Feature PTs and the Consumerism Movement As physical therapy patients increasingly seek to become more involved in their own care, PTs and PTAs face both challenges and opportunities. By Chris Hayhurst | March 2019 Like any physical therapist (PT) who's been in the field for a while, Kathryn Stenslie, PT, DPT, has seen the profession go through many changes. One recent trend in particular, however, really has her thinking about the way she practices—and about how a strong practice should be run. When she started out 20 years ago, Stenslie explains, patients were far less concerned about costs. "Their insurance tended to cover their benefits, so they were usually ready to come in as often as needed." From her perspective, that meant Stenslie mostly could concentrate on her work. "There were fewer restrictions back then," she notes. "There just wasn't much to think about beyond treating people with kindness and working to help them get better." Another factor: Patients couldn't come to her directly. "Before direct access, we were much more focused on making physicians happy. They controlled our business because they were our referral source." Fast forward to today, and the patients Stenslie sees where she now works—Human Performance and Rehabilitation Centers (HPRC) in Columbus, Georgia—often arrive without a physician's referral. And, increasingly, they're bringing a list of questions. "We're getting phone calls ahead of their visit, or even before they make an appointment. And sometimes they'll even stop in to see the clinic, or to describe to us the frustrations they've had with their condition, and to ask us in person how we can help them," she says. "They want to know that we're going to be there to protect their interests—that they're not only going to receive quality care, but also that it's going to be an experience they can afford." In response to these concerns, Stenslie says, she and her colleagues have changed how they market their practice and are looking for new ways to provide value to patients. "The fact is, people are shopping around for care," she notes. "And as much as we PTs don't like to think about it, not every practice is equal. There are great practices, not-great practices, and many that are somewhere in between." In such an environment, Stenslie says, it's important to take "that extra step" wherever possible to set yourself apart from the competition. "If you don't, people are going to notice. And they might just decide to go elsewhere." Giving Consumers What They Want While some PTs may not be familiar with the term "consumerism movement," most have experienced firsthand the effects of this wave that's sweeping through health care. In health care consumerism, analysts say, would-be patients are the drivers of change—leveraging the power of their limited health care budgets to push providers to better meet their needs. What exactly is health care consumerism? There doesn't appear to be a clear, all-encompassing definition. One is "personalization of care to facilitate health outcomes."1 Another source describes health care consumers as those who "want to be better able to make decisions to address their needs…who can make informed choices about the care they receive."2 "Consumers want more from the health care industry," notes a recent report by the consulting firm McKinsey & Company.2 At the top of the list, a McKinsey survey found, is more affordable health care, followed by slightly less-pressing concerns around care continuity and better engagement with their providers. Health care consumers, the McKinsey report notes, would like to see providers act more like major retailers—the Walmarts and Amazons of the world. "The types of interactions and relationships consumers have with these companies strongly suggest what they want from health care organizations," according to McKinsey. It's doubtful that any in health care are hoping to turn their organization into the next Amazon—though the reverse may be true: Amazon has made major moves into health care3—but a growing number of providers are trying to emulate the consumer-centric approach that many health care users deem essential. The American Hospital Association, for example, has made it clear that it supports improved information sharing with the public, including better transparency when it comes to pricing health care services.4 And many health systems are now nearly as focused on the "patient experience" as they are on the care itself. "A growing demand among patients for an enhanced service experience and greater participation in their health care is placing…pressure on health care systems to find ways to become more patient-centered," notes a 2017 guide to ambulatory care improvement by the Agency for Healthcare Research and Quality (AHRQ).5 Ratcheting up that pressure even further, AHRQ reports, are new federal and state regulations designed to push the industry toward "value-based care"—ranging from requirements around reporting patient-experience data to the quality-performance measures that are part of Medicare's Merit-based Incentive Payment System (MIPS). "Patients with better