Sunday, December 21, 2014

Future of Physical Therapy 2015 (Part 3)

Welcome to Part 3 of Future of Physical Therapy 2015.

If you wish to look back further, you can find Part 2 HERE!


So what needs to occur to ensure that a great idea isn't snuffed out by the process and organizational values already in play?

Answer: Ambidextrous Design.

Some people call this a parallel process. Regardless the label, it is the ACTION that matters. What occurs in this strategy is the creation of a separate value chain. Some companies will actually reallocate human resources, giving managers a break or incentivizing them with, "You had to downsize anyway, right?"

By hand picking out key players already in favor of an innovative vision, you are creating an all-star team and are setting them up for success. This is very much like the smart data I mentioned earlier. Where smart data is more about strategically using big data with situational, striated, and actionable user-driven perspectives, the Ambidextrous Design similarly attacks the problem by selecting leaders who are already very intune with the tactical circumstances to which an innovation must emerge.

Leaders in this environment must be involved, highly constructive, minimally critical, positive, and visionary. This is NOT where micromanagement needs to be. (Some would argue, micromanagement never needs to be anywhere, ha!)

The separate value chain is critical because it allows for the development process of any innovation to be evaluated through strategic lenses rather than marginal lenses. This becomes extremely important in the early phases since most projects fail to demonstrate financial gains in nascency. However, the exponential gains are made excitingly abundant in the later cycles.

Separate value chains also allow for a co-existence of the old and the new; this is helpful because the visionary leadership at the top intends on converting everything to the new ways for widespread success. However, if leadership were to make sweeping changes right now, there would be an uprising on their hands. This separate value chain allows for a small department to serve as a pilot of sorts, demonstrating to the larger majority who are resistant to change the value of what they now bring to the table. Once their superior metrics are proven, transferring the new values, processes, and resource models become attractive as any manager would be more than happy to take on those benefits now that they are actually proven.

Another HUGE issue in 2015 will be eliminating the middle man. If one examines the study of supply chain management, it is quickly appreciated that "the middle man" or the "distributor" should ONLY exist if they add value to the entire supply chain.

In healthcare, the supply chain exists to give patients access to the content experts, make available technical skills they cannot perform themselves or for themselves(clinicians, technicians, surgeons etc.), and unlock access to products (primarily drugs and DME).

However, the resources of healthcare have been overwhelmed. There's nearly no more water left in the well, so resources are being rationed. However, the industry is looking at this the wrong way.

It isn't that the well is drying out, it is that we keep drawing from the well while ignoring the oasis behind us.

Why see a gatekeeper who knows little about the problem you have, only to have your gatekeeper send you to the expert afterward? Why go in for an office visit when communicating through an app will do? Why go for a follow up when all anyone was waiting for was the results from a lab study? The prescription can be sent in remotely anyway, right? And, why use expensive machines to diagnose when its been plainly demonstrated clinical diagnosis can glean far more useful and actionable pieces of information for both long term and short term benefits?

This eliminating the middle man is really a battle of eliminating redundancies. Redundancies typically serves to waste resources and make processes less efficient. This will be a very big focus in 2015. While this is a great initiative, it is not enough. Reinforcing an agile supply chain for healthcare will emerge as a key partner. When we think about health services, what is really going down?
  1. A patient (consumer) has a concern or ailment to be addressed.
  2. The patient wants to know if they need to be seen, and if so, to be seen NOW.
  3. The patient wants to receive the solution to their concern or ailment directly and ASAP.
The common story of going to the primary provider, waiting for the one specialist only to be referred to another specialist only to be referred to the diagnostic suite, then a follow up with the first specialist -- all of which took 5 months (if they were lucky). Of course, when this person finally sees the first specialist, they will ultimately be referred to the REAL specialist who could do something about their concern.

These kinds of stories will only exist for FAILING health systems.

Instead, the cutting edge systems will employ predictive modeling where beneficiaries will be contacted for emerging risk factors detected by their clinicians, smart data, and  with self reporting.


Finally, the last key strategy I'd like to introduce for physical therapy and healthcare in 2015 is the entrance into emerging markets. Most emerging markets tend to be disruptive. Others, create an entire genre of their own.

