Most of the time, when I attend a conference—whether that be a physical therapy, healthcare technology, business, or leadership conference—I do so because I want to connect with, and learn from, others in my field. I want to take in and absorb their knowledge to supplement and expand the depth of my own expertise. And most of the conferences I attend—including the Graham Sessions—allow me to do just that. But, this year’s Graham Sessions were different. As in past years, there was plenty of knowledge-sharing—and, of course, opinion-sharing—on everything from how the physical therapy profession should brand itself to what we should be teaching our students. But, what set my fourth consecutive Graham Sessions experience apart from the rest wasn’t necessarily the insight I gleaned from my peers; it was the opportunity to look within myself—to explore the origin of my own perspectives and how they relate to and impact my colleagues, our patients, our profession, and the healthcare community at large. And the timing for such a reflective exercise couldn’t have been better. With WebPT’s official 10-year anniversary coming up in a few weeks, I’ve been thinking a lot about all that we—and when I say “we,” I mean not only our company, but also the entire rehab therapy industry—have accomplished over the past decade. And now, I’d like to share some of my thoughts with you. So, without further ado, here are my top takeaways from the 2018 Graham Sessions:
We are humans treating humans.
We, as physical therapists, like to talk about ourselves as evidence-based practitioners. And that is an accurate label; all of our best practices and clinical guidelines are derived from scientific evidence. But, while physical therapy—and medicine in general—is science-based, patient treatment is not an exact science. Why? Because our patients, like us, are human.
Research and evidence only get us so far.
As such, there is no formula for patient care. We are not mathematicians selecting and applying theorems to different types of problems. The variables we must contend with are not quite as obvious as the X and Y in a linear equation. But, teasing out those variables is part of our job—and it’s part of what separates us from other types of care providers. The level of intimacy we have with our patients is unrivaled by any other medical specialist—with respect to not only the hands-on care we provide, but also the relationships we develop over the course of multiple treatment sessions. Compared to other treatment avenues, physical therapy is very much a process, and building trust and rapport with our patients throughout that process is important. It helps us identify and solve for the variables that make our patients human—variables we can’t screen for using any evidence-based test. And the manner in which we address those variables can have a major impact on patient outcomes.
I’m not saying that science isn’t important. On the contrary, I believe the dearth of data and research in physical therapy is one of our greatest weaknesses as a profession. But, there is a huge gap between cold, hard evidence and knowledge application, and our success as clinical experts hinges on our ability to take evidence derived from the study of large populations and effectively apply it to individual human beings (i.e., our patients).
Human beings are inherently biased.
Another variable that comes with being human: Bias. Now, to the administrators and authors of clinical research studies, “bias” is a four-letter word. And even among those of us outside of the research world, bias isn’t something we’re super-comfortable talking about, especially when the topic of conversation is our own personal biases. During perhaps one of the most memorable and eye-opening discussions in Graham Sessions history—at least in the history of my participation in this conference—an incredibly provocative (and, at times, incredibly uncomfortable) discussion unfolded around how our individual biases influence everything from how we hire to how we care for our patients.
To overcome our biases, we must talk about them.
At the beginning of this session, the panelists and moderator encouraged us to embrace the discomfort—after all, that was the point. And that was the reason the Graham Sessions—which are famously “off-the-record”—provided the perfect environment for this conversation to happen. In the course of a little more than an hour, everyone in the room came to some hard realizations about how they perceive the world around them and how their inherent preferences influence every action they take, whether they know it or not.
There is a diversity problem in physical therapy.
In this particular session, we explored the relationship between our individual implicit biases and the lack of overall diversity in the PT profession. One look around the room at the Graham Sessions spoke volumes about this issue. As one speaker noted, approximately 80% of physical therapists are white. And as another pointed out, this presents a major roadblock in our journey to achieve our overarching mission—as defined within the APTA vision statement—to transform society. “How can we transform society when our profession doesn’t look like society?” asked one attendee.
Our lack of diversity may be keeping patients from seeking our care.
