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Transcript
Marla: [00:00:00] Welcome to the Practice Growth Podcast. Dana, it is such a pleasure to have you today. Thank you
Dana: for
Marla: having me, Marla and Prompt. And it is really a treat because you are a PT turned policy expert, um, and you are the senior director of public policy and government affairs at a Fortune 10 company, and have a lot of the insight into areas that we don't really always understand as clinicians or clinic owners.
Um, so can't wait to pick your brain today and ask you a ton of questions related to value-based care, outcomes, reimbursement, and just what's going on in the PT industry, and how we can help make a change-
Dana: Mm-hmm ...
Marla: or what, if we don't do, what potentially could happen-
Dana: Mm-hmm ... in the future. So happy to talk about those things.
Marla: So let's dive into your background first- Yeah ... because I'd love to know, and our listeners probably want to know, what exactly is the senior director of public policy and government affairs, and tell us a little bit about what you do
Dana: in your day-to-day. Mm-hmm. Well, I didn't know what government affairs was until five years ago, and I have been a PT since 1998, probably before anybody here.
Um, and so I, my long history short is I was a clinician for a long time. I worked in inpatient rehab, I worked in outpatient neuro, then I was in sports medicine, and I did outpatient. And then I moved to home health, where I saw a lot of the opportunity in the frail and vulnerable population, [00:01:30] and started to see opportunities to align what was good for our business and home health with things that were not making sense in healthcare.
So I'll give you an example of kind of interesting. 2001, so this is really a long time ago, um, I had come from inpatient rehab, and I would see a lot of total joint replacements, right, on my caseload alongside traumatic brain injuries and CBAs and amputees. And so all these complex patients and then simple joint replacements.
And what was pretty obvious was they were up and moving, even in 2001, very quickly. And we were sending, in our health system in northern New Jersey, we were sending our patients, right, that our physicians operated on, to... It was mostly I was working at Kessler Inpatient Rehab. They did great, but what happened was they went from there straight to outpatient.
Great trajectory. However, they didn't medically need to be there, right? And so what we identified way before the comprehensive care for joint replacement model was these patients can come to home health, remain in our health system, but aligning that with what's best for the patient, which is keeping them moving, preventing another transition and its risks, right, preventing other nosocomial infections.
And what aligned on a third level was the Medicare fee for being in inpatient rehab was $17,000 about, and it was at that time about 3,000 in home health So we were doing better for our system, [00:03:00] we were doing better for patients, and we were saving about $14,000 an episode for Medicare. Now, Medicare wasn't talking about this at the time, but it really bugged me that we were, in effect, wasting this money, and even back then we were talking about Medicare running out of money.
So we started this program way before anybody was talking about it. Hospital for Special Surgery was sending us all of their patients early because we were the only ones doing it. So we were very well prepared for episodes of care when they came along. Anyway, went from lot of home care years to doing some transitions of care work, um, as a clinical liaison, and again, seeing terrible vulner- like, vulnerable populations not being prioritized for what's best for them, but rather what would extend their length of stay in a skilled nursing facility, which that's the one site of care where you get paid per day, so there's no incentive to discharge patients or to, you know, provide patient education or family training.
And it was coming from inpatient rehab prior. Horror show to me. I just couldn't believe what I was seeing. This coincided with the Affordable Care Act and the beginning of a lot of innovative programs, bundle programs, the ACOs. So our organization started a population health department, and I went into that as a founding member, went into a leadership role, and then created a team that worked in skilled nursing facilities, in patient rehab, the [00:04:30] hospital, and again, found an alignment between what's best for patients, what's gonna be the best for the health system to benefit financially from reducing costs, right?
And reducing the risk of readmissions and complications when patients are going through the system, remaining in inpatient sites of care. Um, and so led a very financially successful program. Again, like, I was a, a pioneer, essentially, a little unicorn. I spent a lot of time learning on my own. Right? Spent a lot of time in my off hours, "How does this work?
How does... Why is this this way?" And then I was recruited to a startup, um, a very, very small startup where I was a, you know, an original leader. And from there, I decided to go to, um, kind of a medium-sized company. Came in under client success and was quickly brought into the government affairs team, which I didn't know what that was.
But essentially, I was a policy expert in value-based care programs, and they just-- There wasn't a lot of them. There still aren't a lot of value-based care policy experts. So is that... Should I maybe move on now to what I do as part of my job? What does it look like?
Marla: Yeah. Wow. I mean, first let's just go back and say what an awesome experience that you've actually Had to be in all the different parts of physical therapy- Yes
and seen from inpatient to outpatient to hospital settings- Mm-hmm ... uh, to, as you said, even on, on strokes and rehab. Uh, so really great that you had that experience and [00:06:00] that public policy kind of found you.
Dana: Yeah.
Marla: Um and you saw the need and the areas for efficiency- Mm-hmm ... um, and ended up in this role. So with that, love to hear a little bit more about what your role entails in your day-to-day and kind of what, what you're working on right now.
Dana: Yeah. Um, so, you know, government affairs makes up a couple of different components for, you know, the healthcare community. I- besides therapists, I find most really don't know it, and certainly, I didn't five years ago. So it makes up basically two main components, those who do direct advocacy, so they're lobbyists or advocating for whatever it is, either their organization or a coalition is trying to accomplish and needs policy change or is defending a policy that works for them.
Um, and then there's the public policy team. So these are, um, folks that generally they're either attorneys or they have master's in public policy as their kind of originating profession, and we do a couple of main things. We analyze, uh, policy that's either impending or is just coming out or proposals and anticipate what policies are likely to come out because of certain trends, because of things that are being prioritized by policymakers, et cetera.
And then we work with business, whatever business or coalition we work for, we work with them to identify risks and opportunities in both the policies that are [00:07:30] coming because they've been proposed or because they're in the works, um, and then risks where, let's say, a business is doing something that depends on a policy either remaining in place or changing and potentially needing to pivot if those risks build.
So we try to be like, I, I, I like to describe public policy professionals, which is where I sit in government affairs, we're like an in-between between the government and our lobbyists and the businesses that we work for. The li- the policy team is the one that works with CMS and the innovation center. So regardless of what payer we're talking about, the administration, right, so whoever is elected, the administration is who runs CMS and the innovation center, which is what most of healthcare delivery cares about, right, on the policy side.
