1. CREATING VALUE AS MEMBERS OF THE PRIMARY
CARE TEAM IN ORTHOPEDICS: COLLABORATION,
BENEFITS, BARRIERS, & UTILIZATION
Steven B. Ambler, PT, DPT, MPH, CPH, OCS
Assistant Professor, University of South Florida
sambler@health.usf.edu
@docambler
Andwele Jolly, PT, DPT, MBA, MHA, OCS
Business Director, Washington University School of Medicine
ajolly@dom.wustl.edu

2. Disclosures
None
• Except…. We:
• Are Nervous
• Never thought this would get accepted
• Would much rather have a discussion
2

3. Objectives
1. Describe the physical therapists role in management of the
movement system and how this places therapists in a primary care
role for many common health conditions.
2. Describe primary care roles for physical therapists related to
conditions that may require orthopedic surgical intervention.
3. Compare and contrast the potential benefits and barriers to
developing collaborative models of primary care across various
practice structures.
4. Analyze potential positive and negative consequences of changes of
physical therapy utilization patterns in a primary care role for
patients that may require orthopedic surgery.
3

4. The Human Movement System
• The human movement system comprises the anatomic structures and
physiologic functions that interact to move the body or its component parts.
4
Washington University in St. Louis, Program in Physical Therapy
APTA, BOD November, 2014

5. Practitioners of the Movement System
• Human movement is a complex behavior within a specific context.
– Physical therapists provide a unique perspective on purposeful, precise, and
efficient movement across the lifespan based upon the synthesis of their
distinctive knowledge of the movement system and expertise in mobility and
locomotion.
– Physical therapists examine and evaluate the movement system (including
diagnosis and prognosis) to provide a customized and integrated plan of care to
achieve the individual's goal-directed outcomes.
– Physical therapists maximize an individual's ability to engage with and respond
to his or her environment using movement-related interventions to optimize
functional capacity and performance
5
APTA, BOD November, 2014

6. Practitioners of the Movement System
6
 General management
 Referral
Examination
Evaluation
Intervention
Outcome
Diagnosis
ICF
ICF
ICF
PCM PCM
ICF
Prognosis
Movement
System
Severity & Intensity
Severity & Intensity

7. Primary Care & The Movement System
• RC19-15: That the American Physical Therapy Association
investigate and identify:
– The roles of physical therapists in primary care teams;
– The services of physical therapists which may qualify as components of
primary care delivery; and,
– The current and future opportunities for physical therapists to integrate
these roles and services into practice, education, and research.
7
APTA, HOD Documents, 2015

8. Why Physical Therapists?
8
Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-
2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197-2223.

9. Why Physical Therapists?
9
Vos T, Barber RM, Bell
B, et al. Global,
regional, and national
incidence, prevalence,
and years lived with
disability for 301 acute
and chronic diseases
and injuries in 188
countries, 1990–2013: a
systematic analysis for
the Global Burden of
Disease Study 2013.
The Lancet.
2015;386(9995):743-
800.

10. Why Physical Therapists?
• Continuing shift away from communicable diseases to non-
communicable diseases and from premature death to years lived with
disability
People are not dying as fast…. A good, but costly problem?
10
Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases
and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743-800.

11. Why Physical Therapists?
• National Health Interview Survey (NHIS) - 2012
• A musculoskeletal health condition was associated with having an activity or participation
limitation linked to a musculoskeletal condition
• A non-musculoskeletal health condition (Heart, Diabetes, Cancer) was associated with
having an activity or participation limitation linked to a musculoskeletal problem
If we have shifted away from a biomedical model focused only on the health
condition… Why then are the biomedical experts still managing the patient?
11

12. Primary Care
• The Institute of Medicine has defined primary care as ‘‘the
provision of integrated, accessible health care services by
clinicians who are accountable for addressing a large
majority of personal health care needs, developing a
sustained partnership with patients, and practicing within
the context of family and community.’’
12

13. Patient Centered Medical Home
13

14. Primary Care
• 53.9 million with 1 or more musculoskeletal disorders
• Per capita medical expenditure averaging $3,578
• In 2007, 164 million receive PT
• All 50 states now have some form of Direct Access
14
APTA. Direct access at the state level. 2016; http://www.apta.org/StateIssues/DirectAccess/. Accessed June 1st 2016.
Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a
systematic review. Phys Ther. 2014;94(1):14-30.