Our cultural homogeneity doesn’t just impact our ability to help every single patient who could benefit from our care; it also impacts those patients’ access to our care. Patient care—especially in physical therapy—is a two-way street. Earning trust and forming strong, collaborative relationships with our patients is integral to their success, and while we can certainly improve our own ability to do that by recognizing and taking ownership of our implicit biases, we must also remember that our patients are human, too—and, as such, have their own implicit biases that influence their healthcare choices. So, we must ask ourselves, are patients comfortable seeking care from a provider who doesn’t look like they do? And when they are asking those in their immediate personal networks—their friends and family members—for healthcare recommendations, as so many patients do, are they being encouraged to see physical therapists? For many segments of the population, I’m willing to bet the answer to those questions is a resounding “no.”
Solving the diversity issue means looking beyond hiring practices.
But aside from tackling this issue at the individual provider level, what can we do to address the glaring lack of diversity in physical therapy? It’s easy to say that practice owners and managers can be more aware of how their biases impact their hiring decisions. But as multiple attendees pointed out, this issue runs much deeper, because we can’t interview and hire candidates who aren’t there. So really, this starts at the educational level—and even earlier. It starts with making this career path accessible and desirable to a wider segment of would-be PT students—which may mean taking a hard look at the seemingly inflated cost associated with our DPT programs. It starts with increasing our visibility in communities and care settings where we are not currently well represented. It starts with forming partnerships and relationships with those outside of our profession—and outside of our current individual networks—to expand our collective reach and our individual perspectives.
After all, as one speaker so poignantly explained, our default reaction to the mere suggestion of bias is to eliminate it—to go “colorblind.” But, she said, that is not an effective or realistic solution; in fact, it is virtually impossible. Instead, we must acknowledge and adjust for it; we must see it in order to navigate it—to chart a path for change. Because while humans, like all animals, instinctively want to be with our tribe, our pack, those who are like us, what makes us human—in the words of another attendee—is that we realize it, which means we are capable of changing it.
There’s more to health and medicine than the interventions providers deliver.
As I mentioned before, our patients—like us—are human beings. And while they all have the same muscles, joints, and ligaments, no two patients have the same cultural background, personal values, and communication style. Still, all of those factors influence the success of the treatment we provide, and it’s why we are taught from very early on to “treat the whole patient.”
At this point, those words are almost cliché in the healthcare world. But have you ever really stopped to think about what they mean? What really constitutes the “whole patient?” During our training and education, we learn to consider and solve for the external factors that may influence our patients’ success—things like their home environment, access to equipment, emotional stability, motivation, and family support.
Health care only accounts for 20% of health outcomes.
But when we look at those factors through a broader lens, we can start to understand their impact at the community level. What are the influencing factors that are affecting our patients’—and potential patients’—ability to access, and achieve success with, physical therapy services? For example, do they have the transportation necessary to travel to our clinics? Are their childcare responsibilities holding them back from accessing or attending therapy? Remember, as Karen DeSalvo explained during last fall’s Ascend conference, “health care itself only accounts for about 20% of overall health outcomes.” In line with the illustration that accompanied her presentation, DeSalvo referred to this segment—which has traditionally been our main focus as healthcare providers—as the “blue box.”
Collaboration—inside and outside of health care—is key to improving the health of populations.
But, that doesn’t mean we have to limit ourselves to influencing 20% of our patients’ health. By looking beyond simple demographics and seeking to truly understand our communities, we can tap into the other 80% in more ways than we might realize. For example, we can form partnerships and collaborative relationships with other healthcare providers—and even non-providers (think ride-sharing and childcare services)—to create a culture of patient-centered care in our communities. That means putting our siloed, fragmented past to bed and embracing the opportunity to collaborate with those outside of our own profession. Physicians and chiropractors don’t have to be the enemy—nor should they be.
As one attendee explained, over the last several decades, in our laser-focused drive to achieve autonomy and independence, we’ve isolated ourselves from the rest of the healthcare community. Now, with models for both payment and care becoming increasingly collaborative, we must work to undo that. And as many attendees noted, this focus on collaboration should be built into modern PT school curricula. Physical therapy students should have the opportunity to learn and practice alongside their peers in other medical programs, and vice-versa. I, like many other Graham Sessions attendees, believe that the model for future healthcare collaboration will be formed in today’s classrooms—and it’s about time physical therapy educators start accounting for that.
Data will bridge the value-based payment gap.
