This is the slideshow I presented in Orlando, Florida to the Florida Physical Therapists in Private Practice for our Annual meeting. We discussed Medicare Accountable Care Organizations and how private practice physical therapists can effectively compete in a vertically integrated healthcare delivery system that is trying to cut costs and increase quality.

1. The Florida Physical Therapists in Private Practice (FLPTPP) presents How Physical Therapists Can Thrive Under Health Care Reform August 20-21, 2011 Orlando, Florida Tim Richardson, PT TimRichPT@BulletproofPT.com Downloadable slide show at http://www.BulletproofPT.com 1

2. Downloadable slide show at http://www.BulletproofPT.com 2 The Florida Physical Therapists in Private Practice (FLPTPP) presents Armin Loges, PT Chris Mulvey, PT Tim Richardson, PTDiane Hartely, PTEric Douglass, PTRobert Dragan, PT Stephen Trinque, PTTom Zeller, PTTricia Trinque, PT

4. America spends more than any other country in the worlds, almost 17% of Gross Domestic Product (GDP), on healthcare.

5. But, America ranks #37 in Quality and Fairness according to the World Health Organization (WHO). Click the link for the 2008 PBS Frontline documentary Sick Around The World.Downloadable slide show at http://www.BulletproofPT.com 3

6. Can We Do Better? Downloadable slide show at http://www.BulletproofPT.com 4

7. Can We Do Better? Downloadable slide show at http://www.BulletproofPT.com 5

8. Can We Do Better? Downloadable slide show at http://www.BulletproofPT.com 6

10. Requiring coordinated care for all services provided to a population of people under Medicare Fee-For-Service.

11. Encouraging investment in infrastructure and redesigned care processes in order to reduce the per-capita cost of healthcare.Eligible providers, hospitals and suppliers may participate in the Shared Savings Program by creating or joining an Accountable Care Organization, also called an ACO. The ACO is expected to transition to population-based payment arrangements Downloadable slide show at http://www.BulletproofPT.com 7

12. What is an Accountable Care Organization (ACO)? Section 3022 of the Affordable Care Act that was signed into law by President Barack Obama on March 23, 2010 requires the Centers for Medicare and Medicaid Services (CMS) to establish a Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs. Downloadable slide show at http://www.BulletproofPT.com 8

13. What is an Accountable Care Organization (ACO)? Risk & Reward Downloadable slide show at http://www.BulletproofPT.com 9

14. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 10 Five Domains Patient/Care Giver Experience Care Coordination Patient Safety Preventative Health At-risk Population/ Frail Elderly

15. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 11

16. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 12

17. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 13

18. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 14

19. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 15

20. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 16

21. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com 17

22. ACO Quality Measures Downloadable slide show at http://www.BulletproofPT.com CMS is proposing to define the first quality performance period as beginning January 1, 2012, and ending December 31, 2012. For the first year of the Shared Savings Program, CMS proposes to set the quality performance standard at the reporting level. 18

23. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com The Physician Group Practice (PGP) Demonstration was the first pay-for-performance initiative for physicians under the Medicare program. Billings Clinic, Billings, Montana Dartmouth-Hitchcock Clinic, Bedford, New Hampshire The Everett Clinic, Everett, Washington Forsyth Medical Group, Winston-Salem, North Carolina Geisinger Health System, Danville, Pennsylvania Marshfield Clinic, Marshfield, Wisconsin Middlesex Health System, Middletown, Connecticut Park Nicollet Health Services, St. Louis Park, Minnesota St. John’s Health System, Springfield, Missouri University of Michigan Faculty Group Practice, Ann Arbor, Michigan 19

24. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com There are three primary ways for an ACO to achieve savings on the care of the assigned Medicare population: Reducing emergency room visits and hospital inpatient admissions. Reducing the provision of specialty care for the assigned Medicare patient population Reducing the provision of imaging and other special tests 20

