The Primary Care Upgrade

Perceptions are Reality, So Take Them Seriously

The American Physical Therapy Association (APTA) did an excellent job in their report on primary care physicians’ perceptions of physical therapy and healthcare consumers at a crucial time.

The healthcare community needs more prompt and upstream access to physical therapists, the care they provide, the outcomes they help create, the value they extract (lower overall per beneficiary annual costs, higher quality), and their expertise. Physical therapists aren’t delivering that at scale right now.

One callout is that this research seems to only include primary care physicians, not primary care providers in totality. In this report by HRSA (Health Resources and Services Administration) on the “State of the Primary Care Workforce, November 2024,” more than half of primary care is now being provided by non-physician nurse practitioners and physician assistants/associates.” 👇️ 

This sentence from the “Background” page of the APTA article explains the “why” behind doing this research in, partnership with Penta Group:

The survey results show that patients overwhelmingly view physical therapist care as something to access only after their PCP recommends it, and they don’t consider PTs the “provider of choice above PCPs or other physicians” for any care.

Not surprisingly, healthcare consumers also don’t think PTs collaborate enough with their physicians. (My take—they do what’s incentivized and what’s required, like other providers). Also, 35% report skipping PT referrals, reporting barriers like time limitations, cost and insurance coverage, and lack of convenience as reasons they don’t access physical therapy. PCPs report these same patient-centered barriers.

I will link the page on APTA’s website where this paywalled article can be accessed for APTA members. Click the pdf cover to access the landing page and summary by the APTA 👇️ 

The healthcare consumer is more of a barrier to patients getting started with physical therapy than the primary care physician

But that’s not the whole story.

A physician may identify a patient whose next best evidence-based step should be prompt evaluation by the physical therapist, but there are many steps between that and patients reaching their achievable goals. 🏆️ 

Steps:

1. PCP identifies clinical need for PT. PCPs are not always aware of what patients are most appropriate for PT vs. other possible options.

2. PCPs aren’t all aware of the breadth of expertise of both PT generalists and of PT specialists or the evidence behind their treatments.

3. PCP tells the patient and explains why.

4. PCP often has to explain why it’s the identified next best step vs. other treatments the patient may have thought would be recommended.

5. PCP must overcome objections that the patient may or may not even tell their PCP. Objections include effort involved and time commitment, preference for passive treatment, concern about co-pays, deductibles, co-insurance, a history of a long past episode of physical therapist professional services, uncertainty about the outcomes, fear of pain, transportation barriers, behavior (such as likeliness to follow-through), and much more.

6. They should offer names of physical therapists and/or clinics with whom they work closely and who have reduced all possible barriers to patient access.

7. The patient must decide they agree with the PCP.

8. They must overcome their own objections they think of before actually making an appointment. They may have to overcome their spouse or partner’s objections.

9. Patient must decide on a physical therapist.

10. They must find one in-network or decide to go out of network (if they have a high deductible health plan (HCHP) or just one with a high deductible, they may be more reluctant to go earlier in the year).

11. They have to make it through onboarding and the front desk process.

12. They have to find an appointment time that coincides with their availability (days and hours).

13. They may have to be on a waiting list.

14. Their pain/injury may be more tolerable in the wait time and they may cancel.

15. They have to have transportation. If they need to use public transportation, that may further limit their availability.

16. They have to have sufficient mobility to get there, in most cases.

17. They have to actually show up for the evaluation.

That’s 17 Potential Steps of Friction! 🫢 😮 😲 😒 😱 

That’s just to get to the first visit, and I’m sure I didn’t think of everything.

This Relentless Health Value podcast episode that was just released paints the picture better than I can. Rushika is the founder of Iora Health (which sold to One Medical, which was bought by Amazon), a pioneering advanced primary care practice that was able to make transformational change to primary care (think 40% reduction in hospital admissions) through value-based care contracts.

Because the payment model has to change for the care model to change, outcomes to change, and spending patterns to change.

On Primary Care Physicians’ Referrals to Physical Therapists

The report states that physicians in the survey were asked who they referred to in the last 6 months, and 98% said physical therapy, 91% said orthopedic/sports medicine, 85% said occupational therapy, and 54% said chiropractic care.