And then we watch for and analyze policies that are coming up legislatively. Now, legislation moves v- very slow, and most everything that ends up turning up, you know, gets marked up in a committee and ends up in a bill, almost nothing ever makes it to a vote or a vote in both the House and the Senate and then getting signed So very little actually ends up, you know, turning into something real, but some things absolutely do.
And then we'll also make proposals, so organizations, like large organizations, large coalitions, will write policy that, and maybe recommend to committee [00:09:00] members in the House or the Senate that they consider a policy, um, or, you know, write, even help write a bill so that we can hand them something to consider that maybe aligns with something that that particular person wants to prioritize for their own agenda.
So it's a very, policy's a very strategic role in healthcare. Um, I'm trying to think of what else. So, oh, the other thing is I represent the organization I work for on a bunch of coalitions. So for, um, for us, it's really value-based care organizations. They can be made up of health systems. Sometimes they're health tech companies.
Sometimes they are physician practices. They can be payers, depending on which type of organization. So I sit on policy committees for some. I sit on specialist committees, um, just depending on what that organization is, and I try to influence, um, policy that is best for both our organization and as, you know, best for patients.
So that's, in a nutshell, what I do. Wow.
Marla: Wow, such a, a foreign world, but really exciting to be able to hear more about being an in in there, right? Yeah. So for, for that perspective, you know, we are always trying to figure out, okay, what can we be doing as physical therapists, occupational, speech, to help move the needle, to help get reimbursement rates up, to help show our [00:10:30] outcomes?
And you get to see every day about how CMS and payers are thinking about-
Dana: Mm-hmm ...
Marla: all these different pieces that we are so concerned on. We're trying to say, "Hey, look at us. Look at what great things we're doing. Look at prevention, that we are, we're helping with the healthcare spending and savings."
Mm-hmm. And we're doing a really bad job at winning at that game.
Dana: Mm-hmm.
Marla: So would love to know from you, what do these payers and CMS, 'cause we all know CMS leads the charge- Mm-hmm ... and everything follows, what, what do they really care about? What metrics are they looking at- Yeah ... that maybe we should focus on a little bit more, um, as the rehab clinicians and, and owners?
Dana: Yep. So, uh, one of the re- reasons I'm in policy is because it's as far upstream as you can get Right? So l- I kinda wanna lead with that because it's where policy is and where it's going and why is what I think therapists and most healthcare professionals don't pay, and they don't have time. Uh, this is, believe me, not a value judgment.
But knowing what is happening at the policy level and why what matters could turn into something real is extremely important. So, you know, where we are in health policy when it comes to healthcare delivery and payer policy is there- we are increasingly, you know, spending a tremendous amount, way more than any other industrialized nation, to get far worse outcomes, [00:12:00] right?
No one is worse in the industrialized world than us in life expectancy and infant mortality. It is just abominable, and we can't keep spending the gre- to the degree that we're spending, which is not, uh, therapy. It... Right? We're not the cause of the spending, so let me start with that. We are the opportunity.
So we have this environment where limited dollars that either come from employers, who pay for benefits, or from taxpayers, who pay for CMS and Medicaid, right? Those dollars are being used faster than we can replenish them, and that is just a fact. There is not enough money. There's a budget deficit every year for, right, CMS.
Every single year we see physician fee schedule cut, and that's because the spending is so outpacing how they can budget for it. So, you know, there's a lot... Just as an example, the conversion factor issue. Every year we have a conversion factor cut, and what I want PTs to know about what that means in a bigger level is the conversion factor's one piece of what makes up reimbursement, right?
So conversion factor, whatever that dollar amount is, is multiplied by the weight of the value of the codes that we bill for. So the conversion factor is not something that a PT is going to have any influence over changing. Reality is medical specialists are the [00:13:30] ones that are doing most of that, and we are not necessarily adding to that conversation, right?
They're the ones driving up the bill for the most part. But where I see a lot of opportunity is in demonstrating that the value that we create is not being captured in the weight of the codes that we're given, right, and the value assigned to those codes. So, like, the physician fee schedule and every payer bases, to one degree or another, bases how they pay on what Medicare pays So the value that's assigned to each of the codes that we use is going to determine our reimbursement.
The conversion factor is something we can't control, really, for, for all intents and purposes. But the weight of the codes and the codes available, that can change, right? And that's controlled by the American Medical Association, the CPT editorial board, and the RVU committee, and codes can be created and codes can be reweighted.
So the trend that I'd love for your listeners to hear, the trend over the last few years, both administrations, so this was under Biden, and we're seeing it again now under Trump and those that they appoint, is they are reassigning the weight of codes towards primary care. And the reason for that, in a nutshell, is they are time-based codes, and much of the work done and that needs to be done by primary care is [00:15:00] not something that's transactional.
So primary care, when it works the most beautifully, is team-based. It is relationship building. It's trust building. It's longitudinal. You know? It's not transactional. But primary care does not have the time, based on the structure of the codes they bill, to spend that time and to hire enough staff to support the work they do.
Specialist physicians h- do not have that issue. They're not time-based. They can do more procedures. They can see more patients, and their codes, the AMA has decided long ago, their, that their codes are weighted much more heavily. So the spending, you know, when we see physician spending is going down, or physician reimbursement, it's not all physician.
Specialist physicians are going like this. Hockey stick. They're able to do more and more procedures and interventions. Primary care and the like are going like this because they cannot keep up with the change, so the conversion factor multiplied by their codes is killing them. So what we saw the last administration do and now we're seeing this administration do is say, "You know what?
We're gonna look at this differently. We're gonna start taking some of the weight of these codes over here in the non-time-based specialty, and we're gonna add weight to the primary care codes because we need primary care to hire teams, and we need to create incentives for them to do longitudinal care because we don't want all the care [00:16:30] going to specialty.
We don't want people, you know, ending up in the hospital because we're not spending the time to coach and train them and engage them in their care." So primary care and enabling and incentivizing the primary care community is like goal number one, two, and three. It, it's not political. All right? This is- The way they go about it may be a little bit different, but primary care and funding of primary care is a top goal of, you know, policymakers in general.
