Allison Jones
Good morning, good afternoon, and good evening. Welcome to the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab.
I’m your host, Allison Jones. Today, I’m joined by Katie O’Bright, the owner of Redefine Health Education. Katie, it’s great to have you on the show today. Thank you for joining me.
Katie O’Bright
Thanks so much for having me. I’m looking forward to a great conversation.
Allison Jones
Yes, me too. So, before we dive into it, I want to give the audience some background on who you are. Take a minute and tell our audience about your background and a little bit about Redefine Health Education.
Katie O’Bright
Yes, thank you so much. Redefine Health Education, which I actually started in April of 2020, was largely inspired by the timeline of COVID. At the time, I was a cash-based practice owner in the Pittsburgh area. I was the sole income for my family as my husband was going through grad school, and we had two little boys. We needed a good income. So, my cash-based practice, which I had just started three months prior, did not survive the impact of COVID, at least it wasn’t going on the trajectory that I had anticipated.
So, I started Redefine Health Education as a way to provide some courses during the time that COVID was transpiring. Here we are, four years later, and this has really become my primary business. Our main mission is to get physical therapists, healthcare administrators, and healthcare systems to understand the impact and the importance of having a PT in primary care or a PT practicing in a primary care provider role.
We offer courses in primary care clinical aspects and are also working on courses for how to integrate a PT into a primary care system. We also have some courses in musculoskeletal imaging. But my background really started in the military. I came out of school and my very first job out of school in 2014 was assigned to a soldier-centered medical home. So, I was a PT in an integrated primary care practice right from the start. That’s how I got my inspiration for what, in my opinion, “right” looks like.
Now, transitioning into the private sector and into the non-federal world, it’s really my hope and goal that we can bring this forward-thinking, upstream model of care to the rest of the PT profession. The profession is currently functioning in a bit more of a historical perspective of what PT was, and we can evolve to be so much better than that.
Allison Jones
Excellent. So, could you delve a bit deeper and explain what primary care PT is? What is it, and what is it not? Please tell me a bit more about that.
Katie O’Bright
Yes, I’m very well versed in this because I was just on a different podcast last week where I explained what this is. So, if we think about primary care PT, a lot of people equate it to direct access. Direct access simply means that you can see a patient without a referral. That’s literally all that it means. You don’t have to change anything about your practice patterns or how you screen or evaluate a patient by law or regulation by seeing a patient through direct access. So, you can still do what you’ve always been doing, but see a patient without a referral.
Primary care PT is actually changing the entire mindset about how you evaluate and interact with patients, and how you sustain relationships with them over time. For example, you might have a patient who comes in, let’s say, for knee pain. That same patient, during your screening for primary care PT, you want to get a really good snapshot of what that patient’s life looks like because that is all going to dictate how the patient is going to do and what’s even achievable to offer them for therapy services. So, if you exclude all of that, which I think sometimes PTs fall into the trap of doing, saying, “Oh, they were already screened by a medical provider,” or “Someone else takes their blood pressure,” or “Someone else takes care of their GI conditions,” or this and that. If we just remove that from our thinking entirely, we’re really missing the mark on what that patient’s full health picture looks like.
So, in primary care PT, let’s say, just going back to that patient with knee pain, you can have Patient A over here who comes in with knee pain, who has excellent vitals, good access to transportation, good social relationships, a good job, money, access to the stuff that they need, eats a healthy diet, participates in regular exercise, doesn’t have a significant medical history. Okay, that’s a straight-up knee patient. We can work on that. And, they don’t have any signs and symptoms of mental health disorders or sleep disorders. Okay. We can treat that like a knee patient. That’s great.
But on the flip side, the vast majority of our population is coming to us with significant medical complexities. In fact, there’s a statistic that I was just reviewing related to blood pressure, where it’s more than 50% of our population in the United States has hypertension. Of that 50%, less than 50% are actually controlled. So when somebody says that they are hypertensive, or they mark a history of hypertension, but they say they’re on a blood pressure medication, you can only be about maybe 30% to 40% confident that patient is controlled on that medication at that time.
