With snow boots cinched and hot coffees in hand, thousands of physical therapy professionals and students have descended upon chilly Indianapolis, Indiana, for the American Physical Therapy Association’s (APTA) annual Combined Sections Meeting (CSM). In addition to checking out the latest and greatest PT tools and technologies—including, ahem, certain cloud-based EMR software—on the trade show floor, attendees will spend the next few days filling their brains with all of the latest and greatest PT news and research during the meeting’s educational sessions. But you don’t have to pack a parka and catch a plane to Indy to get in on all the informational goodness, because I’m serving it up right here on the WebPT Blog. Here’s my frontline recap from CSM day one. Be sure to check back tomorrow for another delicious helping of knowledge.    

Session: Opportunities for PTs to Shape Prevention Practices and Outcomes

If you think all the chatter about driving down healthcare costs in America is starting to sound like a broken record, you’re not alone. What you might not realize is that some of our nation’s most expensive ailments are chronic—and often, appropriate treatment can help reduce the frequency and severity of their associated symptoms and complications. Take heart disease and cancer, for example: these two chronic conditions account for 48% of all deaths in this country—and more than $140 billion a year in healthcare costs.

Add in the fact that about half of all American adults suffer from at least one chronic condition, and it’s pretty clear that PTs have a huge opportunity in the realm of preventive care. After all, the more effective providers are in preventing the onset of major complications through appropriate—not to mention non-surgical and non-pharmacological—disease management, the less money payers and patients have to dole out to cover expenses associated with more invasive treatments. “If we [PTs] can impact some of those issues involved in those diseases, we can make a big, big, difference with prevention,” Anne Mejia-Downs, PT, MPH, said during this session, which she co-presented with Susan Scherer, PT, PhD.

The trick is moving away from the current “sick care” paradigm—the one that is generating billions of dollars in wasteful spending—and toward a model that favors preventive intervention. In theory, that type of shift would create massive savings downstream. For example, 10% of all factors leading to premature death are healthcare-related, whereas 40% are tied to behavioral patterns. This means that when it comes to preventing death—and promoting better health—healthcare providers can get a lot more bang for their buck (literally) if they focus on changing behavioral patterns. These include:

  • tobacco use
  • diet
  • physical inactivity
  • alcohol misuse

“If we could just impact those four issues, we could make a bigger splash in the water than we might think we can,” Mejia-Downs said. And bear in mind that “prevention” isn’t limited to stopping people from ever developing these conditions; the concept of prevention also applies to those who already suffer from chronic disease. In fact, there are three main levels of prevention:

  • primary (i.e., total avoidance)
  • secondary (i.e., early detection)
  • tertiary (i.e., damage control)

To facilitate more effective prevention at every level, the federal government and various independent agencies have released several sets of guidelines and recommendations for addressing the environmental factors—known as determinants of health—that often lead to chronic health conditions. These range from the US Preventive Services Task Force Guidelines and the National Prevention Strategy to the National Physical Activity Guidelines and the Dietary Guidelines for Americans, 2010.

But how do PTs put the principles contained in these massive documents into practice within their own clinics—especially considering the glaring lack of a concrete system for reimbursing such efforts? As Scherer mentioned during the presentation, even though the Affordable Care Act makes abundantly clear the government’s emphasis on promoting wellness and preventive services, “Our system isn’t really designed to integrate the payment for wellness and prevention.” So, the answer to the payment question, at least at this point, is for each practitioner to participate to the extent to which he or she is able—at whichever level he or she can manage. Ideally, those efforts would lead to a higher quality of care and better patient outcomes—which in turn would boost patient satisfaction and improve business health.

PTs are uniquely poised to drive all three shades of prevention. They can accomplish this in two ways:

  • within their own clinics by enhancing patient care (e.g., adding blood pressure screening to the initial examination to identify patients at high risk of certain chronic diseases)
  • at scale by becoming partners in health promotion and wellness (e.g., getting involved in public policy or joining forces with wellness facilities and health clubs)

Therapists also can assert their value as preventive care providers by getting involved in healthcare policy formation. But you don’t have to go lobby on Capitol Hill to effect change in this area. If you’re a PT, you can have a hand in moving your profession forward simply by supporting—and providing feedback on—APTA initiatives, including the Association’s official recommendation that “all individuals visit a physical therapist at least annually to promote optimal health, wellness, and fitness, as well as to slow the progression of impairments, functional limitations, and disabilities.”

As with any endeavor—including the prevention of chronic disease—the key is to be proactive, rather than reactive.