And so what therapists, I think, really need to know about this is you wanna be aligned with primary care for the simple fact that we do a lot of the same things that a primary care physician or an advanced practice provider working with primary care does. We build relationships. We try to change behavior.
We build trust. We coach and train. This is the same as primary care. But what happened in the physician fee schedule this year? What happened? We got a cut, right? We got a cut even though we are time-based. Everyone else, behavioral health, that sits in primary care a lot, the PCPs, geriatricians, they all got a raise.
We are not thought of as part of that primary care team. We are thought of as a specialty, as a referral, and that is hurting us. We do not make the dollars, as everybody listening to this knows, of medical specialists. So we don't-- While we absolutely [00:18:00] need specialists in physical therapy, we have heavily weighted towards positioning ourselves as specialists, and we have not weighted ourselves enough in the area where we have to drive spending.
The more we spend on primary care, the less we spend everywhere else. We know that time and time again. So when a zero-sum game, where there's a pot of money, and it has to be spread across everybody, if the dollars are shifting to primary care and away from specialty care, why would we wanna be over there?
Marla: Yeah. That is a huge opportunity. Uh, it's great to hear because that means there's an opportunity for physical therapists, occupational, speech, to kind of take this- Yep ... and say, "How do we realign ourselves?" Yeah. How do we stop complaining about the reimbursement decrease-
Dana: Mm-hmm ...
Marla: and where we sit in the ecosystem, and what do we do to align ourselves more with primary care-
Dana: Mm-hmm
Marla: be more primary care, preventative, and take that, that area and space that we know we are oh so good at? So turn that back on you. Yeah. What should, what should clinicians in the rehab industry be doing right now to get into that primary care space and stop being known as specialists, but be known as primary care- Yeah
providers and the first point of contact? Mm-hmm.
Dana: And I clarify a little to say, because there w- there's always skeptics that say, "No, we're not primary care," or those that believe we can sit independently in primary care, which we cannot. We are not full scope providers. We can't do [00:19:30] injections. We're not...
Right? We're not doing interventions. We can't be independent primary care providers. But physicians, I argue, shouldn't be either. They can't treat musculoskeletal issues. They, they have very limited tools for doing something about that. So, right, you have primary care docs, you have specialty care docs.
Then you have behavioral health that do primary care, general behavioral health, and then we have specialty. Physical therapy kind of sits in its own, like, universe, right? We know what we do, but the, the fact is that the providers that have access to folks directly that are, you know, the first line of thinking, I either go to primary care or urgent care or the ER, they don't have any awareness of PT as a primary place to receive frontline care.
We've done all this work in direct access, right? We have really coached our therapists to think of themselves that way. But, but what really drives a change at the, like, high level is we need champions. We can't be our own champions. It doesn't work, right? We are a tiny, tiny fraction of spend, and that is good and bad, right?
We're a fraction of spend, so they don't see us as the opportunity. So, it is really an, I see, an inevitable need to embed to some degree primary care in team-based, or bed PTs in team-based primary care. And where there's opportunity for that, the [00:21:00] lowest hanging fruit is advanced primary care organizations that are participating in value-based care models.
And here's why. At the far end of the spectrum, like, to really make this concrete, in a value-based care world at the extreme, what that looks like in primary care is the payer, whoever it is, pays monthly to the practice. They pay them based on both historical spend, and if they weren't spending enough in primary care, more.
And then they look, besides paying them perspectively, they will look back at the end of the year and say, "Oh, you saved a lot of money from specialty care, from hospital care, expected historical spend, so we're going to give you more money as the incentive for doing this team-based care and having teams around you."
So the key there is they don't care about units of billing, right? These teams are not paid based on their volume. So every, you know, that, like, volume not... Value, not volume. What that really means is they don't care about billing units. They care about the best possible outcomes, meaning we avoid high-cost specialty care, we avoid unnecessary imaging, and for gosh sakes, we avoid the hospital.
And we do that by wrapping our arms around the population we serve and building trust, building engagement, using [00:22:30] all kinds of awesome tools so that they use us As a first line. And so where they have behavioral health embedded, very common. You'll see primary care, you'll see registered nurses doing chronic care management, you'll see MSWs, right?
They're doing social needs, they're making home visits. The gaping hole is musculoskeletal balance, safety, gait, all of those things that no matter what anybody says, physicians are not ideal at treating, and most PCPs will tell you. They don't have a big toolbox. They refer. The problem with referrals is it depends on people actually going, it depends on their historical experience with therapy.
So if they used to, you know, let's say they went 10 years ago, therapist had them coming for three months, three times a week, people don't wanna invest that kind of time anymore. That is old school. We've got to rethink how we do that, right? So those old impressions, they live on. And to change how the primary care community thinks of us and how policymakers think of us, we need to be there where patients are, and just like they do in behavioral health...
Okay, physician, let's say physician sees them. They have anxiety and depression. We're gonna collaborate with the behavioral health provider. They're- we're gonna form a team, and we're gonna figure out what they really truly need, and we're gonna co-manage, and maybe behavioral health is doing all of the management.
So you can imagine, someone comes in, they're unsafe as they're walking or they're complaining of knee pain, [00:24:00] whatever. The PT's in there, right? The PCP learns the PT is the one that can help me and help our team manage that patient effectively. Now I don't have to worry that they're not gonna make that referral.
I don't have to worry that they're gonna be concerned about co-pays and additional visits and specialty visits. They don't have transportation, no problem. They're here already, or we provide transportation. And so as we change the vision in the healthcare community of who we are, what we do, that allows us to build this foundation upon which we grow the profession into the frontline caregivers that we know we are, but everybody else doesn't know, truly.
There's not... We're not talked about in the healthcare community very little . So let me stop there, because I'm, uh, doing a lot of the talking.
Marla: Well, now that, that's like the chicken and the egg, right? Mm-hmm. Which one, which one comes first? And you're absolutely right. We need to be embedded in those primary care groups.