While I made mention to this last year, I would still like more PTs to show up in the space of childhood prevention; I've made many mentions to how dentists have done this to prevent cavities. PTs can certainly do this for the many functions of the body. Considering childhood obesity and manner other PHYSICAL concerns on the alarming rise, are not Physical Therapists best suited to address these public concerns?

For healthcare, emerging markets aren't necessarily about treatment of disease and physical ailments. And, it's not even really about keeping the body running in a healthy, fit, and functional way -- in my humble opinion, this has been the goal of healthcare all along.

I think the emerging market we need to carefully and honestly examine is that which involves reimbursement. Reimbursement MUST move beyond billing units and fee for service. If we're honest with ourselves, the more you deliver health services as a system, the more you have sucked in doing your job adequately.

Why would your beneficiaries need more care and more services if you actually did your job to keep them healthy in the first place?

Instead, I suggest to be on the lookout for differential resource management and value added opportunities. These will both help eliminate our problem children and reward our high performers. I mean, really: In acute care, does it REALLY help for a post-op day 3 inpatient to be walked around the hall by PTs or even PTAs? NO! For SNFs, is it really that helpful to boost up a RUG level and have a clinician bat balloons around for minimal gains in Tinetti scores? NO!

However! How incredible would it be for a PT to follow up as a primary care resource to a patient who had a mechanical fall and landed themselves in the emergency department, following them for 2, 3, or even 5 years with regular check ups both physical and digital? Imagine how this would play out for a population of say 5000 people who fell. Imagine the good this would do, the savings that would be made, and the value that would be added by those people staying healthy and actively participating in economy at large!

Feast on the thought that an outpatient office serves as a informatics source and seed site to where a company of several hundred individuals contracts a PT firm to address workplace injury concerns directly. The company already spends over $10 million dollars a year on work injuries. By applying principles of smart data, this PT firm is now able to reduce this company's expenditures on work injuries by $5 million dollars. What of the difference? Well, per the contract, $1.5 million goes to the PT firm! The hiring company saves $3.5 million this year... not to mention the improved productivity throughout.

Toward the end of 2015, I anticipate source and seed processes to take on a social network spirit where like minded allies band together to demonstrate greater value together. This will become powerful on the financial and political front, garnering much momentum to drive legislative changes.

Process and policy changes will occur organically. After all, if Firm A is saving millions because of an innovative process, wouldn't Firm B quickly attempt to adopt it through their own means?


Some Closing Thoughts
For 2015, I anticipate that the large contract model will occur through networks of PTs, attracted to each other in spirit and demonstrating superior solutions to big picture problems that chop shops can't handle. I also sense that PTs will be repeated denied the timid option of billing for clinical services in the near future. I mean really, how much longer before another clinical profession begins to replace what we do for less cost? If you feel absolutely compelled to survive in this space, the network model will still reign supreme when network A demonstrates better outcomes than network B with an average of 10 less visits per case.

Our knowledge base and skill sets demand us to do more. Therefore, we must step out of the box of ONLY clinical care. We need to think on every possible aspect of how we can use our knowledge and skills in meaningful and valuable ways -- not just for patients but entire systems of business.

2015 is the year of healthcare disruption. Roles, accessibilities, and resources never before tapped are going to be mined, trumped and championed. The first few who jump on this opportunity will win out. Wise firms who know that they are behind will seek expert help to seed their success. Those who try to catch up will inherently fail as their organizational structure will refuse to support such initiatives. Some will try so hard that their entire infrastructure will collapse... just watch!

This coming year, I rebuff my encouragement for PT programs to favor clinical affiliations in the space of private practice, acute care hospitals, and out of the box firms who do much more than the day to day workings. There will be plenty of opportunity for that in the working world, now is the time for our students to learn the cutting edge... learning these things after is far too late. Oh and PS. Why not use some of that tuition money during affiliation semesters as financial incentives for clinics of strategic repute and professional integrity? It would only help elevate the profession at large.

The future of Physical Therapy in Healthcare?
  • Disruption. Internal and external disruption. PTs entering emerging roles outside of the clinical space, leading the charge for value added models and innovative processes.
The mechanism?
  • High impact network models; quality coming together, separating the wheat and the chaff. Small business will become the new source code for "big."
The strategy?
  • Ambidextrous, parallel processes -- many will choose a source and seed tactic. Others will separate their value chains to protect and nurture innovative developments.
The winners?
  • Those who are taking on the risks now.

