical therapy

WebPT

“I’m going to physical therapy.” 

Whenever anyone—a friend, a colleague, or even a family member—says this to me, I feel a twinge of disappointment. 

I know, it sounds crazy coming from me; I am a physical therapist, after all. 

But that is precisely the reason behind my discontent: I am a physical therapist—a doctorate-level medical professional with the skills and education necessary to diagnose, treat, and coordinate care for my patients. 

I am not some nameless, faceless provider of a generic ancillary form of treatment known as “physical therapy.”

 

The treatment I, as an individual therapist, provide to my patients is a reflection of my unique education, expertise, knowledge, experience, and talent. 

It is not a mass-producible service.

And yet, when a patient—a healthcare consumer—says he or she is “going to physical therapy,” that is exactly what this entire profession is reduced to: a service. 

 

I don’t think I fully grasped the significance behind this seemingly inconsequential choice of phrasing until I attended the Graham Sessions a couple of years ago. There, a fellow attendee pointed out that when physical therapy patients discuss their treatment, they overwhelmingly tend to emphasize the “what” rather than the “who”—that is, they’ll talk about “going to physical therapy” rather than “going to the physical therapist.” 

It might not seem like a big deal, but it points to a much larger issue. After all, when someone talks about “going to the dentist” or “going to the doctor” or even—brace for it—“going to the chiropractor,” they are unconsciously linking the value of the service they receive to the person providing it. 

 

But, when a person says he or she is “going to physical therapy,” the value shifts to being associated with the service itself—and I am baffled as to why, in the healthcare world, that association seems exclusive to the physical therapy space. 

You would never hear anyone talk about “going to dentistry” or “going to medicine” or “going to chiropractic.”

It’s hard to pinpoint exactly how—or when—this semantic division developed. But, I’m betting it has a lot to do with the fact that physical therapy came into existence as an extension of physician care—in other words, physicians sent patients to therapy and provided therapists with detailed treatment prescriptions. 

Thus, the value inherent to clinical expertise has always rested with the referring physician—and the therapist was merely a tool for furnishing the prescribed services. However, as the physical therapy profession evolved, and therapists became better-educated—and more autonomous—providers, the perceived relationship between physicians and therapists remained the same.

On top of all that, not only have we been beholden to a payment system that does not reward quality, but we’ve also—as a community—resisted efforts to introduce quality (i.e., value) as a condition of payment. 

 

Thus, our payers have continued to see us as a cost to be reduced, rather than a valuable care option to be leveraged. And until we (1) start operating under a payment system that accounts for value and (2) take control of the data and data-collection tools we use to communicate that value, insurance companies will continue to look for ways to slash our payments. 

After all, in their eyes, our services are nothing more than a product—and like anyone purchasing a product, they want to pay the lowest price possible.

But, we know better. 

We know we are not a service; we are not a product; and we certainly are not a commodity. 

 

In fact, in cases involving neuromuscular issues, our clinical expertise matches—and often, far exceeds—that of our physician colleagues. 

And when patients with those issues come to us first, we are not only capable of developing and executing effective care plans, but we also have the ability to do so in a less invasive—and less expensive—manner than most other types of providers. 

Essentially, we produce better outcomes at a lower cost—and isn’t that the very definition of valuable care?

The problem, of course, is that we haven’t proven that value—at least not at scale. 

 

Instead, we’ve:

  • Kept our outcomes and care cost data in siloes;
  • Used proprietary tools to track outcomes, thus rendering it meaningless outside of rehab; or
  • Neglected to track patient outcomes altogether.

There’s no way around it: to prove our value as crucial members of patient care teams—and to shatter the long-held misconception that physical therapy is nothing more than a commodity delivered independent of clinical expertise—we must unite in our outcomes data-collection efforts

Even the practice owners who have implemented outcomes-tracking programs in their clinics often complain that their data holds little influence over insurance behemoths—and that’s simply because, in many cases, big payers want to see big data. 

 

More than that—they want to see data they can easily understand, analyze, and compare across the healthcare continuum. That means it’s imperative that we standardize the process through which we collect outcomes data—including the set of tools we use.