Yep. We need to be part of them. We need to set ourselves up, be the fall risk specialist, be taking care of patients as like a population health sort of- Mm-hmm ... aspect. But as an outpatient provider- Right ... listening right now or clinic owner, how would you recommend they- Yeah ... do that? Because let's say they, they do try to create these value-based care agreements, no one's paying them value-based care pricing.
They're still getting paid- Yeah ... fee-for-service. Correct. So what is, if you say- Correct ... step one- Yep ... of engaging in this value-based care and an actionable item that people could say- Yep ... "I can do that."
Dana: Yep. So [00:25:30] a couple things. If I'm, let's say I'm a clinic owner And I know, and you can-- anything that's CMS-related programs, you can access online and just see who's participating in a program, like the ACO REACH program or the Medicare Shared Savings Program as examples.
Um, and you can identify who's in these models, and when you learn what the levers are for their success, you can proactively outreach and demonstrate how you can help them. So some simple, simple things. If, let's say, I'm a clinic owner, I have an ortho, um, physician that refers a lot of patients to me.
Let's say I identify when I'm, you know, taking a history and physical that they don't have a primary care provider, and I know that these couple of clinics are in value-based arrangements doing team-based care. You can offer, you know, suggest the, the role of primary care in helping them in their healthcare journey and be willing to help connect them to one of these advanced primary care organizations.
It doesn't even have to be one that is in full risk. It could be one that's just participating in some arrangements, but one that is focused on team-based care. Those organizations, those physician groups will also care a lot about annual wellness visits for a whole host of reasons that maybe we go into in a part two.
But part of the annual wellness visit are things like doing full risk screenings. So if I [00:27:00] know I'm getting-- let's say I'm seeing a patient that was maybe referred, maybe somebody wrote a prescription, maybe they just came to me. I can reach out to that primary care provider and say, "I did this full risk screening," and there's other things that you could do that are part of the annual wellness visit, just as a courtesy.
Here's what I'm finding. I'm gonna help them make an appointment or find a, you know, sign a business agreement or BAA and help them schedule that appointment with the primary care doc so they get in for their annual wellness visit. The annual wellness visit is a key source of success in value-based care contracts, and there's always a fight by providers to figure out, how do I get my patients in?
So when you can be, like, aware of the levers that matter to a primary care organization, you can outreach to them proactively and say, "I know that this is an issue. I'm willing to help you with this." Yeah.
Marla: So it's not just the doctor, though, because you could do that- Right ... primary care doctor and be like, great, you share patients back and forth- Right
but nothing's changing at the level of the reimbursement. Right. You have to reach out to the organization, and as you said, you can look these up on CMS. Is that accurate? Yep. CMS.gov. If you look at the Medicare Shared Savings Program or the ACO REACH program will list all of the entities, yes. And then work with that organization to say, "This is what I can do for you-" And then would the organization be paying a value-based agreement?
You would set up that value-based agreement with them, and they would be paying you instead of the insurance, or no? Do I get [00:28:30] that wrong?
Dana: No, it's not that you have it wrong. I think that's kinda step four. Okay. First is y- if we were to just approach, a therapist just approach any org- like, any primary care organization, um, with, "Here's what I wanna do, now pay me for it," there's all kinds of people that are approaching them with that.
There's all kinds of specialists that are asking for what they call subcapitated agreements. It... There... It has to be a step one where practices learn the value we can bring to them. So the annual wellness visit's one example. An easier one is access to care, access to very rapid evaluations, access to even potentially, like, a therapy clinic offering two days a week for half a day, having a therapist on site so that they can immediately get evaluated, demonstrate their value, and start to show them the practice, which will trickle up to whoever is, you know, working with the risk-bearing entity, um, what they can do to support them.
And it is building trust really that gets you to the place eventually where you say, "How can we be partners in this?"
Marla: Mm-hmm.
Dana: Right? It, it cannot and will not be right away, again, because there's no awareness, right? They're also going to want to... If you're gonna propose, you need-- "You should reimburse me for helping create value for you," unless you can show them first, "Here's why," because the data [00:30:00] clearly demonstrates that when I'm involved and my practice is involved earlier, I help you reduce that spending that's avoidable, like the specialist, like the imaging.
Um, when you can show those things tangibly with data, they're open ears because the... you're speaking their same language, right? They wanna reduce those things. They can only pull so many levers. If you can be a provider that aligns with them, demonstrate that, then you open the other doors. I think we want value-based care to be, you know, they're just gonna get into an agreement with us.
But payers are still working really hard to get even primary care to get into agreements because p- generally providers are scared. Fee-for-service is what they know, right? So providers that, let's say I'm a primary care practice, generally with a payer they'll start with pay-for-performance, so they may get a, you know, a small bonus based upon a few quality metrics.
They'll move to something like upside only, so if you do well, we give you a bonus. If you don't do well, we're not gonna penalize you. Then they move to downside risk, right? So we'll give you more if you do well, but we're also gonna penalize you if you don't. So the providers have been on that trajectory- And we need to s- get on that trajectory where we start with proving that we should be part of that conversation, start on pay for performance, and progress towards being part of the full value team.
I think that's, that is a [00:31:30] key takeaway from the audience is we have to show our value to the people that it matters to. We can s- we can say it to, you know, an ecosystem that may not be listening, but the ones that have the incentive to care are those that run value-based care organizations and know the levers for success and the providers working in those organizations.
Marla: Now, you keep saying show the data, the value, which I 100% agree with. Yeah. And all of us- Yeah ... are, are trying for that right now. Like, what are we doing to show better outcomes? What are we doing to show the value?
Dana: Yeah.
Marla: But I'd love to know what we think and we show to the payers may be very different than- Yeah
what they want to see or what we have in our hands, right? Yeah. Like downstream spend, data claims. We don't have access to that. So how do you recommend us, as providers and clinic owners, to be able to sh- get that data, show it- Mm-hmm ... and what is the data that they're looking for?
Dana: Yeah. So the way right now, if I'm a health system or I'm a, I'm a primary care practice or I have a chain of primary care practices, what I will generally do is figure out what my qu- opportunity is, and this is what that looks like.