Future of Physical Therapy 2015 (Part 2)

Welcome to Part 2 of Future of Physical Therapy 2015.

If you wish to look back further, you can find Part 1 HERE!



So, where do we go from here?

2015 - It's Time To DisruPT!

Well, as with all things when sustainability begins to waver, the inevitable is coming around the corner: DISRUPTION! Disruptive innovation classically occurs when industries can no longer keep up with the pace, volume, costs, and burden of their current patterns of operations. Healthcare is absolutely ripe for disruption.

To accurately approach disruption, we must appreciate that disruption usually occurs as a result of combinations and conveniences. In the 1950's, it wasn't a better vacuum tube that disrupted the television industry. Rather, by offering portability (something TV sets were incapable of doing through vacuum tubes), transistors made it possible for TVs to be more than a fixture -- allowing people to use TV in places, times, and situations never before available. In fact, it also made TVs available to consumers who never before were able to afford them as well!

Healthcare needs to be seen through a similar lense. We can't disrupt healthcare by doing what we've already been doing better. Truth be told, what we've already been doing IS NOT WORKING! Why try to improve on it? It's time to run a different route.

Gone should be the days of healthcare seen as reimbursement, profit, and service based billing. Healthcare should be judged and paid for through cost savings and value added outcomes.

What do I mean by this? If a specific service performed by a firm directly saves $5 million dollars for ten thousand beneficiaries in a health system, a significant segment of those savings should go towards payment of the firm's services. Moreover, the positive consequences of keeping an entire population healthy -- the economic boost, improved productivity, etc., such should also be measured and the firm proportionately rewarded for the value they have returned to society at large.

2015 - Prime Opportunities
So what are the opportunities before us? Resource management, big data, prevention, minimizing risk factors, childhood A-B-C's (getting them living healthy as early as possible), the baby boomers, necessary/unnecessary, population, patterns, primary care, segments and trends... these are the buzzwords for 2015. The reason these are the buzzwords for 2015 is because this is where the accountants and analysts have determined the most financial opportunity for cost saving and change now resides.

While it can be noted that some practices are beginning to mature in this space outside of billing for units in the clinic, I think there's still a general stigma to this shift. It is a stigma that we REALLY need to get over and away from as a profession. Healthcare is a service and this service has evolved far beyond the bedside, operating room, diagnostic suite, and treatment table. It is as if we have 2015 capabilities but are operating out of 1995 mentalities; we need to get beyond this barrier and into a place where we can utilize our skills to the max, bringing the all benefits we offer accessible to the public.

So! Let me say it again: Being a clinician is NOT the ONLY way to be a PT. More importantly, shifting our focus away from hands on clinical should not be seen as abandoning the profession. It is not treason nor betrayal for PTs to serve outside of the clinical realm.

Just as the nursing profession just disrupted healthcare a generation ago by providing adjunct expertise to physicians as a more manageable resource and cost pool, PTs need to be thinking in similar ways relevant to this current generation.

I've observed and strongly suggest that PTs who wish to be part of the disruption look into opportunities where we can be a part of resource management, big data, early intervention, and portal access (ie. telehealth, mobile apps, biometrics, etc). After all, can you REALLY survive by billing units while said units are worth less and less each year? NO! We have got to become more, do more, and seek to bring value outside of our clinical walls. It is here I hope to see PT practices approach big business, big contracts, and large population portals en masse to serve in preventive programs, early intervention, and primary care roles.

It's a good time to pay attention to the forest.

Similar opportunities are present in the inpatient setting. Fall prevention, reduction of employee work related injuries, physical screening for discharge planning, diagnostic support in the emergency department, unskilled labor management, and case management are EXCELLENT areas to which PTs can serve with distinguishment.

Actually, I foresee the most valuable role for PTs (inpatient and outpatient) as a type of primary care case management of musculoskeletal concerns for all settings in both clinical care and resource utilization roles.

To these points, DPT programs need to add to their curriculums business studies, particularly that of marketing, supply chain, operations management, and analytics.