care experiences often have better health outcomes," the agency notes. And "patient experience is correlated with key financial indicators, making it good for business as well as for patients." So, how are PTs responding to the consumerism movement and the consumer-focused incentives built into emerging payment models? Stenslie, who also is HPRC's vice president of operations and serves as president of the Institute of Private Practice Physical Therapy, says, "It's something we're working on every day, and our approach is evolving all the time." For example, she says, on the social media front, HPRC is trying to post stories that strike a chord with potential customers. "People are a lot more touched by the emotion of a story, versus 'look how I got this patient's knee to bend fully.' It's more about focusing on what the patients' goals are—what they want to get back to and what we have done to get them back to it." The practice takes a similar approach in the clinic itself, Stenslie says, striving to be "personal" wherever possible. "It's little things like walking patients to their cars, or taking a minute to email them their home exercise program," she says. Or, if a patient needs to purchase something for use in their rehab, "We'll go online and help them find what they need." Every day, the practice tries to "bridge the gap" when patients don't know what to do or have a problem that HPRC can address. Too often, Stenslie says, they'll see "frustrated patients who come to us and report that they have 3 physicians, none of whom are talking to each other." In such cases, she says, "I'm going to be the person who gets the left hand talking to the right hand." Steslie doesn't think there's any single way a practice should cater to the consumer, but she does believe that "because health care is so competitive, and because of the way we'll be paid as value-based care comes into play, we all should be thinking about the things we can do to improve the patient experience." The time is coming—and for many, it's already here—when payments for care delivery are going to depend at least in part on patient-reported outcomes, Stenslie notes. "And to do well there, it's about the patient's perception: how well they got, how they were treated, and how satisfied they were. That's how we're going to be measured, so what we're doing now is preparing for the future." Taking a Team Approach Another clinician with the future in his sights is Jerry Durham, PT, principal at San Francisco Sport and Spine Physical Therapy and a consultant who helps other private practice PTs optimize their businesses. Durham says the consumerism movement is always top of mind in his work. "All you have to do to see how important this has become is go online and read reviews of physical therapy practices," Durham says, citing reviewers who wrote that they believed a therapist ripped them off, or a therapist committed fraud, or a PT was guilty of a 'bait-and-switch.' In fact, he continues, "all of those charges were leveled against me in my own clinic—because consumers didn't understand their costs going in, and they got a sizable bill at the end of their course of care." PT practices need to understand that consumers calling for an appointment today likely are very different from those of only a few years ago, Durham says. "Patients and clients used to expect very little of us, mainly because of their experience with other providers. They needed pain management or joint mobilization at their shoulder, so that's why they came to us, and that's what they expected to get," he notes. "But now they're starting to hold us accountable. They're saying, 'Well, if a software company can answer the phone, why can't my health care provider?' Or, 'If Amazon can deliver something overnight and show me the price on its website, why can't my health care provider do that for me?'" Practice success today, Durham says, requires a "team approach." The clinical component of a patient's interaction with a practice is only a fraction of the overall experience, so PTs, practice managers, and staff alike must work together to give patients what they need and want. "You have to look at your PTs and ask, 'What are your strengths?'" he says. "Look at your aides and ask the same thing. Look at your front desk staff, your billing people, and every single person at your practice, and figure out what each of them can do best to meet and exceed the customer's expectations." Go through that process, Durham says, and you'll find all kinds of ways to improve your practice. "You have to remember, nobody is paying only for physical therapy or for use of a specific piece of equipment. They're paying for an experience, and for your time and expertise. They're paying for a service that gets them the outcome they desire." Partnering With Patients It isn't just PTs in private practice who believe that adapting to the consumerism movement is a matter of survival. Jolene Bennett, PT, MS, ATC, a staff PT with the large hospital system Spectrum Health in Grand Rapids, Michigan, says consumerism is driving change in her organization. "I've been a PT for 