15. Primary Care Models
EMERGENCY ROOM
• Increasing numbers of physical therapists work in emergency
departments (EDs), because musculoskeletal complaints
account for 25% to 28% of ED visits annually.
• Several hospitals have reported that utilizing PTs for
musculoskeletal screenings in EDs results in reductions in
unnecessary imaging, shorter wait times for referrals to
orthopedic or neurological specialists, and improved patient
education.
• Decreased length of stay
• Increased patient satisfaction and referrals to outpatient
Peranich L, Reynolds KB, O'Brien S, Bosch J, Cranfill T. The Roles of Occupational Therapy,
Physical Therapy, and Speech/Language Pathology in Primary Care. The Journal for Nurse
Practitioners. 2010;6(1):36-43.
15
Fleming-McDonnell D, Czuppon S, Deusinger SS, Deusinger
RH. Physical therapy in the emergency department: development
of a novel practice venue. Physical therapy. 2010;90(3):420-426.

16. Primary Care Models
THE UNITED STATES ARMY MODEL
• Since 1970 PTs served in a primary care role for neuromuscular conditions
(due to shortage of orthopedic surgeons during the Vietnam War)
Primary Care
Physician
Orthopedic
Surgeon
Physical
Therapist
Physical
Therapist
Orthopedic
Surgeon or
Appropriate
Specialist
OLD
NEW
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.
16

17. Primary Care – Army Model
• Refer patients to radiology for appropriate imaging evaluations
(radiographs, MRIs, CT scans, and bone scans)
• Restrict patients to their living quarters for up to 72 hours
• Restrict work and training for up to 30 days
• Refer patients to all medical specialty clinics
• In some cases, order certain analgesic and nonsteroidal anti-
inflammatory medications
17
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

18. Primary Care – Army Model
• Prompt evaluation and treatment for patients with neuromusculoskeletal
complaints
• Promotion of quality health care
• Decrease in sick call visits
• More appropriate use of physicians
• More appropriate use of physical therapist education, training, and
experience
↑ Efficiency
↑ Effectiveness
↑ Acceptability
18
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

19. Primary Care Models
KAISER PERMANENTE MODEL
Referral
Algorithm
PT
Behavioral
Health
Pharmacist
Clinical
Educator
NP
MD MISSION
Quality
Accessibility
Affordability
Patient
Satisfaction
19
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

20. Primary Care Models – Kaiser
Model
• Referral Algorithm
– 18 – 65 years
– Nonindustrial injury
– Non-third-party liability
– Afebrile
– Denies chest pain
– Denies abdominal pain
– No seeking medication intervention
– Willing to see a PT vs. MD or NP
30% seen via
algorithm in
PT
20
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

21. Primary Care Models – Kaiser
Model
• PT Evaluation – in Primary Care Setting
– Screen for refer out
– PHI and examination of problem area
– Consult with MD
– Manual therapy if indicated
– HEP instruction/ self-management
– Discussion with specialist if indicated
Patient interview
supplemented by self-
questionnaire
Patients tend to be
younger, acute, 1st time
referred to PT, &
previous episodes
resolved with first line
intervention by MD or
NP
Patients w/ chronic
sx’s seen in traditional
PT setting
21
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

22. Primary Care Models – Kaiser
Model
REQUIREMENTS
• Minimum 4 years of experience
• Demonstrate working with a team
• Kaiser written exam
– Differential diagnoses
– Acute musculoskeletal injuries of peripheral joints
– Radiological review of plain films & MRI
– Laboratory values relevant to primary care
– Pharmacology
22
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

23. Primary Care Models
DEPARTMENT OF VETERANS AFFAIRS SALT LAKECITY
HEALTH CARE SYSTEM (VASLCHCS) MODEL
• Duplicate the US Army Model but with broader approach
23
ChronicDisease Pharmacology
Dietary
Modification
Exercise/Mobility
Prevention
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

24. Primary Care Models –
VASLCHCS
Triage
RN
PT
Another
Provider
24
PT is paged by RN either in PCP or ED setting for
neuromusculoskeletal complaint
Collaborative evaluations (team-based approach) encouraged
when appropriate
Murphy BP, Greathouse D, Matsui I. Primary
care physical therapy practice models. J Orthop
Sport Phys. 2005;35(11):699-707.

