If you read last week’s post you know I left you on a little bit of a cliffhanger. That post focused on the impact primary care PT could have on the healthcare system overall. I had a lot of fun with that one. The potential of primary care PT is something I am so passionate about. As fun as it was talking about the big picture of primary care PT, it’s not the same as discussing the nitty gritty details of what that actually looks like in practice.
That’s exactly what I’d like to discuss this week. This post will focus on a few potential models for primary care, their pros, cons, potential barriers and some possible solutions to those barriers. Here’s last week’s post if you need to get caught up, but if not, read on!
Model 1: Sticking to What We Know
The first primary care PT model might be the easiest as many clinics are already doing this. It also requires the least amount of change. Basically everything stays the same within our private, hospital-based, or self employed outpatient services, except patients actually utilize direct access.
There’s several upsides to this model. The first obviously being that we don’t have to change any big overarching systems or processes. This model also maintains and even increases our autonomy clinically and from an entrepreneurial standpoint. Without relying on physician referrals we can treat patients without influence from a third party. This way we create our own marketing strategies to attract the right patients for our clinics.
Most of the time patients today are sent to us vs coming to us. There is a bit of a difference there. Yes, there still is a good chunk of the “sent” group that are open to PT and want to put in the work. However, there is another chunk of the “sent” group that we know all too well…
“I’m here so when therapy fails I can get my MRI”
“I just want a massage. I don’t really like to exercise”
“I’ll be honest I didn’t even try the exercises you gave me.”
These are the patients that don’t keep their appointments or are uncommitted if they return. This usually leads to lost revenue and burnt out clinicians. I know we’ve all experienced this. Sometimes these patients can be converted! Implementing direct access won’t eliminate these patients, but it gives us more of an opportunity to be our own best advocates. We can put out the message WE want to send about PT as a profession and our individual clinics. This will hopefully attract patients to us vs being sent.
While we may not have to change too many things in model one, there’s definitely some barriers to its successful implementation. Direct access does NOT mean we can see a patient as long as we want, as many times as we want, for whatever we want. MANY states require the signature of another HCP after a certain number of days or visits.
Here’s an example. In Missouri, where I practice, the law states a physical therapist must consult an approved healthcare provider every 30 days or 10 visits, whichever happens first and they CANNOT resume services until after this requirement is met.
The problem is that 1.) patients don’t know this and 2.) sometimes they don’t have an “approved healthcare provider”. So what happens when someone comes to a clinic via direct access and a 10th visit or 30 days is up and there’s no physician to reach out to?
If you practice in Alaska, Hawaii, Oregon, Idaho, Nevada, Arizona, Utah, Colorado, Wyoming, Montana, North Dakota, South Dakota, Nebraska, Iowa, Kentucky, West Virginia, North Carolina, Massachusetts, or Vermont – congrats, you don’t really have to worry about this as you have unrestricted direct access. Your states do NOT impose a rule for signatures after a certain number of days or visits.
For the rest of us, this is something we have to worry about. While we don’t need physician orders to get someone onto the schedule, we may need one to continue seeing them. Given this, it would be beneficial to get the PCP of each patient BEFORE they are evaluated.
How we get this info will be up to individual clinics. You have 2 choices though. You take the patient’s word for it this is actually a physician that knows them well and will sign a POC if needed, or, you call and confirm with the physician’s office. Regardless, this adds another admin burden (although a necessary one), unless you feel the patient can complete their PT before the time comes where you need another healthcare provider’s approval to continue treatment. If you’re unsure how long your window is, here is an updated ATPA resource that outlines the requirements by state.
The last drawback is one that’s maybe even more important for those states with unlimited access. Patients coming to you may have seen another healthcare provider days before you . . . or haven’t seen one in years. They have no idea what comorbidities they have. They likely haven’t been screened for red flags recently or maybe ever.
In order to protect both patients and ourselves, there’s some extra steps we probably want to take. For one, getting a more comprehensive medical history. Ask about known conditions, previous surgeries, family history, medications, red flag symptoms, alcohol/drug use, exercise, the last time they saw a doctor and finally . . . please take their vitals. I know you’re rolling your eyes right now, but you may be the first person to catch their hypertension or another abnormal vital sign and direct them to potentially life saving care. Remember, it’s not only protecting patients, but also ourselves from a legal standpoint!