30 years, and I think what we're seeing is a great thing," says Bennett, a board-certified clinical specialist in orthopaedic physical therapy who works within Spectrum Health's Rehabilitation and Sports Medicine Services. "The consumer is going to find the therapist who is the expert, who treats people well, and who does everything in an efficient manner." Bennett says it's all about PTs standing out for their all-around skills and not just for their productivity. "When you're working to meet consumers' needs, it can't be about how many units you crank through," she says. "There's much more to it—and, to me, that's what's exciting." Her employer, Bennett says, has made a number of changes to accommodate consumers' preferences, from offering Saturday and extended-hours appointments to ramping up their home- exercise programs when patients limit their visits. "Often it has to do with their deductibles," she explains. "People are asking about costs. Maybe they've had a rotator cuff repair. They'll say, 'I know that rehab is important, but can we do this in 1 visit per week, or 1 visit every couple of weeks?'" Yes, they can, Bennett tells them—if they're willing to do the necessary work at home. "And what I've found is, more often than not, these people are much more self-accountable. They do what they need to do because they're financially invested." Bennett's well aware that, under the current fee-for-service model, when patients schedule fewer visits there are financial repercussions for her health system. But this is the direction in which health care is headed. "On the business end, if you're not seeing people 2 or 3 times a week, you've got to come up with more new patients to fill those appointment slots," she says. "That's a challenge, but it's not impossible to overcome." Janet Bezner, PT, DPT, PhD, FAPTA, associate professor in the Department of Physical Therapy at Texas State University and a certified health and wellness coach who has practiced in a range of clinical settings, agrees. "A physical therapist's role—or any health care provider's role—is to help patients build autonomy and competence so that they'll do what they need to do to get better when you're not around. The literature is very clear," she says: "The more control patients have around those behaviors, the likelier they are to actually do them." Bezner says she finds it interesting that these qualities of independence and personal responsibility are the same qualities that are fueling the consumerism movement. "The idea that I don't have to blindly take what my health care provider tells me and just do it is part of the notion that 'I'm in charge of my own health,'" Bezner notes. "It's the idea that I, the patient, know what's best for me. I may appreciate you, the health care provider, telling me what my choices are, and explaining them to me. But in the end, I'm the one who gets to decide." Her Millennial-generation PT students, Bezner adds, seem to have a natural understanding that the consumer is an appropriate source of power and direction. "I see them really appreciating the patient who comes in and says, 'This is what I was thinking,' or 'This is what I learned,' or 'What do you think about this option instead of that?' To my students, that's just the way it is. They don't even blink an eye." PTs in practice today "should be capitalizing on this movement to help people identify the best choices for them," Bezner says, "because when they get to make those decisions, they're going to be motivated to follow through with their treatment plans." That, she feels, is far better than the alternative: unmotivated patients who are passive about their care. "I see consumerism as a real positive," she says, "because it's helping us partner with our patients." Like a "5-Star Restaurant" Sandra Norby, PT, DPT, chief executive officer and cofounder of Home Town Physical Therapy, and president of APTA's Private Practice Section, also thinks the consumerism movement is an opportunity for PTs to improve patient care. The Home Town family of clinics, says Norby—who recently stopped practicing after 30 years as a clinician to focus on management of the business—includes clinics in 4 cities in Iowa. At each facility, she says, the PTs on staff are keenly aware that their patients are their "customers." "I drill into my therapists that we are here to serve our patients," she says. "Yes, our job is to make them feel better and help them move better. But we also want to make them feel as if they're at a 5-star restaurant—to anticipate their needs before they even have to ask." Like many practices, Home Town offers extended hours "to meet the patient where they are, as opposed to demanding that they fit into our mold," Norby says. Home Town also strives to ensure that patients don't "get bounced around between PTs," so they see the same familiar face each time they come in. And they ask patients how they'd prefer to communicate with the practice—by phone, email, or text. "We use a lot of technology for appointment reminders and similar things, and we provide patients with a lot of educational material and