25. Primary Care Models –
VASLCHCS
OUTCOMES
• Holistic Treatment
• Integrated Team-based Approach
• Reduced backlog of orthopedic and neurosurgery from 90days to less than
30
• ↑ Job Satisfaction
• 23% ↑’d Referrals
25
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

26. Primary Care Models
ARMY – KAISER – VASLCHCS
• Summary
– Additional competencies required beyond entry-level education
– ↑ Efficiency
– ↑ Delivery of Patient Care
– ↓Costs
– Challenges in exportability (Army & VA due to payment models)
26
Murphy BP, Greathouse D, Matsui I. Primary care physical
therapy practice models. J Orthop Sport Phys.
2005;35(11):699-707.

27. Benefits & Barriers: Physical
Therapy PCP
Benefits
Direct Access
• ↓ Healthcare resource utilization
• ↓ Invasive interventions
• ↑ Efficiencies
• ↑ Patient outcomes & satisfaction
• ↑ Appropriate diagnostic
strategies
Barriers
Direct Access
• Reimbursement
• Certification Requirements
• Diagnostic Classification System
Deyle GD. Direct access physical therapy and diagnostic responsibility: the risk-to-
benefit ratio. J Orthop Sport Phys. 2006;36(9):632-634.
27

28. Benefits – Direct Access (PCP)
• ↓ Costs to patients and insurance companies
– Mean allowable per episode: $152 less (PT related costs)
– Mean allowable per episode: $102 less (non-PT related costs)
– ↓ Ordered images
• 6 – 8% less ordered
– ↓ Injections
– ↓ Prescribed medications (fewer drug claims)
• 12% less took NSAIDs or analgesics
• ↓ # of visits
– Mean difference of 1.1 visits… and as high as 13.4 visits (older study)
• ↓ General Practitioner (GP) visits post-PT
– 29% compared to 46% within 3 months
– Fewer mean hospital admissions
28
Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical
therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30.

29. Benefits – Direct Access (PCP)
• ↑ Patient Satisfaction (5% higher)
– 9% more evaluated management of their condition as average or above
average
• ↑ Discharge Outcomes
– 2% – 15% more achieved goals
– 79% compared to 60% completed course of therapy
– Greater pain reduction (3points compared 2.5 points)
– ↓ Mean # of days missed from work (17 days less)
– No adverse events in either group
– No disciplinary action or litigation variance in either group
29
Ojha HA, Snyder RS, Davenport TE.
Direct access compared with referred
physical therapy episodes of care: a
systematic review. Phys Ther.
2014;94(1):14-30.

30. Benefits – Direct Access (PCP)
PCP Referrals Uncomplicated Low Back Pain (N = 841)
– 385 to advanced imaging, 377 to PT, & 79 to specialist or other
• ↓ Cost (for PT group)
– $504 (3.8 visits) compared to imaging group $1,306
– Average subsequent costs over the following year were 66% lower
• $1,871 compared to $6,664
• ↑ Chance of surgery, injections, specialist and emergency department visits
within a year (for imaging group)
30
Fritz JM, Kim J, Thackeray A, Dorius J. Use of Physical Therapy for Low Back Pain by Medicaid Enrollees.
Physical therapy. 2015;95(12):1668-1679.

31. Benefits – Direct Access (PCP)
Musculoskeletal primary care providers
• ↓ radiology: 11% compared to 82% for family care practitioners
• ↓ medication: 24% comparted to 90% for family care practitioners
• ↑ return to duty-ratio for military personnel: 50% higher for PT’s
31
McGill T. Effectiveness of physical therapists serving as primary care musculoskeletal providers as compared to family
practice providers in a deployed combat location: a retrospective medical chart review. Mil Med. 2013;178(10):1115-1120.