When asked the frequency of referrals to each provider type, 86% said they referred to physical therapy frequently, 70% said they referred to orthopedic/sports medicine frequently, 50% said they referred to occupational therapy frequently, and 16% said they referred to chiropractic care frequently.

While 88% want to refer to physical therapy more frequently, they identified the lack of enough nearby clinics and appointment times as reasons why they don’t make referrals. They also think compliance could improve for those they do refer.

The value of physical therapy is high, but that’s not enough to change things. 

The APTA published an excellent report last year on the value of physical therapy in the United States. It’s free and linked on this landing page on the APTA website.

They looked at eight medical conditions chosen by “prevalence of the condition and its associated level of healthcare spending across the United States.” Using a conservative approach to making their assessments, all conditions showed a net economic benefit when physical therapist services were chosen instead of non-physical therapist services.

Here’s a snip from page 18 of the report 👇️ 

There’s much more in the report and diving deep is out of scope for this article, but it’s worth the read. As you can imagine, some of the net economic benefit is attributable to avoidable costs of other treatment for those conditions.

I’m going to take a wild guess and say neither the healthcare consumer nor primary care physicians routinely (or ever) refer to PT for vascular claudication, cancer rehabilitation, stress urinary incontinence, or falls prevention.

But physicians also have to have the time and incentive to facilitate and support the initiation of physical therapy when they do identify a need and refer, and then the friction between the decision to have a physical therapy evaluation and making it to the actual first appointment is high.

Those incentives align when the primary care physician is in a team-based, advanced primary care practice where they are responsible for the cost and quality of longitudinal outcomes over the course of the year. That happens in value-based care programs, and the incentives are most strongly aligned when the practice is at full financial risk for the cost AND quality of their patients’ care.

PCPs Report out on What they Want from PTs:

They report valuing PTs who share diagnoses and treatment plans and provide updates.

They want to refer to PTs with expertise.

They want the PTs to show their value and ability to help patients achieve goals with objective data.

They want PTs to act responsibly as stewards of patient resources.

They want their referred patients to receive individualized treatment plans.

They want to work together as a team to provide coordinated care.

I’ll add one additional, most human “want” 👇️ 

They want their patients to tell them how happy they are, how it helped, and why they were satisfied. Patient-reported outcomes are going to align with high-value care, and I’ll make a prediction that we will see more of them over the next few years.

So here’s where we are, with some additional color:

1. Primary care physicians have a positive impression of physical therapists and the care they provide.

2. There are many barriers between a physician referral and patients getting to even a first visit with a physical therapist, and they are largely because of patient perceptions and lots of friction. See above.

3. Physical therapists provide objectively high-value care that helps avoid downstream and unnecessary treatments and care.

4. Despite direct access, which healthcare consumers don’t care about, as a whole, culture drives the perception that PCPs are the gatekeepers and decision makers about who does and doesn’t get physical therapist care.

5. In fee-for-service, the physician loses nothing when a patient who needs a physical therapist doesn’t get to the physical therapist.

6. In fee-for-service, physical therapists don’t have an incentive to collaborate and coordinate care with the primary care physician. PTs’ salaries are generally lower than nurse practitioners and physician assistants, despite being a doctorally prepared medical professional. They can’t spare the time.

7. PCPs want MORE patients to see physical therapists

Enter team-based, advanced primary care where the practice is taking full delegated risk rather than fee-for-service.

Physical therapist is an alternative, often more appropriate, to other high-cost options on the “menu” for PCPs to consider for the “next best step.”

Billable units are no longer the driver of the practice’s earnings when they are fully delegated risk arrangements.

Volume of transactions is no longer the key driver of practice revenue. (But don’t confuse that with the imperative of keeping patients loyal to, or “attributed,” to the practice—topic for another day!)

What drives revenue then, you ask?

Spending time and resources keeping people healthy,

diseases well-managed,

preventive care prioritized,

early detection screenings done,

helping complex patients navigate the health system,

keeping people home and out of hospitals and other inpatient setting,

and more.