resources they can use to learn about their condition and how their treatment can help them." Even after a patient has completed care, the practice periodically will reach out to him or her with instructional articles or videos. "We try to make those touch points wherever we can," Norby says. She's seen statistics showing that patients who attend their first 2 physical therapy appointments are probably going to finish their episode of care. "So, the better we can offer that consumer value and demonstrate how physical therapy is going to help," she says, "the more engaged that individual is going to be—and that should translate to getting better faster." In all the years she's been in the profession, Norby adds, she's never seen patients as "smart with their health care dollars" as they seem to be right now. "Copays are going up. Deductibles are going up. People are paying more out of pocket overall," she notes. "So I get it—they have to be consumers." Norby has dealt with several injuries and conditions herself in recent years, so she has personal experience in this regard. "I have that huge deductible, so I've been a consumer of physical therapy, and I know what it's like to have certain demands," she says. In her case, she specifically picked out her PT because she knew that therapist's skill level. "And I was happy to write out that check," Norby says, "because that clinic helped me so much, and did the things that I couldn't do myself." Chris Hayhurst is a freelance writer. Consumerism and the Physical Therapy Outcomes RegistryAPTA's Physical Therapy Outcomes Registry was created to help PTs make data-informed decisions and demonstrate the value of their services to payers and other providers. Through integration with electronic health record (EHR) systems, the registry allows PTs across all practice settings to leverage data to improve patient outcomes. "Traditionally in health care we collect a lot of data when we care for patients, and that data sits in a single medical record," says Heather Smith, PT, MPH, APTA's director of quality. "The goal of the registry is to take that data and aggregate it so that we can look at larger patient populations."So, how does the registry fit into the concept of "consumerism"? Over time, Smith says, it will become a source of information on everything from the average number of physical therapy visits required for a given condition to the average cost of an episode of care. It also will provide data on outcomes—the results patients can expect when they choose to work with certain providers."When you go to buy a new car, you can figure out its value with a little research online so you know what you're getting into before you enter the dealership," Smith says. The registry, in part, is a response to consumer pressure: "Patients are pushing for more information, and this is one way we're working to give them what they want."Not All Health Care Consumers Have the Same GoalsAlthough anyone who uses health care services is by definition a "health care consumer"—and some general traits tend to apply across the board, such as a desire to keep health care costs under control and a wish to be more involved in decisions affecting their care—there are different segments among health care consumers. McKinsey & Company explains: "We often hear several common refrains about health care consumers—who they are, what they're looking for, and how they act….[but] the reality is different; there is no 'average' health care consumer. Rather, consumers come from a wide range of backgrounds, have differing clinical and lifestyle needs, and hold a variety of attitudes and expectations about health care. Thus, understanding the average health care consumer provides [only] limited information."1The company conducts an annual Consumer Health Insights Survey. Its 2016 iteration identified 6 distinct consumer segments—ranging from "healthy convenience seeker," with relative annual medical spending indexed at 1.0, to "passive reliance consumer," with relative annual spending triple (3.06) that of the healthy convenience seeker.But the difference isn't just in what each segment spends. For example, 77% of "healthy convenience seekers" believe that "taking care of my health is as much my responsibility as it is my doctor's," while only 34% of "passive reliant consumers" have that attitude. When it comes to technology, meanwhile, 56% of "healthy convenience seekers" used online tools to find a primary care physician, while only 30% of "passive reliant consumers" did."Any strategy to engage consumers and serve them well must be predicated on a nuanced understanding of them, since it is the nuances that often influence the likelihood of success," McKinsey & Company writes. "Payers and providers need to know which segments to engage (and when), how those consumers can and want to be reached, and what engagement approaches they will respond to best." ReferencesCordina J, Kumar R, Olson E. Enabling healthcare consumerism. McKinsey & Company. 2017. https://healthcare.mckinsey.com/sites/default/files/Enabling-Healthcare-Consumerism_R6B.pdf. Accessed December 18, 2018.