So, functioning in a primary care mindset, we are taking all of that into consideration with every patient that comes in the door. And you’re kind of serving as a care navigator where, yeah, you might end up seeing that patient for their knee if they’re appropriate, but you’re not excluding all of these other socioeconomic, past medical history, mental, emotional health, social health factors. You’re not excluding all of that. You’re including it as a part of your relationship with that patient for as much or as little as the patient consents to.
So, I think that’s something that is an evolving concept in physical therapy, and a lot of it is being driven by the fact that we have significant physician shortages. Of the physicians that are available for care—and physicians will attest to this; this isn’t me saying this—they’re placed in very impossible working conditions where they have to see 50 or 60 patients a day. You get 7 to 15 minutes. What can you possibly do with our complex medical conditions, given those working conditions?
So, I think primary care PT is just another way that we can be a part of the greater medical team and serve that patient best at the right time.
Allison Jones
This might be a little bit obvious, but how does primary care PT better serve the patient and better serve PTs?
Katie O’Bright
It might be obvious, but I think to our profession, sometimes it’s not so obvious. So again, when we’re thinking about how we’re setting up our businesses and how we want our businesses to be run—I’m speaking as a business owner now—if I were an owner of a physical therapy business, when I think about the traditional model, I think about a linear relationship where you receive a referral from someone, an orthopedic surgeon, primary care, whatever, and that’s like, “Okay, PT, evaluate and treat for knee pain.” You kind of start at this initial evaluation and then you treat, treat, treat, and then you have this hard discharge.
Often, that linear relationship, which has a historical perspective to why it exists (though that’s outside the scope of this episode), doesn’t serve patients well in our current model. We have increasing insurance restrictions and justifications that we have to make in order to justify maintaining that relationship. Sometimes, insurance companies give patients five visits, and then you have to go through this whole process in order to justify more visits. Who really is that serving at that point? With primary care PT, perhaps the patient will understand that they can get to us before it gets to a point where they need more than five visits.
I think a lot of patients in general, and this is just from me interviewing the general public, a lot of patients in general, and a lot of referring physicians don’t like to send patients or patients don’t like to go to physical therapy because they’re concerned about getting into this trap of, “Oh, if I go to PT, I’m going to be stuck there two to three times a week for six to eight weeks,” because that’s what every PT clinic is doing. That’s what a lot of PT clinics are still doing now in 2024, which is crazy. If we move upstream and we start to see patients earlier in the process, and we don’t make them commit to this two to three times a week for six to eight weeks concept, they’ll be more likely to seek out our services to begin with.
So, by approaching things from a primary care mindset, not only can we improve the people who are knocking on our door to begin with, but we can also, you know, patients find value in that tremendously because they know, “Hey, I have this expert that I can go to right off the bat that I don’t have to, like, funnel through primary care, I don’t have to see all the specialists and get all this stuff done. I can go right to this person who’s going to give me a really good answer, and I won’t feel like I’m getting sucked into this, you know, quote unquote plan of care,” because the plan of care could literally be one visit. It could be one visit and refer. It could be one visit and hey, let’s just have a couple of touchpoints over the next couple of weeks. Or it could even be something where a patient comes in and you know they have a chronic condition, like COPD, and you know maybe they just need some care to get them through an exacerbation. They get a little medication adjustment by their pulmonologist and you just work with them through that exacerbation, but you say, “Hey, you got to keep up with this, so check in with me in three months.”
So, it’s really good for patients. It’s really good for us because we can then provide the care that the evidence and the research is showing that we should be doing instead of feeling like we have to, and I’ll just use this term, we have to cash in on every patient that comes in through our door by exhausting their insurance benefits. And I’m speaking all of this because I’ve worked in these types of clinics that promote these types of concepts.
