Chuck Klosterman, author of Sex, Drugs, and Cocoa Puffs, will tell you that you absolutely can compare apples to oranges. However, he’s never worked in health care. Sure, both apples and oranges are fruits—just like all patients are people. But picture this: two PT clinics—both alike in dignity, in fair USA, where we lay our scene. One clinic averages 10 visits per case; the other, 20. If that’s all you have to go by, then you probably assume the first clinic is much more efficient—and effective—at patient care.

Not so fast. After all, case and patient mix are critical factors. Perhaps the second clinic treats patients with more severe injuries or complicated pre-existing conditions. Thus, comparing clinics based solely on case-load efficacy is unfair. To truly measure the quality of care provided, one must examine the patient outcomes achieved.

But again, we run into an apples-to-oranges problem. Considering scores of regularly completed outcome measurement tools (OMTs) alone, one clinic may demonstrate faster functional improvement compared to other clinics. However, certain patients heal better than others. Let’s use two ACL reconstruction rehab patients as an example: one takes 10 visits longer to achieve the same level of function as the other. But that's not necessarily a reflection of the quality of the care each patient received, because one patient is 30 years older than the other and also suffers from knee osteoarthritis. Both patients receive excellent care, and both patients get better. But without taking into account these critical patient case details, all you have on paper is a visit count—and that’s not the sole way practitioners want to be judged.

Thus, if clinicians don’t take complicating factors into account, then the quality of their data, the justification of their care, and ultimately, the legitimacy of PT in general are all invalid. And that hurts bottom lines, as this study from the Journal of the American Physical Therapy Association explains: “assessments of provider performance that are tied to public reporting or financial incentives that are based on unadjusted outcomes may penalize providers treating the sickest patients who fail to show enough improvement or require more visits in a treatment episode.”

So, how do practitioners account for complicating factors consistently and at scale? Enter risk adjustment. According to this overview published on CMS’s website, “The purpose of risk adjustment when comparing outcome rates (e.g., hospitalization rates) for two different patient samples is to statistically compensate (or adjust) for risk factor differences in the two samples so that the outcome rates can be compared legitimately despite the differences in risk factors.”

Whereas unadjusted outcomes can lead to poor payment or penalties, risk-adjusted outcomes—and the valid data they provide—help level the data playing field. According to this risk adjustment primer by the Veterans Health Administration (VHA), “risk adjustment facilitates more rational resource allocation based on need. Most capitated payment methods use some type of risk adjustment to come up with payment amounts that take into account providers’ resource requirements for treating their patients.”

Furthermore, risk-adjusted OMTs allow healthcare practitioners and payers to establish baselines for tracking quality and efficacy over time, both internally and across facilities, regions, and the country. Similarly, such measures allow practitioners to prove the effectiveness of specific treatments or interventions. “Without adequate risk adjustment, it is impossible to say whether perceived improvements in patient outcomes reflect better treatment, healthier patients or other factors,” states the VHA primer.

To circle back to our two ACL patients, let’s assume the therapists regularly use the lower extremity functional scale (LEFS) to assess improvement throughout both episodes of care. LEFS accounts for age and other complicating factors. Thus, the therapists are able to better—and more fairly—assess and prove the efficacy of their care.

For all of the above reasons, OMTs must be risk-adjusted, which means test results take into account differing levels of patient complexity, such as age, weight, litigation, diabetes, cancer, and heart disease. (For a list of some of the most popular risk-adjusted OMTs, check out this post.) Patient complexity doesn’t end with the aforementioned comorbidities, though. According to the VHA primer:

Geographic factors, population densities and distances between facilities may have profound effects on practice patterns, access to care and patient outcomes. Coverage limits that differ across state medical aid programs may influence veterans’ illness severity, as well as the spectrum of services those veterans seek from VHA. In addition, recent research has shown that higher patient income is positively associated with better clinical outcomes.

And as the previously cited CMS overview states, “In general, risk factors for an outcome are chosen first by conceptually and clinically specifying the potential risk factors, and then assessing which ones are empirically related to the outcome.” (For a deeper dive into the methodologies and processes for developing those models, I recommend this CMS overview. While it focuses specifically on home health, its discussion of risk adjustment is very informative.)


Payment reform is happening, and the key to ensuring not only proper payment, but also physical therapy’s rightful place in the care continuum, is outcomes data. But it has to be the right outcomes data. And as Heidi stated in her recent founder letter, that’s data that is “measureable, comparable, actionable, and perhaps most importantly, meaningful to all stakeholders.” Risk-adjustment ensures the comparability of data, which moves PTs one step closer to proving their worth and effecting change with payers. To frame it Matt Damon-style, it empowers you to ask, “How you like dem apples?