And since patients presently and historically have viewed their PCP/family physician/geriatrician/pediatrician as the quarterback and even gatekeeper of their care, patients still consistently go to their PCP when they have pain, difficulty walking, balance issues, movement impairments, etc.

Physical therapists (and occupational therapists)—

Patients that need you are at their primary care provider’s office! And while there are few exceptions, physical therapists (and occupational therapists) are not there.

Far more patients need the expertise of a physical (and/or occupational) therapist and never receive it than most of us likely realize.

The “Opportunities” Section of the APTA’s Report is Good, but Missing Something Key

The APTA rightly calls out opportunities, like stronger synergistic relationships between PCPs and PTs and new collaboration strategies. Their recommendations are great, but I still don’t think go far enough to match this moment in time.

For all PTs with an APTA membership, I highly recommend accessing this report! I only cover a small portion of the content in this article and it’s very well-done and informative, no matter what your practice setting.

Along those lines, here are my broad recommendations to my fellow therapists in private practice/outpatient settings:

Physical therapists must partner with advanced primary care practices who are in any stage of the practice’s VBC payment model participation, even stage zero. In that case, offer to work together as a joint venture!

Physical therapists must embed within advanced primary care practices taking fully delegated risk with payers. Be on-site for direct, personal hand-offs from physician to physical therapist. Build the trust and respect of PCPs and patients at a deeper level. Deepen the synergistic relationships, care coordination, and collaboration that can only come from practicing together.

Physical therapists must take sub-delegated risk on certain populations. That means taking sub-delegated risk with PCPs at risk, that means providers at risk. Learn how they evaluate claims data to find opportunities that are win-win-win.

Partner with an actuary. Apply the same (longitudinal) lens to your data as actuaries do to other providers’ data when supporting risk-based contract participation.

Know your data and your value, because the practices and payers are looking at your value compared to other practices and other options, and can identify which PTs and practices will help them be successful.

Physical therapists must develop a proficient understanding of the major alternative payment models in Medicare (because in Medicare FFS, the programs are standardized, making it more straightforward to learn and become comfortable with the concepts).

How do they work, what do the risks and rewards look like, how have participants be successful?

Physical therapists should be or already should have met with GUIDE model participants and with the future TEAM Model participants. (I have written about these models and the articles are in my Archives section of my newsletter site). Please ping me if you want to know more.

Physical therapists (and occupational therapists!) should view value-based care as a gift to the profession(s). We provide high-value care that is not adequately reimbursed in fee-for-service (compared to medical specialists) by any fee-for-service payer. We have high burnout rates. We are not unlike PCPs in many ways. PCPs earn substantially less than specialists and provide a lot of care and coordination of care that’s not reimbursable in fee-for-service (although CMS has made more billing codes available over the last few years for PCPs and mental health providers to provide additional services, with some at the practice level).

Check out how PTs’ earnings compare to PCPs, specialists, NPs, and PAs 👇️ 

This is from the APTA’s website looking at 2023:

And here is part of a Becker’s ASC Review 2024 compensation report comparing RN, NP, and PA salaries. Keep in mind RNs need only an associate’s degree at a minimum for licensure and NPs and PAs need a master’s degree at a minimum for licensure, while PTs need a doctoral degree (unless grandfathered in at a lower educational level from past requirements):

PCPs’ reimbursement is growing, thanks to re-allocation of RVUs, new primary care reimbursement codes, and value-based care model adoption, like the Medicare Shared Savings Program (MSSP). And MSSP saved taxpayers $2.1 billion in net savings to Medicare in 2023!

Healthcare funds are shifting to primary care. I’ll go out on a limb and say there is no other reasonable way for PTs (or OTs) to earn even what NPs and PAs earn and continue caring for patients in the medical model if we don’t have broad participation and grow our visibility in advanced primary care.

We must access patients more upstream, where patients already are, and where higher reimbursement is available and achievable at the practice level for those taking accountability for the cost and quality of care.

The train has left the station and few physical therapists have arrived at the station’s front door.

You heard it here first: value-based care was inadvertently made for PTs and OTs. Now we have to prove it.