So, I do think that overall by moving more upstream, whether that’s we’re in our own PT clinic and we’re offering this model of care, these quick consults, you know, the revolving door model or where maybe we have our own PT clinic, our own PT business, but we work with the family medicine clinic down the road and we say, “Hey, what do you think about us putting one of our PT’s in your family practice one or two days a week?” and, you know, you work something out, you figure it out, and you get in there. Well, guess what? Those family medicine providers are going to start seeing the value that you can bring to the table. Your face and your business is going to then be recognized not only by those practitioners but also by the community and by the patients that are coming in for care there. And they’re going to say, “Hey, this actually seems like a really good option.”
Whereas before when you don’t have those like kind of immediate early access touch points, patients don’t even know what physical therapy is sometimes and they don’t want to go because they heard from their sister that it’s pain and torture. There’s just a lot of public misconceptions. So, if we have that opportunity to get upstream like that, what we’re noticing is that the clinics that are doing this in the private sector, that they’re actually seeing better downstream referrals. You know, you get a referral and they actually come and they actually complete their care. So, I think that it is just truly better all around.
Allison Jones
Yes, so that leads into my next question. You mentioned the term “cash in,” which is often seen as a dirty word. Everyone is concerned about reimbursement, making money, and surviving and thriving. You alluded to it. How does primary care PT impact your reimbursement and your revenue flow?
Katie O’Bright
Yes, that’s a really good question. So, in our current practice model, we know that patients with—and, okay, so I’ll talk about musculoskeletal for a second here, but we have to understand that musculoskeletal is just a blip in all of the conditions that we could possibly work with as physical therapists. When we think about our profession, we think about caring for individuals that have functional needs. I think that in general, the people who are missing out on our care are individuals with heart disease, individuals with COPD, individuals with cancer and cancer-related impairments, and individuals with cancer survivorship impairments. These people are not traditionally seen by physical therapists, and there’s a huge percentage of these patients that would benefit from even a couple of visits.
So, I’ll talk about musculoskeletal just for a start. When we talk about musculoskeletal care, it’s estimated that only about 7% to 14% of all musculoskeletal issues ever see a physical therapist. So, just in musculoskeletal alone, we’re already totally missing the mark. Now, coming back to natural history, we also know that a lot of musculoskeletal pain conditions are self-limiting, and they have a natural history that they just typically tend to get better with time. But we also know that the first provider that they see dictates how that’s going to go.
Because if you have a patient who comes in and they develop a bout of neck pain for the first time, and that patient also has a history of anxiety, and maybe they’re going through a difficult life transition, or maybe they’re not sleeping well, the first provider that you see, if they say, “Hey, let’s get some X-rays because you’re having this bout of neck pain and we don’t know what it is, let’s get some X-rays.” And those X-rays, oh, by the way, are probably not necessary, most likely. So, you get those X-rays and, you know, the radiologist reads them and maybe there’s some degenerative changes. Then maybe the PCP gets it back and says, “Hey, you know, just some wear and tear in your neck, degenerative changes,” you know, and then, you know, of course, these radiology reports say they have some, like, big scary words which we know are not really big and scary words, but to patients, they can be really big and scary.
And if the first provider that sees them doesn’t understand how to communicate those imaging findings in a way that promotes reassurance toward the patient, that patient can then start to ruminate and start to perseverate on those imaging findings. And then, you know, that creates a process in the nervous system that perpetuates pain cycles and perpetuates systemic inflammation and then you end up with pain that lasts a whole lot longer than it should.
So, when we just talk about those factors alone, it would be substantially more important or it would behoove everyone, and I’ll come back to reimbursement in just a second, it would behoove everyone to sort of flip the model and let the physical therapist be the one to see these patients first, manage the patient first, and educate the patient first.
So, how does that affect reimbursement and revenue and all of that? Well, if we do that, remember what I said about 7% to 14%? Maybe that turns into, oh, I don’t know, 80% to 90%, but maybe that 80% to 90% is one- to two-time visits, you know, one-time consult. We do all of the screening. We understand the risk factors. We understand, you know, the health status of the patient and you know, their trajectory for everything, and we can say, “Hey, you got back pain for the first time. I can do some things in clinic right here that will help make your back feel a little bit better. We encourage you to stay active and, you know, provide you that safety netting and here’s what to do if it doesn’t get better in this time frame.”