26. Inadequate post-discharge follow-up

27. Lack of coordination between inpatient and outpatient healthcare teams.21

28. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com Smith et al reported on the discharge recommendations of 40 physical therapists treating 762 patients at a large, acute care hospital. Smith wanted to see how often the therapists’ recommendations were followed. The therapists’ discharge recommendations were followed 83% of the time. There was a mismatch in PT recommendation and patient discharge location in 124 of 743 cases . When the therapists’ recommendations were NOT followed, the patients were 2.9 times MORE likely to be readmitted than when the recommendations were followed. The hospital had an 18% 30-day re-admission rate, which is consistent with the literature. 22

29. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com Specialist Costs 23

30. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com Imaging Costs Overutilization of CAT scans: Double billing the Medicare program 24

31. Downloadable slide show at http://www.BulletproofPT.com What is an Accountable Care Organization (ACO)? Imaging Costs 25

32. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com 26

33. What is an Accountable Care Organization (ACO)? Downloadable slide show at http://www.BulletproofPT.com 27

34. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 28

35. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 29 Epidemiology The branch of medical science dealing with the transmission and control of disease and the mathematics of the collection, organization, and interpretation of numerical data, especially the analysis of population characteristics by inference from sampling.

36. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It is an approach to health that aims to improve the health of an entire population. One major step in achieving this aim is to reduce health inequities among population groups. Population health seeks to step beyond the individual-level focus of mainstream medicine and public health by addressing a broad range of factors that impact health on a population-level, such as environment, social structure, resource distribution, etc. An important theme in population health is importance of social determinants of health and the relatively minor impact that medicine and healthcare have on improving health overall. From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes“. 30

37. How to Manage a Patient Population Diagnosis The process the clinician uses to move progressively from a region of low clinical certainty to a region of high clinical certainty. In low probability conditions, screening tests are used to generate diagnostic possibilities and to “rule out” improbable conditions. In high probability conditions, diagnostic tests are used to confirm, or “rule in” likely conditions. Both testing and treatment carry risk. Downloadable slide show at http://www.BulletproofPT.com 31

38. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 32

40. Treatment Based Classification

41. Pathological Conditions

42. Psycho-Social ConditionsDownloadable slide show at http://www.BulletproofPT.com 33

43. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 34

44. How to Manage a Patient Population ODI SPADI Downloadable slide show at http://www.BulletproofPT.com 35

45. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 36

46. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 37

47. How to Manage a Patient Population Clinical Decision Rules Prediction of Community Acquired Pneumonia (CAP) Temperature > 100.04o Pulse > 100bpm Crackles/Rales on auscultation Decreased breath sounds on auscultation No asthma The clinician assigns one point for each of the findings that is present. Downloadable slide show at http://www.BulletproofPT.com 38

48. How to Manage a Patient Population Clinical Decision Rules Prediction of Community Acquired Pneumonia (CAP) Prevalence of Pneumonia in Primary Care = 2% Downloadable slide show at http://www.BulletproofPT.com 39

49. How to Manage a Patient Population Clinical Decision Rules Prediction of Community Acquired Pneumonia (CAP) Prevalence of Pneumonia in the Emergency setting = 8% Downloadable slide show at http://www.BulletproofPT.com 40

50. How to Manage a Patient Population Prediction of Community Acquired Pneumonia (CAP) Downloadable slide show at http://www.BulletproofPT.com 41

51. How to Manage a Patient Population Prediction of Community Acquired Pneumonia (CAP) Lung Sounds: Normal Lung Sounds: Crackles/Rales Lung Sounds: Wheezing Downloadable slide show at http://www.BulletproofPT.com 42

52. How to Manage a Patient Population Prediction of Community Acquired Pneumonia (CAP) ...compared with... Downloadable slide show at http://www.BulletproofPT.com 43

53. How to Manage a Patient Population Derive Sn, Sp, +LR, -LR with a 2x2 table Need Pneumonia numbers Downloadable slide show at http://www.BulletproofPT.com 44