If all our schools do is teach our students to be clinicians, when they graduate that is all they will know to be and feel it is important to be.

If we are to disrupt healthcare; if we are to become more, to evolve into something significant on the largest of scales, we need to empower our students to think outside of the clinical box; we need a generation of leaders in thought... we already know that they will take action.

2015 - Problem Children

When I take a look at the biggest problems in healthcare, I feel that much of it occurs because of the bullwhip effect - a term from supply chain management. Essentially, miniscule errors upstream cause tremendous variabilities and errors downstream. Think about all the missed musculoskeletal diagnoses you've caught; acute PTs, think on all the strokes you've screened out when CT scans said "negative"; consider the sheer number of prescription of drugs and inappropriate referrals to specialists... all these, in my humble opinion, are the result of a process based bullwhip effect -- seeded in outdated practice patterns, poorly applied data, and using a sift rather than going to the source. Keeping to our current path means subjecting ourselves to a masochistic epidemic of inappropriate utilization in healthcare services; drugs, inpatient stays, and redundant office visits are only the tip of the iceberg.

We need to honestly ask ourselves some rather ugly questions:
  • Do I really need a physician to educate me on how an antibiotic will be ineffective for the flu symptoms I have?
  • Is a physician really the best clinician to perform my PHYSICAL?
  • How about prescribing pain meds to... everyone?
  • There are problems inward as well: How "skilled" is it to turn on a diathermy machine and leave a patient for 20 minutes? Oh, and don't forget to use that NuStep. After all, your administration told you to do it, right?
  • Since we're in the month of December, how ethical is it to scare an assisted living resident to stay for 100 days in the "health center?" After all, they don't want have to go through the trauma of going back to the hospital, now do they? And, even if they do, they still have 100 days come New Year's!
  • How much is billing neuro-re-ed really helping our bottom line in the long run?
  • Is it really worth fighting for the table scraps of Medicare dollars?
  • How about chop shop clinics where aides do all the ther-ex and clinicians do 8 or 23 minutes of whatever else?
  • Home health extensions ad nauseum?
Like I said, I'd be bringing up some ugly topics. I also bring solutions. The way I see it, the ugliness exists because people have been brought to the brink of financial disaster in a system that is filled with erroneous processes.

Through all this, many experts and industry leaders are turning to "big data" for clarity. Identifying trends, managing patterns, etc. While I strongly agree with this strategy of digging deeper to find the roots, I challenge some in their methodologies. Personally, I'm not a fan of the term "big data" for healthcare... at least not yet. I think right now, it is the time for SMART DATA. Currently available data in healthcare can get problematic when it is "big" because it can quickly obscure, eclipse, and make murky the commonly obvious, otherwise elucidated by what many have felt (myself included) is best termed as "smart data."

(A topic for another time.)

In any case, for healthcare, data can be quite unclear because no one has truly been honest with the situation and themselves. This has caused the industry to sacrifice clinical excellence, best practice, honest outcomes... betraying the patient experience. Those who have had found the secret, however, they aren't sharing -- not yet, anyway ;)  And that's okay! It is there competitive advantage. Soon, it will be to their best interest to share and stand on the pedestal as industry leaders in disruptive innovation.

I would suggest that clinical excellence with the patient's best interests placed in priority and under the authority of respective content experts will bring truly meaningful and valuable observations to light. Through such analytics, solutions can be synthesized which are applicable in scale and breadth -- these are smart solutions using smart data which will produce satisfied patients, satisfied providers, and favorable finances.

2015 - Key Strategies to Successful Innovation
As we all know, change is inherently met with opposition no matter what, where, or when it occurs. Why? Well, it's not that the any given majority are ignorant, backwards thinking, or archaically minded. The resistance to change on the larger scales occurs because of organizational behavioral factors. Primarily, what has been termed the "innovator's dilemma" causes organizational behavior to favor what has always worked. After all, our core competencies is what made us great to begin with, right? This can quickly lead to a group think of: "Why fix something that isn't broken?"

I know I've said it before on Twitter...(finding it right now):
So what needs to occur to ensure that a great idea isn't snuffed out by the process and organizational values already in play?