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  • Outcomes: A Clinician’s Simple Perspective Image

    articleMar 30, 2016 | 6 min. read

    Outcomes: A Clinician’s Simple Perspective

    International performance improvement expert H. James Harrington said, “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”  Using outcomes instruments is an effective and relatively easy method for measuring and understanding a patient’s response to treatment. With a clearer understanding of patient responses to therapy interventions, …

  • Is PT Valuable? Why Outcomes Data is the Proof We Need Image

    webinarFeb 3, 2016

    Is PT Valuable? Why Outcomes Data is the Proof We Need

    In this day and age, it seems like everybody wants more for less—and that’s certainly true in the healthcare realm. With nationwide reform efforts pushing providers to deliver higher-quality care at a lower cost, value—and the ability to prove it—is absolutely critical. Most rehab therapists will tell you the services they provide are more valuable than anyone knows. And that’s precisely the problem. No one knows the value of physical and occupational therapy. But outcomes tracking can …

  • WebPT + Outcomes: A PT Software Love Story Image

    articleMar 7, 2016 | 7 min. read

    WebPT + Outcomes: A PT Software Love Story

    Developing and launching WebPT Outcomes has been a labor of love—one that’s lasted about 15 months. At times, it felt more like the kind of love you’d have for a sibling—after he or she pushes you off the bunk bed and you split your lip open. You know, that kind of love. But, after lots of triumphs—and just as many fat lips—it’s been wonderful seeing the fruits of our labor come to life. Hello, WebPT Outcomes: the …

  • Which Outcome Measurement Tool Should I Use and When? Image

    articleFeb 18, 2016 | 5 min. read

    Which Outcome Measurement Tool Should I Use and When?

    WebPT Outcomes  is the first fully-integrated outcomes tracking software specifically for PTs and OTs. One big way that WebPT Outcomes differs from other rehab therapy outcomes tracking software is the outcome measurement tools (OMTs) our product contains. As WebPT co-founder Heidi Jannenga explained in this founder letter , “historically, therapists haven’t had access to outcomes tracking tools that (1) align with the type of care they provide, including the conditions they typically treat, and (2) produce data …

  • Founder Letter: Why Data is Only One Part of the Value Story Image

    articleMar 9, 2016 | 7 min. read

    Founder Letter: Why Data is Only One Part of the Value Story

    Over the past several months, I’ve talked a lot about how therapists can prove their value (namely, through tracking outcomes data ). But, even though data provides the value proof we need, it’s not the end of the story. It’s up to us to turn that data into something meaningful—something we can act on that will actually help us demonstrate the value of our care. And that means using data in conjunction with defensible documentation to inform …

  • Fight for Your Right to PT: 10 To-Dos from the 10th Annual Graham Sessions Image

    articleJan 24, 2017 | 17 min. read

    Fight for Your Right to PT: 10 To-Dos from the 10th Annual Graham Sessions

    The first rule of the Graham Sessions is that you don’t talk about the Graham Sessions. Well, sort of. This annual “think tank” event isn’t quite as clandestine as Fight Club, but the rules are definitely a bit different than those associated with any other PT industry conference. After all, the point of this meeting is, quite simply, to talk—to have real, open, honest conversations about the controversial issues facing the physical therapy community. And to ensure …

  • Founder Letter: Why I’m Betting on Outcomes Image

    articleFeb 4, 2016 | 5 min. read

    Founder Letter: Why I’m Betting on Outcomes

    I’m not much of a gambler. Some folks enjoy the rush that comes with putting all their chips on the table and risking everything on a single roll of the dice. Well, no offense to all you card sharks out there, but if I’m going to go all in, it better be on something I’m pretty darn sure of. So, when I say I’m betting on outcomes, you know I’m not bluffing. In fact, I’m 100% confident …

  • Founder Letter: Is the World Ready to #ChoosePT? Image

    articleOct 4, 2016 | 9 min. read

    Founder Letter: Is the World Ready to #ChoosePT?

    Fall is officially here—and all across the country, people are enjoying cozy sweaters, crisp mornings, and pumpkin spice lattes. For those of us in the physical therapy space, fall brings another exciting seasonal ritual: National Physical Therapy Month (NPTM) . Each October, the PT community—led by the APTA—unites around a specific theme as we celebrate and promote our profession. In an effort to bring even more attention to its #ChoosePT campaign, the APTA has decided to make …

  • Outcomes and OMT FAQ Image

    articleApr 26, 2016 | 11 min. read

    Outcomes and OMT FAQ

    In January, we hosted a webinar focused on the importance of outcomes tracking in physical therapy. In addition to explaining why it’s absolutely critical that therapists collect objective data on patient progress, we highlighted a few of the reports available in WebPT Outcomes . With the move to a value-based payment environment already in full swing, outcomes tracking is a hot topic in the physical therapy space, and that meant lots of thoughtful question from our webinar …

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