32. Barriers – Direct Access (PCP)
Do you treat patient via direct access? Percent
Acute care hospital 11.6
Health system or hospital-based outpatient facility or clinic 34.2
Private outpatient office or group practice 81.3
SNF/ECF/ICF 12.7
Patient's home/Home care 13.2
School system (preschool/primary/secondary) 63.8
Academic institution (postsecondary) 46.7
APTA Direct Access Utilization Survey Executive Summary February 2010
32

33. Barriers – Direct Access (PCP)
APTA Direct Access Utilization Survey Executive Summary February 2010
33

34. Barriers – Direct Access (PCP)
APTA Direct Access Utilization Survey Executive Summary February 2010
34

35. Barriers – Direct Access (PCP)
• Employer requirements that all patients have a referral appear to impose a
significant barrier to direct access. This requirement exists in all types of
practice settings but is especially prevalent in both inpatient and outpatient
hospital-based settings. A large percentage of respondents indicated a need
for resources to help them remove hospital/institutional restrictions to direct
access.
• Although reimbursement is often mentioned as a barrier to direct access,
there is an indication that this barrier may be more perceived than real in
many situations. The number of respondents who reported claims denials
for patients seen without referral was relatively small.
• Certification requirements prior to treating patients via direct access, in
those states where it is required, appear to impose a significant barrier to
provision of direct access services by physical therapists
35

36. Alternative Payment Models
Athenahealth.org
36

37. Bundle Payment
37

38. Bundle Payment: Comprehensive Care
for Joint Replacement Model (CJR)
• The Comprehensive Care for Joint Replacement Model (CJR) is a new
payment model being tested for episodes of care related to total knee and
total hip replacements under Medicare. The model will be tested in 67
metropolitan statistical areas for 5 years beginning April 1, 2016.
• Programs under the model will be administered by hospitals in the
participating areas, and physical therapist practices will be impacted in
those areas.
• Hospitals will be at financial risk for the care provided during the initial
hospital stay, plus 90 days after discharge from the hospital
APTA. Comprehensive care for joint replacement model (CJR). 2016;
http://www.apta.org/CJR/. Accessed June 1st 2016.
38

39. Comprehensive Care for Joint
Replacement Model (CJR)
• The average Medicare payment for hip and knee procedures ranges from
$16,500 to $33,000,according to the CMS
• Medicare estimates a cost savings of $153 million over the 5 years of the
model
39

40. Comprehensive Care for Joint
Replacement Model (CJR)
• All Collaborators are required to engage with the hospital in its care
redesign strategies and to furnish services during a CJR episode
• Collaborators may include:
– Skilled nursing facilities
– Home health agencies
– Long term care hospitals
– Inpatient rehabilitation facilities
– Physician Group Practices
– Physicians, non physician practitioners, and providers and suppliers of
outpatient therapy.
40
Smith H, L.; Drummond-Dye, R. Comprehensive Care Joint Replacement Model: Physical
Therapy Perspective. Alexandria, VA: American Physical Therapy Association;2012.

41. Comprehensive Care for Joint
Replacement Model (CJR)
• Hospitals are given a target cost per episode annually
• Providers are still paid under their respective payment systems
• Cases are reconciled post episode to determine if they have met the target
cost
• Hospitals may have financial relationships with collaborators allowing
them to share risk and savings in the episode to support their efforts to
improve quality and reduce costs
41
Smith H, L.; Drummond-Dye, R. Comprehensive Care Joint Replacement Model: Physical
Therapy Perspective. Alexandria, VA: American Physical Therapy Association;2012.

42. Comprehensive Care for Joint
Replacement Model (CJR)
• Hospitals will be placed in one of four quality categories for each
performance year: Below Acceptable, Acceptable, Good, and Excellent
• Categories will be determined by quality composite score (scoring
methodology on CMS website)
Quality Category Eligible for Reconciliation Payment Eligible for Quality Incentive Payment
Below Acceptable No No
Acceptable Yes No
Good Yes Yes
Excellent Yes Yes
http://www.singletrackanalytics.com/blog/15-12-06/making-sense-your-first-bpci-reconciliation
42
Smith H, L.; Drummond-Dye, R. Comprehensive Care Joint Replacement Model: Physical
Therapy Perspective. Alexandria, VA: American Physical Therapy Association;2012.