Organizations will go to, um, one of a couple of entity data company types, so a VDRC, and I will have to tell you after what that stands for 'cause I, I will mess it up, or a QE, which is a qualified entity. These are organizations that purchase claims data from [00:33:00] CMS and other payers, and they directly can link for anyone who is willing to subscribe to the data that they have.
They can link across annual- annually, look at their population, and connect interventions that happened or didn't with spending patterns. So simply, like, if we think about what a therapist can influence, if i- it kind of an if-then, what we wanna be able to say is, "If we have very quick access to patients, let's say, with low back pain-" Oh
then their spending on total healthcare cost drops." We are creating value, not just the dollars that we're spending, um, for the patient. We're creating value because we are lowering the annual cost of care for that person, that individual person. So when we l- you know, so when I was in the health system, we did this.
We looked-- We didn't focus on physical therapy because, again, we're this much of the pie. We were looking at things like- Inpatient rehab spend, skilled nursing spend, sur- you know, surgeries, um, imaging. And we would look to link this provider with this kind of spend and look for aberrations, good and bad.
So who are our high-value providers? Who, when a patient with X diagnosis is with this provider, yields the best both outcome and spending? And the goal of these contracts is to do both, right? You [00:34:30] want to reduce the total cost of care, which requires reducing hospitals and specialists, I know I'm a broken record, um, and you want to improve the outcomes, and the two of those together are what really create value.
So if the worst thing, if we're looking at that data, and we identify a therapy, two therapy clinics, one, when they get a patient with a low back pain diagnosis, let's say, um, that patient ends up predictably going to a certain specialist. Maybe that specialist is a low-value specialist. They do way, you know, above two standard deviations of low back surgeries that they shouldn't compared to other specialists.
You can look and track that and identify where a practice has a pattern of treatment and referral that is not benefiting the organization taking risk. And a payer can do this too, right? Payers, they don't tend-- they're not yet looking, that I know of, much at therapy, but they, I think they will. So especially because we're starting to see some of that in some of the little models that are coming up that therapists are benefiting from, again, larger conversation.
But what therapists think of as outcomes, we wanna reframe. Not that those outcomes don't matter, but if you're talking about creating value in a finite amount of dollars in a population, so payers have dollars. They can't make more dollars. They're given dollars by the sponsor, either CMS or the employer, [00:36:00] whatever, and they have to use those judiciously.
If I'm a therapy clinic owner, here's what I want the data to say. When I have early access to a patient, let's stick with low back pain, they not only don't go to specialists at the same rate as those around me, right, the clinics around me, but when they do go to a specialist, they go to the high-value specialists, where the data shows they are doing interventions on the right patients at the right time.
They don't have, right, a hockey stick of surgery as soon as they see a patient, for example. We also wanna see that even when I, quote, "discharge," I hate that word, when we discharge a patient from a regular service That even after they're discharged, they don't go off on their own and go for imaging or go to a specialist down the line.
So we wanna be able to say, "Not only did I have an impact when I had them, they didn't go to the ER, they were not on opioids," right? They didn't go to a specialist during that time. Of course, unless it's medically necessary, caveat, right? But then down the line, even when I wasn't seeing them regularly, they didn't go to specialists.
They came to me. They called us again if they needed something, and we had that influence that spanned an episode that looks ... Doesn't matter how long the episode is with therapy. Let's say it's a six-month episode. There's arbitrary nu- you know, time frame sometimes. That we look different and better than someone else.
If you're looking at the [00:37:30] data, we are higher value, we create more value than the others. If I'm a primary care practice or I'm a payer, I wanna partner with that clinic. Is the payer looking at our data? No. But if we , if, like, a large organization works with one of these data entities, you can find they will work with you to analyze that data.
You can find how valuable or invaluable you are, or high, high cost or low cost, and then make changes so that you can present yourself after that with a great story of here's how our practice changes the trajectory of care, leads patients to the best value providers down the line, and avoids unnecessary and avoidable other care.
That's the story we wanna be able to tell to anybody who asks.
Marla: Ooh. And that's absolutely what we probably are doing a lot of the time. Yeah. We just aren't telling the story. Right. Or being able to. That's right. So what I hear from you, being part of Prompt and, and EMR and technology- Mm-hmm ... is that, um, the infrastructures, the, the EMRs, and this, you know, hopefully we talk again in a year and I'm able to show you some new stuff that we've done, uh, should be able to maybe partner with these claims data and these- Yes
different groups that we can pull that in, and then the providers and the organizations, the PT groups and owners can share that story. Right. They can have access. Because that's a missing piece right now. Like, I can say my, I know my providers are [00:39:00] saving all these back patients. We have direct access.
Right. They're coming to us. Do we do a really good job? Yeah. But we're not proving that back to the entities, so we're not getting any better value-based care agreements.
Dana: They're not looking for it. No. That's the thing. They're not looking. We have to bring it proactively without seeming like we're right away looking for something in return.
We want them to say, "Oh, my goodness. We didn't think to look at this opportunity." But now we see an o- as the payer or the at-risk provider, now we see an opportunity. The more we use this practice The more we partner with them, the less we spend and the better our attributed patients do. We want more of that because now ther- you as the therapy organization, you understand what matters to them, and everyone cares about what matters to them.
We do the same thing, but those who really excel and are gonna be the innovators in the PT space are gonna be the ones that know what matters to the people that need to amplify our value. So know what it is you wanna show. Once you have a chance to look at the opportunity or the risk in your data, you can then work on it.
You can figure out what strategies you want, you know, to implement, and then you can speak to that story so beautifully and effectively with anyone who asks. You want the data to show you are high value in every way, shape, and form, and in ways that you don't think of. I'm gonna tell you, and I'm gonna show you the exact numbers.
Here's what we [00:40:30] saved compared to that type of journey or that type of journey. When I was in the health system, just as a little side note, because this was so effective, I would bring skilled nursing facilities together, tremendous opportunity, you know, to do better in that space. And I, you know, we would unblind to the organizations we worked with, patient journeys per organization.
And so we would deep dive into these journeys. We would go into the data. We went into all the EMRs. We figured out what the story was, and we would show the spending in different parts of the journey, and then what was the final outcome? So a bad outcome at a high level would be patients spend 100 days in the skilled nursing facility, and then they were back in the east- in the ICU, spent $200,000, and then died on a ventilator or went back.
