We interrupt my series on Physical Therapist Pet Peeves to bring you some excellent data from Health Affairs Sept edition on Virginia Mason, Collaboration Among Providers, Employers, And Health Plans to Transform Care Cut Costs And Improve Quality (abstract only, full text for subscribers only).
EIM blog reported to the physical therapist community on the day of publication the now widely distributed WSJ article on Virginia Mason’s novel efforts to wean itself off pricey tests through the use of Physical Therapists (not physical therapy!) as front line patient access points. It has been our belief for some time that physical therapists are truly force multipliers that achieve cost effectiveness and outcome through the consistent adherence of EBP for low back pain. (another example is here). There is also no question that downstream costs in imaging, pharmacy, and surgery can be realized by greater utilization of physical therapists. Fortunately, as the Health Affairs Article points out, we now have empirical evidence.
The article details the importance of the collaborative process in getting groups of providers to agree on defined clinical pathways for high cost drivers resulting in a “value stream”. Virginia Mason’s group defines quality in terms of access, high patient satisfaction, rapid return of functioning and the use of evidence based care at an affordable price. While we often think of EBP in terms of our own profession, the most critical point of agreement amongst collaborators is that EBP be based on a particular clinical question as opposed to the expertise of a single practitioner. The majority of providers participating in the clinical value stream complete full course in EBP and their belief is that the first office visit where the appropriate treatment is determined and initiated is the most important step. For low back pain, this is the job of physical therapists.
While much of the article points out the significant savings in value stream headache by avoiding over utilized MRI’s in the diagnosis, LBP is given ample coverage. Rapid access to care is deemed critical in achieving correct care AND savings. From the article:
For our back pain value stream, the use of physical therapists to perform some functions previously assigned to physicians improved Virginia Mason’s financial performance by increasing the number of patients seen and making more efficient use of physician time. Under the back pain value stream, we were able to accommodate 2,300 new patients per year, compared to 1,404 under the old system, in the same physical space. The physicians also became more efficient under the new system, with an average billing of 58.3 relative value units per day compared to 28.1 relative value units per day under the old system. Relative value units are the basis for physician payment under fee-for- service, so they represent an estimate of revenue generated.
Costs to the employers were decreased through the elimination of unnecessary imaging tests and fewer patient visits to providers. In addition, rapid access to care and increased efficiency of care delivery contributed to more rapid return to work. Postvisit surveys of patients seen in our back pain collaborative value stream revealed that patients in this collaborative required fewer physical therapy visits and fewer lost work days than local averages (4.4 compared to 8.8 and 4.3 compared to 9.0 for physical therapy visits and lost work days, respectively)
Perhaps even more indicting on cost elements is the dollar assessments of providers:
Providing the services of an orthopedic surgeon or other procedural specialist costs approximately $4 per minute. A generalist physician whose practice consists predominantly of patient evaluation and management, rather than performing procedures, costs Virginia Mason $2 per minute. A nurse practitioner or physical therapist costs $1 per minute or less.
Acuity is likely a factor in the decreased number of visits vs. local averages which supports early and direct referral to physical therapists. While there are advantages to organizations of a vertically oriented system like Virginia Mason, it is not a difficult task for a payor to direct care on low back pain to physical therapists. This should be the standard.
We will likely continue to pile up evidence that PT’s are the force multipliers in healthcare. We now have to actively advocate for appropriate changes to make it happen.
Thoughts?
larry@physicaltherapist.com
