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As the manager of a Sports Medicine Clinic, I often am put into a position where I have to explain how/why what we do is different than a lot of other places. When this question comes from others in the healthcare industry (other AT’s, PT’s, OT’s specifically) I’m hesitant to answer. Why? Because these days everyone thinks outside the box.

A few years ago, going against dogma was the cool thing to do, and of course, everyone jumped on board. What this led to is a whole industry that thinks outside the box. Guess what, all that happened is the box got bigger and the so did the dogma.

We need to stay inside the box. BUT, everyone needs to think creatively. The problem is, everyone is focused on being an outside the box thinker, that they have forgotten (or never learned) how to think creatively within the confines of a box (or problem). Don’t believe me? Answer this:

You have a post-op ACL reconstruction patient (you pick the graft). Research shows that a return to any sport prior to the 6-month mark leads to an increased risk of injury regardless of how well/normalized they are. Best practice would be to keep them in formal rehab for that full 6-months until the physician releases them to full activity. 6-months equals 24 weeks. 2 therapy visits per week results in the need for 48 visits; 3 therapy visits per week results in the need for 72 visits. But, insurance gives you 20.

So, thinking creatively, how do you keep them engaged in SKILLED therapy for 6-months without going past 20 visits? And, a hope exercise program (that’s not a typo, because every home program is hoping they get better and don’t come back) is not an option – SKILLED therapy only. Do you go with dogma- 3 visits a week for 6 weeks and send them on their own to handle their rehab, or do you only see them 2x per week for 12 weeks, and then cut them loose for the next 12 weeks? Or, do you think outside the box and see them 2x per week for 6 weeks (12 visits) and then follow up on their progress on a HEP every 2 weeks for the next 16 weeks (8 visits)? That’s still not a full 6 months, and they are not engaged in skilled therapy unless them doing things under their own supervision is considered “Skilled”.

If someone cannot think creatively enough to answer the logistics part of this situation (the easiest of the tough parts), how will that person be able to understand the clinical complexity of the situation?

Many times after I give the overview of our program to another professional, in response I’m often told: “we do that.” I immediately think of the saying “they don’t know what they don’t know.” The fact that their operational decision on how to handle the situation above is one of the 3 options I listed shows me something different, and actions -not words- show intent.

To solve the multi-layered healthcare crisis, we need to think creatively inside the confines of the box.

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  1. Do you provide patients with “cash” based plans? Either to be used with insurance or in lieu of? I have been thinking about the same things you addressed in the article and have thought about offering packages to patients, similar to personal training sessions packages i.e. 12 sessions for so much per session.

    1. We do not. Offering the same service (ACL Rehab) at 2 differing price points raises several issues. A cash-based program would have to be priced equivalent to the billed insurance charges. Otherwise, many red-flags are raised on both the financial and ethical side of things.

      1. A solution to that ethical point is making the cash self-pay rate the average contract reimbursement per session. So, session done, interventions and units tallied up, and it is billed to the insurance company and the contract rates are applied and it comes out to $110. Average out over commercial and Medicare, the average is say $112 per session and that’s would be the cash self-pay rate.

        This is at least the principle solution a large OP ortho clinic is using to address the problem in the article.

        They also tend to blow through all available session/amount cap and leave the patient with this self-pay option without really informing the patient.

        I see the issue being addressed in the article and I want to give the patient the best options available for the best care possible.

        1. Yes, that does address the ethical point, and it does keep the patient engaged in therapy.

          But, critical thinking needs to be applied to the clinical approach as well. An approach to provide complete rehab needs to be developed for every common surgical case in <20 visits.

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