43. Creating Value
• Many ways to consider value…
• For now: Outcome achieved and cost required
• Outcomes questions still linger
• Individual
• Population
• Experience
• Adherence to guidelines
• Diagnosis
• ICF
Creating Value in the Interim
43
Moore JD. Unpacking Payment Bundles. Physical therapy. 2016;96(2):139-141.

44. One, not so new, example… ACL Injuries
• Who should manage this person?
• Is a knee injury in need of ongoing management? (is it preventable?)
• Is this a movement problem?
• What diagnosis would be primary?
44
Medical Movement System
ACL Tear PROM Impairment secondary
to Tissue Imp.
Tibiofemoral Rotation
Hip Adduction

45. Who should manage cont..?
Medical Movement
Diagnose pathology Diagnose movement syndrome (clinical
dx/screen for pathology)
Determine course of care: advice and
data linked to other pathology
Determine course of care: advice and
data linked to movement response
Fix the tear Fix movement problem
Deal with medical complications from
fixing the tear
Return to function
Improve performance
Prevent Injury (could start with this)
2 7
45
Hui C, Salmon LJ, Kok A, Maeno S, Linklater J, Pinczewski LA. Fifteen-year outcome of endoscopic anterior cruciate ligament
reconstruction with patellar tendon autograft for "isolated" anterior cruciate ligament tear. Am J Sports Med. 2011;39(1):89-98.
Stergiou N, Ristanis S, Moraiti C, Georgoulis AD. Tibial rotation in anterior cruciate ligament (ACL)-deficient and ACL-
reconstructed knees: a theoretical proposition for the development of osteoarthritis. Sports Med. 2007;37(7):601-613.

46. What do we do now?
• ACL Reconstruction
– PearlDiver Patient Record Database-United Healthcare
– 2 visits pre-operatively (3-months pre-op)
– 17 visits post-operatively (6-months post-op)
46
Zhang JY, Cohen JR, Yeranosian MG, et al. Rehabilitation Charges Associated With Anterior Cruciate
Ligament Reconstruction. Sports Health: A Multidisciplinary Approach. 2015;7(6):538-541.

47. Proposed post-op management at
one facility
• Physical therapy should see early and the duration of care should be similar
and extended
– Must consider when needed the most
– ~2 yr follow-up
• Frequency should vary greatly and should be based on
– Criteria decided by team
– Patient context
47
Grindem H, Logerstedt D, Eitzen I, et al. Single-legged hop tests as predictors of self-reported knee function in nonoperatively
treated individuals with anterior cruciate ligament injury. Am J Sports Med. 2011;39(11):2347-2354.

48. Proposed post-op management at
one facility
• Improved continuity of care
– Outcomes
– Satisfaction
• Interdepartmental benefits
– Increased revenue
– Increased efficiency (less visits/more pts)
Value: Outcome achieved and cost required AND… Increased revenue in the
interim?
48

49. Current proposal
49
ACL Surgery
Surgeon f/u
determined for
medical care
Post-op with PT
Management of
Movement
System

50. Case 1
• ACL reconstruction with hamstring autograft and lateral menisectomy
• Started therapy 10 days post-op
• 6 months
• 6 visits
– 1/wk for 2 wks
– 1/month to 3 months
– 6 month f/u

51. Case 2
• ACL reconstruction with hamstring autograft and medial meniscus repair
• Started therapy 5 days post-op
• 6 months
• 12 visits
– 1/wk for 8 weeks
– 1/month 4 months

52. The future?
52
Knee Injury
Surgery/Conservative
Management of
Movement System
PT Surgeon
Entrance
Determination

53. Barriers to implementing in the
interim
• Organizational structure
• Organizational environment
– Interprofessionalism
• Development of procedures
• Scheduling
• Volume
• Development of outside relationships
• Initial patient education and acceptance
53

54. Summary
• Physical therapists are practitioners of the movement system and are
positioned to be the primary care providers of that system
• Numerous opportunities exist for physical therapists to take the lead in care
of individuals with movement problems and to do so in a way that
increases “value”
• What that value means and to whom is still a discussion that we should be
participants of
• Physical therapists should be innovative in the interim to determine the
multiple ways that they can participate in primary care
54

55. QUESTIONS
55