54. How to Manage a Patient Population Downloadable slide show at http://www.BulletproofPT.com 45

55. Downloadable slide show at http://www.BulletproofPT.com 46

56. Disruptive Innovation Downloadable slide show at http://www.BulletproofPT.com “The business models of health are frozen in the hospital and the doctors’ office. The path to fixing the system is to disrupt those models.” Clayton Christensen The Innovator’s Prescription There are really three business model under one roof in the hospital: Precision medicine that can be “Routinized”. The goal is to identify areas where automation of repetitive tasks can improve care and save costs. Example: Total Knee Replacements. Intuitive medicine that requires highly trained specialists using costly diagnostic testing machines to discover the best treatment approach. Example: Gregory House, MD. Empirical medicine is the costly trial-and-error realm of chronic disease management. Christensen predicts an increase in patient autonomy, self-diagnosis and self-care choices. The rise of social networks will feature prominently in this realm. Example: Outpatient Physical Therapy. 47

57. Disruptive Innovation Downloadable slide show at http://www.BulletproofPT.com 48

58. Disruptive Innovation Downloadable slide show at http://www.BulletproofPT.com 49 Non-physician professionals, like Registered Nurses, Physical Therapists and Physicians Assistants, will tend to disrupt the business practices of primary care physicians Primary care physicians will tend to disrupt the business practices of specialist physicians Specialist physicians

59. How Physical Therapists Can Drive Better Outcomes Exercise is generally NOT harmful. Power training. Increased, self-directed activity is essential to reducing disability. Promote activity: walking, yoga, running, lifting, resistance programs, Zumba, Pilates, gardening, golf, fishing. Downloadable slide show at http://www.BulletproofPT.com 50

60. How Physical Therapists Can Drive Better Outcomes Hurt ≠ Harm. Emotional/Mental factors may drive 30-55% of musculoskeletal outcomes. Behavioral training more important than Cognitive training Downloadable slide show at http://www.BulletproofPT.com 51

61. How Physical Therapists Can Drive Better Outcomes Adequate physical activity is linked with important health outcomes… Reduced cardiovascular disease Type 2 diabetes Some cancers Future falls risk Osteoporotic fractures Depression Physical function scores on standardized self report measures Downloadable slide show at http://www.BulletproofPT.com 52

62. How Physical Therapists Can Drive Better Outcomes Behavior Change Assumptions Education Knowledge Behavior Change Downloadable slide show at http://www.BulletproofPT.com 53

64. Self-monitoring

65. Feedback – Functional Scales

66. Consequences/rewards

67. Exercise prescription

68. CuesDownloadable slide show at http://www.BulletproofPT.com 54

69. How Physical Therapists Can Drive Better Outcomes Goals Do single leg standing x 30sec. three times per day to improve balance. Cues First thing in the morning do single leg standing x 30sec. in the kitchen while the coffee percolates. Downloadable slide show at http://www.BulletproofPT.com 55

70. How Physical Therapists Can Drive Better Outcomes Educational/cognitive interventions LESS effective at promoting physical activity Targeting knowledge, attitudes or beliefs Mass media (vs. individualized instruction). Train-the-trainer models (vs. staff providing interventions directly to patients). Idiosyncratic provider interventions (vs. standardized recommendations). Downloadable slide show at http://www.BulletproofPT.com 56

71. How Physical Therapists Can Drive Better Outcomes “Medical Theater” Real treatment effects/outcomes due to some aspect of the medical intervention other than the physiologic effect. NOT a placebo! “A placebo is a substance or procedure…that is objectively without specific activity for the condition being treated…” Downloadable slide show at http://www.BulletproofPT.com 57

72. How Physical Therapists Can Drive Better Outcomes What drives outcomes in addition to the intended treatment? Dress: The white coast and stethoscope Language: Medical jargon based in Latin Diagnosis and Expectation: The effect on functional status over time of a diagnosis of “disc degeneration” Cost: More costly medical treatments have a higher cost and a higher perceived benefit Color: Blue pill vs. Red pill study by Blackwell Downloadable slide show at http://www.BulletproofPT.com 58

74. Branded Analgesics for Headache (1981)

75. Red pill vs. Blue Pill for Mood Alteration (1972)

76. Internal Mammary Artery Ligation for Chest Pain (1959, 1960)Downloadable slide show at http://www.BulletproofPT.com 59