The answer and more, coming up in Future of Physical Therapy 2015 (Part 3)

Saturday, December 20, 2014

Future of Physical Therapy 2015 (Part 1)

This is a follow up post from one of my all time, most popular blog posts "Future Thoughts for Private Practice Physical Therapy" from January 2014.

As a one year follow up, I will be comparing my current thoughts to the circumstances from a year ago. Moreover, there will be some discussion on larger issues at hand to where Physical Therapists are very well positioned to disrupt healthcare at large.

PS. This is a long post. Want to skip to the "good stuff?" It starts at "2015 - It's Time To DisruPT!"

PPS. Every once in a while, I diverge from my characteristically positive and constructive presence to delve into some hard, honest topics. There will be some of that in this post. However, as always, I practice what I preach and I bring solutions as well.


Future of Physical Therapy 2015

It has been a very interesting year in physical therapy, in healthcare, and in life. The world has gotten a lot smaller, and sadly, it seems to have also gotten a lot messier. We're doing okay, but people don't seem to be as happy. Many of us want change -- constructive changes. However, it doesn't really seem like anyone really has the answers to be agreed upon.

Yet, for all that we wish to have changed, we can take a look back on 2014 and appreciate that a lot has already changed. For myself, I've finished writing a book and am grinding through the publishing process (P.S. Know of an interested literary agent? Let me know!)

I have also changed employments several times and have officially experienced every segment in healthcare. That's right! Acute care, rehab, skilled, outpatient, home health, wellness, consulting, etc. you name it, I've seen, heard, done it, and moved on. Come April, I will finish an MBA in Marketing from the University of Michigan - Dearborn. From there, who knows!!! Apparently, some people wish for me to go into professional leadership, policy making or even politics... *shudders*

In any case, after some truly inspiring conversations with several leaders in healthcare, I came back to look upon my blog to see what has been the most influential posts, interactions, and concepts in the last year. Sure enough, this exploration into the ideas of THE FUTURE won out. And so, I'm here to give the public what they want with this 2015 follow up.

2014, Year To Date.
To really explore 2014, I had to look back to 2013 to see where we were at. In 2013, the physical therapy world demonstrated a true interest in the external components in the range and scope of the profession. Novel interdisciplinary trends around the world, primarily cooperative and collaborative efforts with the nursing profession were getting traction on the inpatient side of life. On the private practice front, we saw that PTs began to establish independent communities, primarily based on content, products, and schools of thought verified by social proof.


I felt that much of the physical therapy world (and healthcare) struggled with the circumstances described in my SWOT analysis through 2013 until things started to get shaken up in early 2014.

This is where things truly got interesting. We've seen that private practice PTs have truly branched out to become owners of businesses. It's not just the clinic hours that PTs are getting income from; there are larger fish to fry including products, new service lines and brand experiences, and some legitimate legal gains in several states.

There exists a growing spirit of unity, particularly amongst the students and new grads. They are interested in finding ways to bring the pieces together. Also, more PTs are getting out there into commercial, retail, and even open market spaces. It also appears the DPT programs are starting to take notice that if they do not facilitate change, there won't be many PT schools left due to reimbursement backflow and cost of loans.

So, all in all, many positive directions were taken in 2014 -- primarily the strategic placement of the many chess pieces involved -- much as a chess master makes before the critical and decisive move.

Unfortunately, while strategic movements was in play, financial decline also occurred. A new wave of audits occurred in a grand and terrifying way. Third party payers were pairing with Medicare dollars in an effort to maximize market share and thus revenue dollars, edging out competition where ever possible under the guise of resource management.

The market responded with another parallel wave of "creative" billing and extension of health services. As there was only so much money in the pot, the powers at be decreased the portions to be divvied out per service in response. This only created a destructive feedback loop. Companies realizing their margins were quickly shrinking continued to push utilization in hopes of demonstrating sustainable growth to senior management and shareholders. Of course, we know what happened... "everyone" did this and "everyone" got hurt as a result.

As an industry, healthcare version 2014 has finally wallowed to a point where we've come face to face with this fact: putting profits before patients has gotten us as close to rock bottom as we can possibly bear.

As dire as that may sound, we also see that opportunities abound. Yet, current processes seem to hinder putting innovative action plans into play.

So, where do we go from here?


The answer and more, coming up in Future of Physical Therapy 2015 (Part 2)