The Episode of Care that Cost More

Miss Edy still can't kneel down.

She told me today in physical therapy.

Miss Edy has been a physical therapy patient before for short courses of PT that have, thus far, ended with a surgical procedure.

She has, at various times, received therapy for her right hip, knee, low back and neck.

In that time span, she has had her right hip replaced and has had rods-and-screws implanted in her spine.

Her complaint was always right knee pain and an inability to kneel.

She never had hip pain.

She never had back pain.

She can kneel on her left.

Pathology Persuades

Miss Edy is convinced that her surgeons did a great job on her hip and back but she is perplexed why she cannot kneel on her right.

Kneeling is a skill.

Kneeling can be taught.

Physical therapists often need to ask their patients , specifically,

"Can you kneel?"

The OPTIMAL scale specifically asks patients, "Can you kneel?".

Did Physical Therapy Fail Miss Edy?

Why did each of Miss Edy's courses of PT end in surgery?

Did the surgeons, armed with her impressive MRIs, push the surgical option too hard?

In our fee-for-service system, they had every incentive to do so.

Did Miss Edy have too much faith in technology?

Did she have low self-efficacy?

In Search of a Better Model

I have taught students and new graduates the importance making decisions by the rehabilitative model instead of the medical model.

Sometimes I get blank looks.

Sometimes I get rolling eyes.

Sometimes I get "Tim, it's just too theoretical for daily decision-making!"

But, when I still hear physical therapists saying "We need to put a little ultrasound on your shoulder for the tendinitis", I know they have abdicated their diagnostic decision-making in favor of the physician's diagnosis.


Patients hear enough of that - they need to hear a unified message of hope from physical therapists.

"You can do it!"

An Epiphany

I was never taught a disablement model. I graduated from PT school in 1992 and I learned about Nagi in 2001 when the Guide to Physical Therapist Practice was delivered to my doorstep like an extra phone book.

I dutifully read it.

I learned about Nagi's framework which has since segued into the ICF framework seen above.

How do PT decisions relate to Miss Edy and the cost of her episode of care?

I wonder if the entire episode were managed with her chief complaint in mind?

"I can't kneel down."

How much would it cost?

Would she have been saved from two major surgeries?

This image shows the payment model that distinguishes between our current system and some alternatives:

• fee-for-service (yellow)
  
• episode of care
  
• Condition-specific capitation (aka: risk-adjusted global fees)

Get the Report here and view some physical therapists discussing the alternatives here.

$100,000 dollars later, Miss Edy still can't kneel down - but now we're working on it.