Even as care becomes increasingly patient-centered and value-based, payment models—especially those that apply to physical therapists—continue to lag behind. And that puts us in the awkward position of trying to deliver efficient, high-quality care while being financially incentivized to deliver high-volume care, regardless of its quality. But, while it may seem counterintuitive, we can’t afford to wait for the incentives to change, because by then, we will have made ourselves irrelevant. If we continue to dig our heels in and operate solely in a fee-for-service capacity, then five or ten years down the road, our payers will see us only as a cost to be reduced or eliminated—fat to be trimmed, so to speak.
But, if we proactively gather data that proves the value we provide—and proactively use that data to insert ourselves into payment arrangements featuring a value component—then we can ensure our relevancy in the long term. I’ve been urging PTs to track outcomes data for a long time now, and the counterargument I hear time and time again is that even with data, therapists often earn only modest rate increases—not enough to have a significant impact on their revenue or profit margins. And that’s a fair point. But, based on what I’ve heard at the Graham Sessions—this year and in previous years—the real problem is that there’s a disconnect between the data we present and the way our payers are able to apply that data. Again, fee-for-service is a complicated animal—not to mention one that’s en route to extinction.
It’s time to flip the insurance payment script.
So, why not flip the script? Why not pre-empt the inevitable transition to episodic, value-based payment and go to the payer with our own pay-for-quality models? Remember, our payers have needs and problems they’re trying to solve for, too. Put yourself in their shoes and think of ways you can help them. You already know—or at least I hope you know—that you can reduce their costs, because physical therapy is a much more cost-effective treatment option compared to more expensive and invasive interventions like surgery and pharmaceuticals. So, deliver data points that help prove that—and put skin in the game with payment models that hinge on your ability to deliver that value. And bear in mind that from our payers’ perspective, the more data we have to support the efficacy and cost-efficiency of our care, the more open they’ll be to our ideas and suggestions. That means we have to get over our fear of “exposing ourselves” by sharing our data for large-scale research and analysis efforts. We have to step back and see the bigger picture. This isn’t about competing with each other; it isn’t about one practice stealing patients and revenue from another. It’s about elevating the entire profession—in the eyes of our peers, our patients, and our payers.
That way, we can stop fretting over which CPT codes to use and how many units to bill, and start focusing on what we need to do to get our patients better in the most efficient way possible. And isn’t that what we all want to do anyway? Value-based payment isn’t something to be afraid of; rather, it’s an opportunity for us to do what we do best—and be rewarded for it.
Our patients are our payers.
For decades, health care has been running on a “middle-man” model. Patients were disconnected from the insurance companies that paid their medical bills. Now that we’ve entered the era of high-deductible health plans, however, patients are no longer passive participants in the payment process. They are personally responsible for a greater portion of their healthcare costs than ever before, which means they are taking greater control of their healthcare decisions. They are putting more time into researching their care options and selecting the ones that will give them the most bang for their buck. And they are looking for data to back up their decisions.
As one of this year’s speakers—who happens to work for an insurance company—postulated, healthcare consumers are already starting to demand this sort of comparative data. And one day, it will be there—and it will be publicly available. And if that’s the case, don’t you want to be in control of it? Don’t you want to be the one collecting and providing it?
We must meet patients where they are.
Furthermore, just as we must start thinking outside of the traditional third-party insurance model, we also must start thinking outside of the traditional patient acquisition model. I think we all know by now that we can’t rely on physician referrals forever—especially considering the increasingly consolidated nature of healthcare business in general. Instead, we must begin to consider ways we can meet patients where they are—perhaps even before they actually become patients. During my brief stint as a “shark” in the 2018 Graham Sessions’ version of the hit TV show “Shark Tank,” I had the opportunity to hear from several therapists who are innovating the manner in which patients learn about and access physical therapy care—by creating fitness-based clinics, providing cash-based home therapy, acting as healthcare managers in concierge-style practices, and even treating patients in the emergency room.
At the end of the day, our future as physical therapists depends largely on our ability to step back from the comfort of what we know and consider the unfamiliar. It’s about, as one speaker put it, “reading the tea leaves.” It’s about anticipating trends, challenging the status quo, and realizing that “because we’ve always done it this way” isn’t a good enough reason to continue down the path we are on. Because quite frankly, that mode of thinking has done way more harm that good. But, it’s not too late to change course, to look within ourselves and find the strength and motivation to create the physical therapy profession we all want to see—for ourselves, our patients, and our future colleagues.