And then you have an open door and the patient can come back to see you if they need to, and they can just not if they don’t need to. So, how does that change everything? Well, guess what? Physical therapy evaluation codes pay a whole lot more than treatment codes, and you don’t have to run into all of the nonsense of like, “Oh, well, we can’t bill the same two treatment codes in this,” I don’t know, all the insurance nonsense that I don’t deal with anymore because I’m in the cash market because I can’t stand insurance. All that.
But if you just think about the impact of having more touchpoints with more patients with just musculoskeletal problems alone, and then think about the downstream impact on that patient and each one of those patients’ quality of life, their finances, then the insurance companies are like, “Oh, well, we see that PTs are not seeing patients for a million visits, so maybe we should reimburse these primary care consultant PTs a little bit more.” How about that? That’s interesting. So that’s just food for thought to start that conversation.
Allison Jones
Right. So why aren’t more people doing this?
Katie O’Bright
Okay. That’s a loaded question. I think a lot of it has to do with history, the way that these businesses have been run for decades, really, because of the evolution of our profession. So, I think a lot of it has to do with that. I think a lot of it has to do with our own profession being restrictive toward itself. There are still people in our profession who do not want to see patients direct access or as a first point of contact. Yes, they still exist. I know because I’m a part of these clinics that want to make this happen, and that’s some of the pushback. Some of the pushback is PTs don’t want to do it. They don’t want to function in that role. That’s a problem. That’s a serious problem.
So, what we try to do, I’m also the education chair for the Primary Care Special Interest Group, which is currently housed under the APTA Federal. I highly encourage everybody to explore that. We have so many different resources and connections for people. We also have a Primary Care PT Summit & Think Tank, which is going to be our second annual conference in Denver, September 20th and 21st this year. So definitely, look into that, follow me, and I can hook you up with all that stuff.
But why aren’t more people doing it? I think a lot of it has to do with culture and history. Many people, especially when we think about some of the larger corporate models, run their businesses based on the number of visits. It’s very difficult for these larger corporate businesses that have numerous regional clinics. If that’s their business model, if that’s their key business metric, it’s going to be really challenging to change that even slightly.
Also, there are some people who don’t want to engage with or collaborate with physician groups because they think that they’re going to fall into the whole physician-owned practice, which was, quote, “a cancer to our profession.” I actually think there are way bigger issues in our profession than working with physicians. In fact, some of the physicians that I’ve had the opportunity to work with directly have provided the best setup for myself, my patients, and the physicians. So, I think there are bigger problems out there than that.
I also think that sometimes businesses or PTs themselves don’t feel comfortable working in the consultant role. So, you go from maybe having a 45 to 60-minute evaluation time and switching into the primary care role, you might be doing more of these quick consults where you’re doing a very quick screen to rule out red flags. You’re functioning as a care navigator and dealing with appropriateness, triage, care navigation, referral recommendations. So, I think that a lot of people, probably the same people that don’t want to do direct access, are the same people that would have a problem functioning in that role.
So, I think that a lot of it has to do with culture rather than actual barriers, and it just takes a really solid pioneer to sort through the process and make it come to fruition. It takes a lot of time, a lot of grit, and a lot of perseverance. And, you know, it’s a new program, so you have to work out the kinks. And that takes an investment of time, which then translates into money. So, there are a lot of barriers, but I think there’s also a lot of hope and a lot of potential. And I also think there’s a lot of risk for businesses that just want to stick with doing what they’re doing because, as we know, reimbursement continues to plummet.
Allison Jones
Right. So, if you’re a practice or a provider that is interested in getting started with primary care PT and you wanted to start doing this today, how would you approach it? What are some tips?
Katie O’Bright
Okay. That, again, is a loaded question because there’s so much strategic planning involved in a new program like this. My first recommendation would be to map out exactly what your goal for the program is, because the goal of the program in your practice might be totally different than the goal of a program if you were in a hospital system or something like that.