So, how do we begin amassing that data? How do we get a large enough portion of the therapy community on the same page with regard to outcomes tracking? 

Well, it starts with getting the word out—which is precisely why I’ve been so prolific in my outcomes-focused content efforts. 

 

I have been beating this drum for quite a while now—and you can rest assured that until the rehab therapy community has established an effective, coordinated outcomes-tracking strategy, that beat will go on.

Whether we like it or not, the era of value-driven health care is upon us. And that means that, like all other healthcare providers, rehab therapists can no longer afford to accept the false presumption that their value is rooted in their interventions. 

Because as we all know, truly valuable care encompasses so much more than the treatment itself: it’s about how and when the treatment is delivered, the patient’s overall experience in receiving it, and, most importantly, the person providing it.

So, are you with me? 

Will you join the movement to end the commoditization of our profession? 

I hope so—because with all hands on deck, I truly believe we’ll see the day when “I’m going to physical therapy” vanishes from our patients’ vernacular, and “I’m going to see my physical therapist” takes its place.

 

Originally posted on the WebPT Blog.
 

 

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Comments

Thank you!  Thank you!  Thank you!

Very well stated.

I am glad you are bringing this to the collective awareness of physiotherapists.

When physiotherapists negotiate set fees with third party payers such as ICBC, MSP, Veterans Affairs, Department of National Defence, RCMP, etc. they are thinking from the perspective of physiotherapy being a commodity.  For example, fee for a one-on-one private "hands-on" physiotherapy session from a physiotherapist with 20 years experience and thousands of hours of additional "hands-on" courses in physiotherapy manual practice, massage, and osteopathy is the same as for a 20 minute gym session of exercises on various machines overseen by a physiotherapist overseeing a kinesiologist (or physiotherapy assistant) watching a number of patients at the same time on various machines in the gym.

When hospitals and clinics "run patients through" clinical pathways (algorisms) they are, likewise, thinking from the perspective of physiotherapy being a commodity.  A hospital hand clinic may have the standard procedure of verifying the doctor's diagnosis of carpal tunnel syndrome by taking a standard history and performing standardized manual tests.  Then, based on the results, apply splints and teach exercises and stretching "as per protocol".  The experienced private physiotherapist would more likely take a more comprehensive history (as seemingly unrelated traumas are usually contributing factors) and use gentle "hands-on" techniques to release tensions and restore suppleness to the affected areas (affected areas almost always include entire arm, shoulder, neck, head and thorax .... and ALL the affected tissues ... even organs as appropriate).  It is interesting to note that, like musicians, physiotherapist who use "hands-on" methods to treat patients become much, much better at it over the years and decades of "practice".

The outcome measures could also include a cohort study with test subjects of patients with proposed orthopedic surgeries being randomly divided into test groups from the onset of their referral to an orthopedic surgeon.  One group being processed as though physiotherapy is a commodity (standard procedure of diagnostic imaging, waiting to see surgeon, visit(s) with surgeon, waiting for surgery appointment, hospital intake meeting, surgery, follow-up physiotherapy, follow-up surgeon visits, etc.) and the other group having the diagnostic imaging then being seeing by experienced "hands-on" physiotherapist(s) for one-hour visits as needed (established by the usual practice of the participating physiotherapists - which would likely be similar to having one hour sessions once per week for up to 12 weeks).  It would be interesting to assess various outcome measures at various times (including 10, 15 and 20 year follow-up for satisfaction, number and type of additional orthopedic surgeries, pain, range of motion, mobility, quality of life, lifestyle changes, orthopedic care choices, cost, etc.).

While potentially valuable, we as physiotherapists should be alert when it comes to establishing "best practices", "standardized care protocols", "clinical pathways", etc.  Issues to consider:

*To what extent will the research be based on the current practices of those doing the research? (For example, will research by those who use electrical modalities and / or exercise be focused on establishing the best devices, best settings, best exercises, best number of sets and repetitions, etc while ignoring other effective treatment methods? .....and will this result in a trend for newer physiotherapists to empoly electric modalities and exercises over developing their skills in using manual therapy methods?)