They used up their days, then they couldn't. And then we s- what was the return on investment of them spending $70,000 in skilled nursing to end up in the ICU versus having them in for a short time, getting them transitioned home, empowering the patient and family, talking about serious illness and end-of-life care, and then showing what other provide-- We would unblind it and say, "This is what this provider did.
You, provider over there, you need to do better." Because if we are telling the patients in the hospital, "This is the type of outcomes and the partnership we have, you wanna be one of these providers. You don't wanna be one of these," [00:42:00] it's incredibly effective. Incredibly effective. So at some point, you know, we have bring that awareness to those who have the incentive to care, right?
Those that have the incentive to care, we show them how our work creates value and meets their needs, right? It's things that they care about: access Outcomes and spending as the, you know, main levers, um, then ears are wide open. But if we don't know what each other are talking about, they don't know what we do really.
I mean, they, again, just the healthcare ecosystem thinks they know what PT does. They don't really.
Marla: So the easiest way to really do that right now- Yeah ... let's say you don't have access to claims data is- Mm-hmm ... to work with a employer group, and to actually- Yeah ... do that in that setting- Yeah ... and say, "Show me..."
Because they know their data. Right. They know their, how much spend is happening. "Show me, show me some areas where your highest risks are. We're gonna come in- Yeah ... and provide care to your employees- Yes ... at a rate." You know, I don't know if you can give us a, maybe what's a good rate to say that is, right?
"And then we do that for a year, and we show you, and look at the data to show that you actually spent less in dollars elsewhere- Yeah ...
Dana: specialist, shots,
Marla: ICU, EA,
Dana: and so forth." Yeah, yeah, yeah. Self-insured employers are the way to go. If you are using a third-party insurer completely separately, they are not gonna have access to that [00:43:30] data.
It's the self-insured employers that are taking on all of the risk themselves. They're the ones that are going to have more transparency and be willing to look at novel solutions. What I would caution against is offering a capitated rate. That's not value, right? We can't pay a rate and expect a different outcome.
It is, what we want to move towards is getting paid a higher, I think in the short term at least, getting paid a higher amount, uh, for our services, and then getting paid bonuses based upon us impacting the total cost of care. Because when we separate spending from outcomes, we aren't changing, it's still fee-for-service, right?
We're taking a bundled price, but that's not bundled payment. Bundled payment in the value-based world means, let's say it's capitated. Let's say we do do capitated. Okay, we'll take $1,000 for this episode, but we will also be given on the back end at the end of the year, we will be getting a portion of the savings when you look at the difference between the historical experience of this type of patient versus what we accomplished, we want additional dollars.
We are underpaid on a fee-for-service basis. Not just- Tremendously. Tremendously underpaid. Not, so not just on the value side, we need more upfront now, right? So that's where, like, wa- talking to CMS about here's the value we can create, but we are [00:45:00] losing, we're not, we're not able to, you know, attract and retain even as many therapists as we need to.
We need higher reimbursement, and we deserve it because the value we create is so high. We need more upfront money, first of all, so either higher bundled payment- Followed by a reconciliation so we can get even higher bonuses, but we need it right now. And that's the dichotomy, right, where, you know, if you look at what primary care, what a payer will do is they'll say, "What is this?
You've spent 3% total cost of care on primary care. That's not enough. You can't manage a population with 3%. We are gonna pay you 7% of the total cost of care upfront monthly. And then based upon your impact on the total cost of care, we're gonna also share in the savings that you create." So you can have primary care practices making 50% more on the regular if they build out a team and keep people out of the hospital, keep them doing advanced primary care more within the primary care setting.
We wanna get there, but we have to start with more reimbursement.
Marla: Yeah.
Dana: I mean, we are just underpaid.
Marla: Well, th- I mean, goodness gracious, I, I love that model, and I think that is exactly how therapists and providers should be paid. So how can we solely as a Marla Renery who's a, who's a provider- Yeah ... who can reach out to CMS at any time-
Dana: Yeah
Marla: and collectively as a group, an entity, an organization, what should we be doing now to set ourselves up to [00:46:30] make that change and get paid more?
Dana: Yeah, so there's different ways individually you can, you know, think about your role. Some of that's gonna depend on y- your personality. Like, what are you interested and willing to do?
Is it more, um, getting a group together, putting a presentation together, and then reaching out to CMS, the schedulers, and asking for a meeting so that you can present an argument for what you want, and why? And understand whatever you present has to also align with their goals, right? All their- Yeah, which we just talked about.
So if you're... Exactly. Yeah. It's the same with policymakers. So it's a good time to talk about this. What does this administration CMS care about? Prevention, primary, secondary, tertiary prevention. They care about, um, leveraging tech to make care safer, more affordable, more actionable, to incentivize behavior change.
Um, and you know, like I said, they care a lot about primary care, and they care about providers being aware of the role that they can play. They have to meet those goals. They are investing in those goals. And the models, the payment models they put out, you'll see they all will track towards how do we incentivize participation in something or mandate participation so that we can get value and the patients get value in return.
So knowing what they care about, definitely wanna go into those [00:48:00] conversations knowing what have they been say- what has CMS and the Innovation Center been saying this year,
Marla: right? They put out a lot
Dana: recently. Tons. They blog over after blog after blog And they say what they mean, and they mean what they say.
When you read something they put out, like sometimes it'll be an executive order followed by CMS or the Innovation Center, sometimes it's Dr. Oz, sometime- it depends, you know, who's focused on it, will then put out their plan. They'll write a blog about it, then they might do a request for information. This is where therapists are not, at all that I know, getting involved in.
If an RFI, request for information, comes out from CMS, therapists think of every way possible you can present a valuable angle to answer that RFI. The purpose of request for information is to gather information so that they can use that information to create something that helps them meet their goals.
So know what their goals are, uh, you know, understand what the request for information is asking, sometimes it's fairly straightforward, and then think about what are all the ways I, as a PT, OT, ST, whatever, I and my clinic can, if given the right opportunity, can respond and help them meet that goal,
Marla: right?