So there’s model 1. Large big picture stuff stays the same, but we make modifications or take extra steps to implement successfully. A lot of pros, but definitely some things to be aware of that if done incorrectly could make things hard. Onto model 2 which is very different from model 1 and may even be new to a lot of you.
Model 2: All Under the Same Roof
I’ve seen this model discussed in several different places. The first time I read about it was in this 2019 study out of Sweden where PTs actually worked in the general practitioner’s office. Patients were scheduled directly with a PT versus the GP for musculoskeletal complaints within that same clinic.
Model 2 is different compared to how we do things now, but there’s some upsides. Direct triage to PT could increase utilization of direct access. Like I said in my last post, many patients don’t even know direct access exists. Part of the reason they call their GP for musculoskeletal pain is because they think they have to. This model could be the most effective in decreasing healthcare cost. It catches the patients who would have otherwise spent healthcare dollars for a primary care visit before seeing a PT.
Another big benefit of this model is it actually solves many of the issues from model 1 due to not having to worry about tracking down a PCP to sign POCs. If you need one they’re right there in the building! Not to mention it would be MUCH easier to communicate with the physician about a particular patient if needed. I mean how many times have you tried to call a physician’s office with no answer or leave a message only to never get a call back? It’s a lot easier to talk to someone when their office is just down the hall from you.
Being under the same roof as the MDs could lead to some really high quality care for patients. Red flag symptoms popping up? The PT can talk to the MD the same day and discuss in-person what’s going on, possibly leading to more timely and adequate care. Or what about neuro patients? A PT seeing a Parkinsons or MS patient and noticing some changes would be able to directly collaborate with the neurologist or GP. They can then direct the patient promptly to other therapies, treatments, or meds, for quality, multi-factorial management of a condition.
As you can see, model 2 sounds great for a lot of reasons. Though I firmly believe it only happens successfully if we all truly work as a team. If PTs and MDs are going to practice this closely together it’s going to take the right mix of individuals to make it happen. The PT or the physician cannot take on too much of a “big brother” role.
How long would you last in model 2 if someone was always looking over your shoulder? Or trying to over direct the exercises or approaches used in your treatment sessions? I probably couldn’t do it for very long. This goes both ways. If we start trying to suggest medications and other treatments that don’t fall within our scope, the MD isn’t gonna feel all that warm and fuzzy towards us either. Both sides will need to have mutual respect for the other’s individual skill set and knowledge for this to work.
We lose the autonomy that we’ve worked so hard to get if we get into GP offices only to let ourselves be completely dictated. We need to find physicians we could work with as partners. If I ever find myself considering working in this kind of model I think I would ask myself this question. “Would this person have my back if a patient asked to see “the real doctor”? Because you know that’s gonna happen…I think the answer would tell you all you need to know.
The other downside is more of a personal preference honestly, but one that I think is worth mentioning. In my first few years as a PT, I’ve learned so much by working with other PTs. I’m fortunate enough to have coworkers that are willing to share their knowledge and we often collaborate and pick each other’s brains for ideas.
In model 2, it may be possible you’re the only PT or one of just a couple PTs working under that roof. I personally think I would miss working with other PTs. I’m also still early in my career and PT’s more experienced than myself may not feel that way. This is something that could be remedied through strong mentorship relationships outside of the clinic or if the clinic itself provided good access to continuing education. Again, really more something I thought of based on personal experience, but felt it worth mentioning.
We’ve now gone through models 1 and 2 , both very different and have their own pros and cons. But is there a model where we merge the two?
Model 2.5: Physician Offices Triage to Independent Clinics
I present to you model 2.5, where the best bits of model 1 and 2 come together! Some of you may already operate where you get referrals from specific physician offices that aren’t necessarily tied to your clinic under the same system. Model 2.5 is like that, but just like in model 2, patients are triaged to clinics right from the get go instead of seeing the MD or NP prior to the physical therapist.
Pros are basically that of both model 1 and 2. We keep our autonomy as there’s some distance between us and MDs, but we know there’s someone to reach out to if we need a POC signature or want to communicate with them. We don’t have to change a lot of internal systems or how we do things, but increase the use of direct access.