77. How Physical Therapists Can Drive Better Outcomes “Medical Theater” Downloadable slide show at http://www.BulletproofPT.com 60

78. How Physical Therapists Can Drive Better Outcomes “Medical Theater” Downloadable slide show at http://www.BulletproofPT.com 61

79. How Physical Therapists Can Drive Better Outcomes “Medical Theater” Downloadable slide show at http://www.BulletproofPT.com 62

80. How Physical Therapists Can Drive Better Outcomes “Medical Theater” Downloadable slide show at http://www.BulletproofPT.com 63

81. How Physical Therapists Can Drive Better Outcomes Health Coaching Hotspots by AtulGawande, MD featuring Jeffrey Brenner, MD New Yorker magazine article Frontline “Hotspotters” Video Downloadable slide show at http://www.BulletproofPT.com 64

82. How Physical Therapists Can Drive Better Outcomes The Six Sources of Influence Downloadable slide show at http://www.BulletproofPT.com 65

84. Lectured the students: “Use Condoms!” – didn’t work

85. Had college students make an educational video to teach high school students about protected sex.

86. Technique worked.

87. 80% of the college students bought condoms immediately and the amount of condoms purchased was greater than a control group.

89. Critical Pathways of Care: Starbucks/Aetna Saves Money, Improves Outcomes Downloadable slide show at http://www.BulletproofPT.com 68 How Physical Therapists Can Drive Better Outcomes

90. Costs and Productivity Downloadable slide show at http://www.BulletproofPT.com 69

91. Structured Data Structured data is another way of referring to data that is entered into a specific field as opposed to free text in a chart note. 60% of the narrative note data is lost to the EMR. Downloadable slide show at http://www.BulletproofPT.com 70

92. Structured Data Downloadable slide show at http://www.BulletproofPT.com 71

93. Structured Data Downloadable slide show at http://www.BulletproofPT.com 72

94. Structured Data Downloadable slide show at http://www.BulletproofPT.com 73

95. Structured Data Downloadable slide show at http://www.BulletproofPT.com 74

96. Structured Data Downloadable slide show at http://www.BulletproofPT.com 75

97. Structured Data Downloadable slide show at http://www.BulletproofPT.com 76

98. Structured Data Downloadable slide show at http://www.BulletproofPT.com 77

100. Which structured data point is predictive of future disablement?

102. Structured Data Downloadable slide show at http://www.BulletproofPT.com 80

104. 10% of those who drink have alcohol problems that adversely affect their lives and their families lives.

105. The mortality rate of those who drink 6 or more drinks per day is 50% than matched controls.

106. Alcohol is a major factor in suicides, homicides, violent crimes and motor vehicle accidents.

107. Physicians are about to recognize, without decision aids, only about half of the problem drinkers they encounter.

109. Downloadable slide show at http://www.BulletproofPT.com 83 Decision Rules CAGE Rule for Alcoholism Screening

111. Nystagmus in different gaze positions

112. Test of Skew with prism crossover test of ocular alignmentPrevalence of Stroke: 25% of dizzy patients in the emergency setting are experiencing a stroke. HINTS is Head-Impulse, Nystagmus, Test-of-Skew.

113. Decision Rules Downloadable slide show at http://www.BulletproofPT.com 85

114. Decision Rules DVT risk and prevalence is increasing. DVT and Pulmonary Embolism (PE) is “the most common preventable cause of hospital death in the United States”. 2 million Americans develop DVTs every year and 200,000 die of the associated PE. Each year, over 25,000 people in England die from venous thromboembolism developed in hospital. Downloadable slide show at http://www.BulletproofPT.com Screening for Deep Vein Thrombosis 86

115. Decision Rules Downloadable slide show at http://www.BulletproofPT.com Screening for Deep Vein Thrombosis 87

116. Decision Rules Downloadable slide show at http://www.BulletproofPT.com Screening for Deep Vein Thrombosis 88

117. Active cancer? Bedridden recently >3 days or major surgery within four weeks? Calf swelling >3cm compared to the other leg? Collateral (non-varicose) superficial veins present? Entire leg swollen? Localized tenderness along the deep venous system? Pitting edema, greater in the symptomatic leg? Paralysis, paresis, or recent plaster immobilization of the lower extremity Previously documented DVT? Alternative diagnosis to DVT as likely or more likely? Downloadable slide show at http://www.BulletproofPT.com 89 Decision Rules Screening for Deep Vein Thrombosis (DVT)