So it's like the answer to the tests are there. That's right. They're putting
Dana: it
Marla: out there. That's right. They're saying, "This is what we care about. This is what we want to achieve." It has to be us, as providers, actually reading it, looking at it- That's right ... diving into it, asking for a meeting with CMS, and then putting a little bit of effort into [00:49:30] presenting what, we have to be thoughtful, thinking how can we-
Dana: Mm-hmm
Marla: take what you want and show you a plan to put that forward. Now, do you think, let's say we did put the effort to do that- Yeah ... individually or as a group, a lot of people say, "Is that really gonna help?"
Dana: Yeah, that absolutely helps, 100%. I, I mean, there's several s- you know, specific things that I have had a chance to give feedback on that have led to what we see in a model.
So, um, you know, I think at this point, a lot of therapists are aware of the TEAM model, the Transforming Episode Accountability Model. It's an acute hospital model, acute care surgery, uh, followed by 30 days after. The hospital's responsible for the total spend, so if everybody outside spends too much, the hospital has to pay back CMS if it's different from their target price, what they expect to pay.
Now, it's 450 pages, the first proposal, so I understand that a lot of therapists didn't read it.
Marla: It's a lot to read.
Dana: I- it's my job, so I read it. Um, but they specifically called out that hospitals should consider partnering with outpatient therapy clinics. They even gave them an acronym. How many therapists do you think even know that that's in there?
They mean a value-based contract. What they're saying is, develop a partnership where if they are willing to do this to make you successful, the agreement says they will get something in return.
Marla: Wow.
Dana: So the hospital can't control things- outside of the [00:51:00] hospital, they can con- they can set the episode up for success, right?
They can prepare people. But they want to get people home, right? That's the goal of the model. Not inpatient care. We want them home, either going to outpatient rehab or outpatient in the home, or home health. That is what makes the model successful. Moving out the hospital, avoiding anything avoidable on the inpatient side and getting them home.
But the problem is, if the hospital doesn't have a strong relationship with the providers that can help them meet that goal, they can't just change their discharge patterns. They have to know that that handoff- Is there ... is, is there is something in place where they commit to being there when they need them, that they understand what makes them successful, and that they can truly be partners.
This go- this is an old story from old episodic models, but now they called out therapy clinics. Every therapy clinic in a Team-model geographic area should be reaching out to the hospital with, "Here is how I can help you. Here is how I can receive your patients. Here's what I will do." So one of the things, as an example, again, weedy, but the Team model requires that you connect back with your primary care doc.
They don't want there to be this void where someone's hospitalized and they never go back to their primary care doc. Again, primary care is the focus of the administration. But if [00:52:30] you go, and you know this, you know that it's in the model, you go to the hospital and say, "I will ensure that we get an appointment with that primary care doc, and we do our best to make sure that they have a way to get to that appointment," you're f- you're solving a problem for them that they can't easily solve themselves and taking the burden.
Now you're a partner. Once you partner in Team, you've opened the door to everything else that that health system could want to partner on. And then when you asked before, "Well, how do you get into these contracts?" This is a direct way to demonstrate your value. But if we don't take the opportunity glaring at us, what...
It's harder, right? So.
Marla: That is so, such a great nugget. That is such great advice. And I have to tell people, you don't have to read the 400-page document. You could have AI- Totally ... and say, "Please r-," and you upload it in Extract this. Right. Extract this information. This is what I want to do. This is the hospital I want to partner with.
This is the- Yeah ... piece that just came out. Help me put together a plan.
Dana: Right.
Marla: And there you go. Then go ahead and take that, take that action, because that's something that all providers would love to do, as, as- Yeah ... we had providers. We want to make it easy, accessible. And I, I love that part about having them have the date when they see their primary care provider, just like we have in our EMR system.
When's your next orthopedic surgery follow-up visit? Right. Right.
Dana: Same idea.
Marla: When is your next- Primary care provider visit. And if we can fit [00:54:00] that and help that, and then also talk back to the systems we're working with and say, "Are we affecting HEDIS measures?" Yeah. "How?" I really think we can set ourselves up for success and turn ourselves in a different spot in this ecosystem instead of where we are right now, which is, if anyone's not listening, if anyone's not watching, um, it's just going down.
Dana: Yeah. And I guess just to really drive home why I think team is such a big opportunity, you know, I talked all this time about outpatient providers. It is so much harder to pull levers with hospitals. Why is that? How do hospitals make money? Heads and meds. Every admission is their, that's their reimbursement.
There's not a way to incentivize not hospitalizing people when your money is hospitalizations. So there are ways that hospitals can impact total cost of care once a patient gets there, and one of them is saying, "You're gonna be responsible for what happens 30 days after." They know it worked from the BPCIA program, the Bundled Payment for Care Improvement Advanced.
They know it worked in CJR. This is the next iteration. They shrunk the time from 90 days out to 30 because they want them reconnected to primary care faster, and that was a barrier in the 90-day episodes, right? So they came right out and said, when they put the first 400 and some pages out, "Our goal is to scale this to as many DRGs," which is, that's how hospitals are [00:55:30] paid.
They're paid on one diagnosis. At the end, the coders decide on a diagnosis, and there's a reimbursement. That's how they're paid. So we wanna scale this to as many diagnostic related groups as possible. We're gonna start with these five we think are really low-hanging fruit, where the episodes have a lot of opportunity.
We can do a lot better. And as soon as, you know, when we see this works, we wanna... DRG plus 30 is a great way to get hospitals to do more and better with preparing people and setting up their trajectory for success. Readmission rates in some of these surgeries are just horrendous. Spending in unnecessary post-acute, horrendous.
Every transition of care leads to complications, med rec issues, you name it. We all know this, right? So there's every incentive this adminis- any administration has to figure out, well, what would incentivize a hospital to care more about something once they're discharged? And episodes of care are a really big way to do that.
The other is, um, hospital global budgets. So there's... We won't dive into this, but there is a model that is starting in Maryland and, um, replacing the Maryland model in January, and it's, and gonna be in six states
Marla: Yeah
Dana: And it's a global budget model, and what that means is the payer, Medicare, Medicaid, and it'll be one other payer, are going to pay upfront to the hospital.