This model does come with its own major con and a couple hefty unknowns. The major drawback is we’re still essentially relying on referrals from other physicians. This I know is something we’re wanting to move away from. We maintain our clinical autonomy in this model. The downside is we’re still chained to the idea of requiring MDs’ referrals to fuel our business. This puts us back in that space of patients being sent versus coming to us.
How would this work too? Would a MDs office work with multiple PT clinics or only one? What happens if that PT clinic is full and unable to schedule new patients? Who’s to say one clinic in the area doesn’t become a monopoly for all the referrals? I don’t think either is a good thing. I could also see this leading to increased mill PT practices that are absolutely detrimental to patients and the PT profession.
The big question mark with model 2.5 is would these physician offices even be up for it? I mean, there’s PT clinics out there that say “We’ll do what we can to squeeze in more patients and make more money.” I’m sure there’s physician offices that do the same. When faced with a choice of “cram this patient in and bring in more money for our clinic” or “refer this patient to a different clinic where they’ll make money from it instead”. I’m not entirely sure what they’d choose. Some doctors out there believe and support direct referral to PT. There’s also those who don’t believe we should have direct access or honestly would rather get the payout for themselves. Where the majority lies, I honestly don’t know, but it would play a huge impact on the possible success of a 2.5 model.
Preventive
The final model is sort of an add-on to the other two, but will need its own implementation plans. I talked about preventative PT in my last post. It could be integrated into model 1 or 2, with slight differences as far as how we get patients.
For Model 1 we’d try to turn current patients into users of preventive screenings by offering them a yearly “check up” to assess their movement and address any musculoskeletal concerns they may have. We could use marketing strategies of our choosing to advertise these as well to attract new patients!
I know a lot of clinics out there do either free or discounted one-time screenings to try to convert to patients, but that’s not what I’m talking about here. Plenty of other doctors get paid in full for different screenings. I mean your annual primary care visit is essentially a screening especially if you’re generally a healthy person. Yes, part of that is because insurance usually covers annual PCP checkups, but what I’m trying to get at is to stop selling ourselves short.
Instead of patients coming in one time for a screening because they’re having an issue, encourage them to use this even when they’re not. That’s the point of prevention. Educate patients on the benefit of a “movement check up” every year to keep them mobile and doing the things they want to do.
In model 2, if we’re talking about working in primary care clinics – why not throw in a PT check up along with your annual physical? Patients could see the general practitioner like normal, then walk down the hallway to see a PT all in the same visit!
Model 2.5 would probably be the least successful at preventive PT in my opinion. It would require physicians offices to attempt to convince patients to go for another visit at a different location. Again, if there’s not a lot in it for them I’m not sure if there’s a high probability they’ll even remember to do this or utilize it in general. The physician’s office would need to be the ones educating patients on the benefits of meeting with a PT. As I’m sure almost all of us have experienced though, other healthcare providers sometimes have a skewed view on what it is we exactly do.
How you get paid and adjust to additional work volume is always going to be an issue no matter what model you choose. How would we integrate preventive visits into already swamped schedules? And how would we charge for preventative PT visits? I mean if the patient has something that requires continued PT we could likely bill like a normal eval. But if they don’t? Is it just an eval-discharge? But then realistically what do we put in as a diagnosis code if billed to insurance? OR do we just charge a cash fee for all preventive appointments? Honestly I think cash is the safest answer as far as reimbursement goes, but that option may discourage some patients from actually utilizing the service.
Preventative care is a new and exciting avenue for PT. It would likely take some trial and error before getting in right. But you know what they say … you don’t know until you try.
Everything is Possible
All these models are doable. I don’t think one is necessarily better than the other. All of them could have a place in the future of PT. One day all these models may be implemented and active at the same time. If that happens, the question then is which one do YOU want to be in?
Discuss in the comments which model sounds best to you and why. If your clinic is already doing some of these or something similar, what is it? And what’s your experience been so far? In this post I also tried to offer solutions to some of the barriers, but if other solutions to any of the models come to you drop those in the comments section as well! The only way we hopefully advance these models is to start a conversation and then take action. Share this article with someone to help make the conversation bigger. Lastly, don’t forget to subscribe to get all posts from The PT Page directly to your inbox!
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