Session: Tales from the Trenches: Direct Access as a Mindset Through the Continuum of Care

Direct access isn’t just a law; it’s a mindset. That was the basis of this open-forum discussion with panelists Karen Litzy, PT, DPT; Kyle Ridgeway, PT, DPT; and Ann Wendel, PT, ATC, CMTPT. Physical therapists often talk about direct access in terms of the legal policies that dictate a patient’s ability to seek physical therapy services without a physician’s referral. And because these laws vary so much from state to state, many conversations about the value of direct access end up derailing into a back-and-forth volley of “in my state, PTs can do X” versus “in my state, PTs can’t do Y.”

The way Ridgeway sees it, though, PTs can’t truly have universal, unrestricted direct access—regardless of what the law says—until they integrate the proper mindset into the way they practice. “Fundamentally, before we even talk about the logistics and the legislation, we have to talk about, ‘What is the mindset of a direct access practitioner?’” he said.

As this presentation brought to light, the unfortunate reality is that only 18 states have complete, unrestricted direct access to physical therapy services—and most of those states passed their direct access legislation back in the 1980s, before HMOs and managed care delivery models established physicians as the “center of everything,” Litzy explained. Since then, it’s been much more difficult for PTs and their advocates to push direct access bills through individual state legislatures.

Still, despite the existing legal barriers that prevent PTs from freely providing their patients with the type, frequency, and duration of therapy treatment that they—as doctorate-level medical professionals—see fit, physical therapists shouldn’t simply accept a fate of eternally bowing down to physicians and other legally-designated primary care providers. PTs can still take it upon themselves to consistently practice, as Ridgeway put it, at “the top of their license.” That terminology, too, has taken on a variety of connotations, but essentially, it refers to providing treatment that is on par with the full suite of capabilities garnered from one’s training. That means making confident decisions about all patient care that falls within the PT scope of practice—and, in some cases, knowing when a patient’s needs fall outside of that scope. In other words, as Ridgeway summarized, “We have to own it.”

And for PTs to truly own their roles as vital members of a patient’s full medical team—something that will only become more important as the standard model for healthcare delivery becomes increasingly collaborative in nature—they have to foster “a culture of accountability” within their own profession, Ridgeway said. Litzy echoed Ridgeway on that point: “If this person is coming directly to you, the buck kind of stops with you.” That burden of responsibility makes some PTs uncomfortable—fearful, even—and that is precisely the mindset PTs must abandon if they ever want to reap the full benefits of direct access and command the level of respect they deserve. “I know there are physical therapists who are afraid of direct access, and my question to them is, why? What makes you think you can’t do this?” Wendel argued. “We’re trained to be out there doing this, and if there’s hesitation—if there’s an issue—then you should be addressing it. We can’t hide.” Plus, as Ridgeway pointed out, many PTs—even the ones who are uneasy about breaking out of the established referral process—already practice with somewhat of a direct access mindset, even if they don’t realize it. For example, a PT is embracing a direct access mindset simply by evaluating a patient and getting excited about finding something a physician missed.

Beyond the risk many PTs associate with direct access, there also is the issue of referrals. That, too, boils down to perspective. Because to let go of the physician-referral business model, PTs must change the way they think about referral sources. This is a topic to which we’ve dedicated a lot of screen space here on the WebPT Blog, and today’s panelists reiterated what we’ve said before: potential referral sources are everywhere. It’s up to PTs to find them and, more importantly, build relationships with them. They can be massage therapists, acupuncturists, shoe store employees, running group leaders, and even hair stylists. And don’t forget about the referral power of the almighty search engine. As patients grow more and more tech-savvy, Google searches may soon become providers’ most important source of referrals. And that means all PTs—including those who work in institutional settings—need to have some type of web presence. “Even if you don’t have your own practice, get yourself a landing page,” Litzy said. “It doesn’t have to be a full, fleshed-out website. But it’s important for you to be online, regardless of what setting you’re in.” Furthermore—and this also is a topic we’ve covered extensively here at WebPT—PTs should never underestimate the power of generating referrals to other providers, especially physicians, as those providers are likely to reciprocate referrals down the road.

Of course, even if PTs can collectively buy into a direct access-centered mode of thinking, the puzzle will never be complete without the legislative piece. So, in addition to adopting fresh perspectives, PTs must continue to advocate for the adoption of fresh legislation. As one audience member pointed out, ““We are physical therapists; we are musculoskeletal experts. And that’s really where it should stop.” But to make sure that it’s where it actually does stop, all PTs—regardless of specialty or treatment setting—must continue to get involved, especially at the state level. As Wendel said, “Direct access is not just an outpatient physical therapy issue…it’s something that impacts all of us, and it’s something our profession really needs to get on board with…We’re all in this together, and we need to take responsibility.”


Stay tuned; my report from the front lines of CSM continues tomorrow. Are you in Indy? What have been your favorite presentations and key takeaways? Share in the comments below.