118. Downloadable slide show at http://www.BulletproofPT.com 90 Decision Rules Screening for Deep Vein Thrombosis (DVT)

119. Test Question: “Do you believe that you should not do any activities that make your pain worse?” Downloadable slide show at http://www.BulletproofPT.com Decision Rules Screening for Fear Avoidance Beliefs In one study of 80 patients, George estimates the population prevalence of elevated fear avoidance behaviors to be 37.5%. 91

120. Downloadable slide show at http://www.BulletproofPT.com The largest single, modifiable factor affecting worker and our patients’ outcomes may be the psychosocial factor. As stated by Waddell... “…fear of pain and what we do about it may be more disabling than pain itself.” 92 Decision Rules Screening for Fear Avoidance Beliefs

121. Downloadable slide show at http://www.BulletproofPT.com 93 Decision Rules Screening for Fear Avoidance Beliefs

122. Downloadable slide show at http://www.BulletproofPT.com 94

124. Depressed patients 3x more likely to be non-adherent with their medical treatment.

125. Of the world’s ten leading causes of disability, five are psychiatric/addictive conditions.

127. Downloadable slide show at http://www.BulletproofPT.com 97 Decision Rules Screening for Depression Prevalence of acute depression is 25% in Americans. Prevalence of chronic depression is 6.7% in Americans

128. Decision Rules Physician Quality Reporting System Health Information Technology: Adoption/Use of Electronic Medical Records (#124) Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation (#126) Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear; Preventive Care and Screening (#127) Body Mass Index (BMI) Screening and Follow-up (#128) Documentation and Verification of Current Medications in the Medical Record (#130) Pain Assessment Prior to Initiation of Patient Treatment (#131) Falls: Plan of Care (measure #154) Falls: Risk Assessment (#155) Downloadable slide show at http://www.BulletproofPT.com 98 The Affordable Care Act makes a number of changes to the Physician Quality Reporting System, including authorizing incentive payments through 2014 and requiring a penalty, beginning in 2015 for professionals who do not satisfactorily report.

130. Back Pain: Physical Exam (measure #149)

131. Back Pain: Advice for Normal Activities (measure #150)

132. Back Pain: Advice Against Bed Rest (measure #151) “Several of the proposed ACO quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System...”

133. Decision Rules Ottawa Rules for Ankle Fracture Following Trauma Downloadable slide show at http://www.BulletproofPT.com 100

134. Decision Rules Ottawa Rules for Knee Fracture Following Trauma Downloadable slide show at http://www.BulletproofPT.com 101

135. Decision Rules Screening for Spinal Fracture Downloadable slide show at http://www.BulletproofPT.com 102

136. Decision Rules Downloadable slide show at http://www.BulletproofPT.com 103 Cancer Screening in Lower Back Pain

138. Knowing when not to treat is as important as knowing when to treat.

139. Maintain a list of health professions to refer patients to when indicated.

140. Maintain a high “index of suspicion” for pathology

141. Collect baseline data. Create systems. Push down data collection to every person in the clinic.

142. Standardize your Examination. Screen low AND high risk populations.

143. Find patterns.

144. Follow-up104

146. Alcohol/Drug screening

147. Adult weight loss

148. Childhood obesity

149. Stress reduction

150. Yoga

151. Pilates

152. Acupuncture

153. Massage therapy

154. Exercise boot camps

155. Group support programs (eg: depression)

156. Encourage patients to find a primary care provider105

158. Physical therapists can address population health

159. Physical therapists can address behavioral health

160. Physical therapists may need to alter patients’ and physicians’ expectations

161. Structured Data is a new type of documentation

162. Clinical Decision Rules are a “Technological Disruptor” in Health Care......if we use them!

163. Thank You Downloadable slide show at http://www.BulletproofPT.com 107