*Will protocols turn physiotherapy into a commodity?

*Will effective quality alternative methods of providing physiotherapy be left behind?

I am retired, but very grateful for your opening this conversation.

 

 

Thank you for joining the conversation with these thought provoking suggestions.

@CPA_Melissa

I was disappointed about the writer's solution of simply having outcome measures being monitored to improve image of physiotherapy, which makes me think that really, physiotherapy is a commodity, as reliance on outcome measures (which is just one tool to oversee patient satisfaction or outcome) written in paper are just stats (You know the expression "it's just a part of statistics").

A beautiful response from this other writer sets the bar high.  

Also, one of the sad things I see that happen in this profession is poor loyalty to colleagues.  You do not see this in medical profession, nursing, etc.  And yet, we always compare ourselves that our services are like prescribing meds that need to be followed.  

I have seen PT's with variable experiences and the most notable are the ones who are retiring.  I was shocked to see PT's (not only one but many) with 30 yrs of experience utilizing PTA's or Kins to interview or observe PT's.  All of them business owners.  What agenda are you in?  You simply don't do this as people talk!  Don't be offended and I forgive you, btw, but you have to stop.

 

 

 

 

Very well said!

You get upset that someone is receiving physiotherapy from someone who is not a physiotherapist and your solution is a better outcomes based practice. Perhaps if physiotherapy or physical therapy was a term that could only be used by an educated registered  physiotherapist or physical therapist might be the more logical solution. Why is the term physiotherapy not a protected term? Why is it that anyone from physio to chiropractic receptionist can call what they do physiotherapy simply because they can turn on an ultrasound machine? You offer a poor argument and a worse solution.

I agree wholeheartedly with the Rep 26 Comments.   

Thank you for posting the Blog.

 

Gowri Atkinson

You are right. What prevents me from using and others from analyzing outcome measure data could be limited man power in the clinic. I would love to write a national link on all our invoices directing patients to share their experiences or even just outcome by their Physiotherapist on line at home. I am often suggesting patients cancel their last appointment with me if they achieve their goals and would prefer not to return to only tell me how great they are feeling and doing since treatment from me. Considering the distance some patients travel and cost of each treatment I think my choice of encouraging the cancellation of  their last appointment is good for patients but has consequences in collection of valuable data. A national service to collect and analyze this data after patients have reached their goals would give us Physiotherapists potentially lost data that insurers and our profession requires to strengthen our perceived value. 

I am so relieved that somewhere among us physiotherapists, are those like the commentators on this blog that reflect my own experiences and beliefs-- and how I interact with patients/clients.  The down side is that my approach continues to impact  very negatively on my ability to "compete" financially with commodity-based physio!

I have been enjoying and learning from these Reps. I feel it was a great idea to review these types of situations. It has brought some clarification to my practice and reminded me of the importance of keeping an eye on billing practices. My only criticism is that in a couple of these Reps we seem to be putting the Chiropractic profession down. I've heard many physiotherapists, course instructors and mentors make similar comments throughout my career and I myself was once guilty of doing the same. Instead of putting down the entire profession, perhaps we can just continue to focus on making our profession better. The video from Aviva showing the Chiropractor and lawyer was eye opening for sure and I'm glad to have watched it. I certainly hope physiotherapists in Canada have not behaved in similar fashions but can we please stop bashing other professions to make ours seem better? 

 

 

Well Said ! 

Without the proof of improvement in patients results, It would be hard to convince any insurance companies , Goverment or even patients what the Physios are cable of doing ,and the real value in taking physiotherapy.  It's really important regulatory body takes  steps to educate Physios to use one common system to measure outcome of any patients . 

 

A couple years ago I called a clinic near me and asked for an appointment with a PHYSICAL THERAPIST. When I showed up a Dr. XXX came out and introduced himself. I pointed out that a PT can't use the title Doctor and he said he was a chiropractor. This happened at another clinic a couple months later. In neither case did I stay for the appointment. This is a marketing issue for the chiros and totally inappropriate. I wrote to their College about the general issue, though I have no idea if they did anything about it (it wasn't a complaint about the specific individuals, since I didn't remember either one's name). 

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