The same as I told you about primary care. They're gonna pay them upfront. Now the incentive is, don't hospitalize them. [00:57:00] Do a better job when a patient ends up in the ER of saying, "Is this where they really belong?" Right? And if they don't, partner with primary care to help them stay out, 'cause we're gonna get paid anyway.
We're on a global budget. Hospitals don't l- generally love it, um, because they want... Like, all their goals are f- are based on more volume. So you have to be willing to think very differently to get into global budgets. But this administration really likes this idea, and, you know, w- would expect to see more of it.
Again, more in the community. So we have these two big levers for hospitals, not a heck of a lot more, right? So doctors, outpatient providers, lots you can do, but their goals are to prevent the hospitalization. So what can we do on the hospital side? Team is an important step, and everyone listening, realize they want to scale this so that as many hospitalizations as possible, the hospital's responsible for the payment that happens outside.
And that's based, again, for anybody who doesn't know, on a target price. If CMS says, "You have a hip fracture and an ORIF, and then there's 30 days after, you shouldn't spend," I'm making up a number, "You shouldn't spend more than f- $35,000." Well, if someone spends 30 days in a skilled nursing facility and the surgery, it's gonna be 50, 60, 70,000.
That extra money beyond that target is the responsibility of the hospital, nobody else, to pay back CMS. Now, that's individual, everything, [00:58:30] right? You put everything together and then see pluses and minuses, do we owe or do we get money back? But this could cause hospital losses. Everyone is motivated by what they could lose before they're motivated by what they can gain, right?
So, but they don't have easy ways to pull those levers. So we do. There's things we can do. So the,
Marla: it's happening right now in the new administration, the opportunity's there. Yep. The resources are there, just like you said.
Dana: Yep.
Marla: Team, a f- a few others. And I definitely- Yep ... would say to all of our listeners, you hear- heard it here first, so take-
Dana: Yeah
Marla: hold of the opportunity. Don't get stuck in our easy-to-repeat ways that we do every day, which is just following the fee for service, see a patient, length of stay. Branch out from that. Branch out to the CMS, branch out to your hospital systems, and- Yeah ... really be able to take hold of this information out, that's out there and say, "These are the models I can bring to you," and try it.
And I'd love any of our listeners that do, if you have success and kind of take this, please follow up with us, or they could probably reach out to you a little bit for some help as well. Um, but I definitely want to hopefully have people change where we're headed. And- Yes ... if there's last-minute advice for- Yeah
our listeners and our- Yeah ... our clinicians about where we are headed and just what they should be doing right now, some last-minute advice for them.
Dana: So I'll go to
Marla: something that I didn't bring up, which is data
Dana: integration interoperability, is that is sort [01:00:00] of the legacy that we're hearing from folks, you know, at CMS.
They want one of their legacies to be that they took leaps and bounds forward in interoperability. Th- this is something that we need to do a lot better with, right? So interoperability is every point of data can connect to every other so that payers and providers and patients can access their data, and then once payers have it, they can just do automatic pulls out of EMRs, anybody's EMRs, and anything else.
So, you know, wearables, for example, RPM, RTM, anything that's available that's data. When they reach this true interoperability, payers can just extract this from us. So there is complete transparency. So we can't hide behind certain documentation that we think is defensive because once you have the data and you apply AI and ML to it, and you decide what that algorithm's going to be, then you can really figure out on your own, without input from others, this is what quality looks like.
This is what good outcomes entail. So we have to be ready for a time when payers demand that you are interoperable with all of your providers you work with, and that they can access your APIs and extract everything right from your EMR. This is not 10 years away. This is happening now. [01:01:30] There are, I don't know how many hundreds of companies now, have committed to the h- the data health tech ecosystem commitment, where they're, you know, public companies and, and lots of other companies are saying, "Okay, we are going to get on board, and we are going to do everything we can to open up a- access to our data and help you CMS meet your goals."
And know that that's, that's right now. You can go on the health tech ecosystem on CMS. You can read all the companies. They are building by the day that have committed to this. Once that's available, the whole trajectory of healthcare changes. They don't need data reporting. It is just available to them.
So just to be, you know, aware of, interoperability is not a 10-year-away thing. It's happening now, and we have to be ready for us to be connected to anybody else in the he- in the, in the ecosystem.
Marla: So you're saying think ahead, be part of- Yes ... an EMR that's going to do that- Yes ... that's going to be interoperable, and, um, we, we partner very closely with Note2.
That is, yeah, on that you just said. Very cool. Um, and do have an open API, which is where we're, we're really headed for- That's awesome ... in the future. So happy to hear that that is a big takeaway and that that's not- Huge ... 10 years
Dana: away. It's
Marla: now. No. But the more interoperability, the easier access of sharing data- Mm-hmm
can be, I do think is where, where we'll get to. Yeah. Um, and hopefully being able to pull some claims data in, which I think is instrumental as well. It's the data sharing. It has to go both ways.
Dana: Yeah. Right? So claims data needs to be shared more, and [01:03:00] payers need access to the data directly. It's that bidirectional component that we're gonna be, we're moving towards now.
Um, and it goes through leaps and bounds, and then it can be slower, depending on the goals. This administration's goals are very much we know that we have to catch up with other industries that are doing this, and this will make our lives tremendously easier and more fair. And so, right, be ready, and since you guys are already, it sounds like, ready, that's great.
Marla: Absolutely. Well, I, I really appreciate all of these different tips and advice, and hopefully make some change for some of our listeners where they can, they can take this and be able to, um, say, have some items that they can work towards, uh, and a- appreciate the insights coming from someone who lives and breathes it every day.
Yeah. And is a PT, so you want to help the industry. I
Dana: want the industry to embrace this. There's so much opportunity right now, but we have to embrace it in order to get there.
Marla: And that's our final takeaway. Take the opportunity in front of us, embrace it- Yes ... and become more part of that primary care team.
Um, and thank you again. I
really
Dana: appreciate you- Oh ... being on our show. This is fun.
Marla: I love... I could talk about this all day. I'll have you on again, for
Dana: sure. All right. Thanks
again.