In a hospital system, maybe their primary care or family medicine, internal medicine teams see a ton of musculoskeletal complaints, and they just have such a high volume that they need a PT just to function in that consultative role in that area. But maybe if you’re a private practice owner and you have a smaller clinic, maybe your goal is to change up the model a little bit so you can have more community engagement, and you can have more direct consumers that are coming to see you directly for your services. So again, identify what the goal is. Is the goal to provide kind of like an urgent care alternative where if people are getting these acute injuries, you can set up your practice to have this kind of same-day access situation, or is it more so you want to set up to be a part of the primary care team where you’re just acting as an extension?
So, maybe these patients have annual well visits with you where you conduct an evidence-based evaluation of very specific criteria for their given age group, for their given status. So, you’ll have different criteria for somebody who is in the pregnancy, postpartum, peripartum status. You’re going to have different criteria for that. You’ll have different criteria for the aging population, different criteria for the pediatric population. And all of it, you know, just understand that when I say criteria, I’m not talking about like ankle dorsiflexion limitation. That’s not what I’m talking about. I’m talking about what’s their risk for hypertension. What’s their risk for diabetes? Are they on an obesity trajectory? That is a change in their life. Identifying these major risk factors and then identifying, “Oh, okay, so you’re an aging person and your six-minute walk test is actually, you know, you’re kind of getting a little short of breath. You’re kind of desaturating a little bit. Did you know that?” So, that’s kind of what I’m referring to when I talk about these more screening or preventive measures.
So, are you wanting to set up more of an annual visit preventive medicine kind of model, or do you want to mostly just focus on injuries and reactive medicine? So, that would be tip number one. Figure out what the goal of your program is and what your capacity for that is. Do you have the actual capacity to dedicate to that? Then you want to do a pilot test. You want to figure out all of those aspects related to, “Okay, let’s do a three-month pilot test. We’ll figure out, you know, if you’re in the insurance model, you’ll figure out what payers need to do this in that, which, you know, insurance companies you’re going to have trouble with or that you need to call to make some specific justifications or, you know, figure out if there’s any prior auth nonsense that needs to be taken care of.”
And also, if you want to have a hybrid payment model where, okay, you identify that with maybe certain payers or certain insurance companies, this type of model is not going to necessarily work. Well, you put together, you know, a paper that says, “Okay, for all you know, Blue Cross plans, this is what would be covered under this and then this is what you would be expected to pay.” Do you want to participate in more of a subscription or membership style model of payment? Which for a direct primary care and then for those who are listening that aren’t familiar with direct primary care, it presents humongous opportunities for PT. Just go to dpcfrontier.com and there’s a mapper there that will show you what DPCs are in your area. DPCs are basically all the doctors that have left insurance practice and have gone to an affordable monthly membership. It’s not concierge, which is very expensive. Direct primary care is meant to be an affordable membership style primary care.
So, that’s another option to, like, partner with people like that or to just run a payment model like that. There’s endless opportunities and there’s so many considerations. I do have a mentorship program for those that are interested in learning more about sorting all of these things out, if you are wanting to go down that direction.
Allison Jones
Where can people find out about your mentorship program? They’re interested.
Katie O’Bright
That’s a great question. So, my website, redefinehealthed.com/mentorship, I think, is the correct URL. But you’ll be able to find it if you go to our homepage under redefinehealthed.com. If you scroll to the bottom, I think the last thing on there is the mentorship page. So, you just click that button and find out more. You can also send me an email at info@redefinehealthed.com. I’m happy to share any information or answer any questions people have.
Allison Jones
There is a lot to cover in our discussion with Katie today, so please join us for part two on our next episode. Until then, thank you for tuning into the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. We look forward to seeing you on the next episode.
==========
Thanks for listening to Therapy Matters. Do you like the podcast? Give us a five-star rating, subscribe, and tell all your friends about the show. Want to be a guest or know someone that would be a great guest speaker? Contact me at marketing@raintreeinc.com
Therapy Matters is brought to you by Raintree, therapy and rehab’s favorite EMR. Raintree is the only all-in-one therapy EMR, delivering a complete and seamless end-to-end patient journey from first contact to payment to patient retention. To learn more about Raintree, visit us online at raintreeinc.com.
