Ep 202: Boosting access to outpatient physical therapy for all, with Dr Roy Film

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today. Depending on where you work,

[00:00:24] patients might find it easier or more challenging to access musculoskeletal rehabilitation.

[00:00:29] And even if you do work in a direct access setting where people can see you without a

[00:00:34] referral, there are often barriers for people accessing the high-value musculoskeletal care

[00:00:39] that you would like to provide. Today, my guest is Dr Roy Film, Physical Therapist, Educator

[00:00:46] and current President of APTA Maryland. Roy has spent much of his career working on ways

[00:00:52] to help more patients get access to high-value musculoskeletal rehabilitation, including in

[00:00:57] his advocacy work with the APTA and now in his PhD research. Today, we talk about what

[00:01:04] it means to advocate for better access to physical therapy. Roy Film, welcome to JOSPT Insights.

[00:01:12] Thanks. Thanks so much for having me.

[00:01:14] Thank you for coming on the podcast today, Roy. I think most of us get into working in healthcare

[00:01:19] because we want to help people. And there's many different reasons that make it easier or

[00:01:25] harder for clinicians to deliver high-value care to people with musculoskeletal pain. And equally,

[00:01:31] there's many factors that make it easier or harder for people with musculoskeletal pain to access

[00:01:37] healthcare. You've been at national and international policy tables discussing big picture in musculoskeletal

[00:01:44] health. What do you see as the most prominent issues facing the community? Broadly, patients, clinicians,

[00:01:51] researchers, policymakers, administrators, and others. What's the biggest issues facing them today?

[00:01:57] We'll start with a very low-key question, Roy.

[00:02:02] Yeah, there's a lot in that. You know, talk for hours just about that. I think one of the biggest

[00:02:09] issues overall is access to care. That definitely affects patients perhaps a bit more, but getting

[00:02:16] access to care is really important for practice owners as well and being able to reach more patients

[00:02:23] or administrators as well. So this is kind of a broad-reaching one. And I think with access to

[00:02:29] care, at least, there's a bit of an issue with outpatient orthopedic PT in that it's elective.

[00:02:37] Just like orthopedic surgery is elective, outpatient rehab is elective. So if it's hard to access care,

[00:02:43] at a certain point, people will opt out. They will not choose PT. And insurance companies,

[00:02:51] some insurance companies have done a really good job at putting up more barriers to care.

[00:02:56] There are systemic barriers that have put into place under the guise of business-related metrics,

[00:03:04] things to try to make sure that they're providing ethical care to their other policyholders

[00:03:10] that aren't pursuing elective care. Like in the state of Maryland, in my role as chapter president,

[00:03:17] we've been trying to pursue fair copayment legislation where the copayment for physical

[00:03:23] therapy would be set to the same level as for a primary care physician wellness appointment.

[00:03:28] It was completely eye-opening that the insurance lobby would be quite as disingenuous as they were.

[00:03:38] They framed the reason for not being agreeable to it as if it would increase their policyholder rates

[00:03:46] so much that it would drive them out of business. They were successful at convincing the state legislators

[00:03:54] that this was enough of a concern that they'd have to table the discussion and send it to a study.

[00:04:00] And then they effectively made sure that it never got out of committee and was never heard by the full general assembly.

[00:04:06] So it's a really tall task that we're up against. And this is happening in 50 states around the country

[00:04:12] and Washington, D.C. People have enough barriers to accessing care, especially if you live in a rural area.

[00:04:20] There might not be a PT for miles. Even in urban areas, there are significant access issues that I think a lot of people don't think about.

[00:04:29] They figure, well, there's a PT pretty close by, but it might take a very long time to get there,

[00:04:34] even if they're just a few miles away. Trying to navigate public transportation is really a big barrier to accessing care.

[00:04:43] So it's not completely the fault of the insurance company. It's not completely the fault of some of the built environment of a place.

[00:04:53] There are a lot of systems in place that really make it harder for people to access care.

[00:04:59] And setting copayments really high make it very, very difficult for people to choose PT.

[00:05:07] But what insurance companies do is grease the path to cheaper care, which may be a $10 home payment for a month's supply of opioids.

[00:05:19] You talk about lobbying and being at the table with insurance companies.

[00:05:24] These are the sorts of things that I don't think we think about when we go into a PT degree.

[00:05:29] As we said at the start, I think pretty much everyone goes into a degree in health professions generally because we want to help patients, right?

[00:05:38] And it's not until you get into those systems and structures that you realise that, well, there's a lot of complex stuff going on here that dictates what I can do as a clinician,

[00:05:47] which can feel really limiting and frustrating.

[00:05:51] And I think some of the issues that we're talking about seem like they're very much tied to the structure and the governance with very little that I can do as a frontline clinician to affect that.

[00:06:02] What would you say to someone who is feeling uncertain of what they can do to help improve equity or work towards equity in musculoskeletal healthcare specifically, Roy?

[00:06:12] It can make you feel cynical that you can possibly do anything at all.

[00:06:17] Now, as far as individual clinicians focusing on equity, well, there's all sorts of equity.

[00:06:24] So it depends on what you want to target, what you really value as a clinician.

[00:06:31] So personally, I've been focusing on the opioid crisis for quite a long time because of some older family members I've had who have actually passed away due to opioid overdose from oxycodone.

[00:06:43] Although I was already interested in that space, it really showed it to me in a very different light, made me recognise some of the really significant challenges that patients and families have in that regard.

[00:06:57] So when people are trying to work on equity of access to care for people, equity of being able to even access life-saving naloxone, things like that, the landscape has changed drastically over the past 10 years related to things like that.

[00:07:16] When people talk about equity, most of the time they're talking about racial equity.

[00:07:20] Now that's something that often is tied to socioeconomic equity and getting access to care for people in different communities can be challenging on top of that because it's not so straightforward.

[00:07:35] There are known issues with people who may not trust the health system because historically it hasn't been designed to help people from their community.

[00:07:45] So when we look at studies related to equity, it's very common for people to disregard some of the findings saying, well, you can't say that this is really a problem of the health system.

[00:08:00] This is people's choice.

[00:08:02] They're electing not to go to outpatient orthopedic PT, for instance.

[00:08:07] And we don't have the data to say anything other than that.

[00:08:11] So yeah, we don't know that's the case.

[00:08:13] We make a lot of assumptions.

[00:08:15] And in this area, when we have so many unknowns, researchers are making a lot of assumptions going in and have to mitigate that bias by really using good methodology to try to address that and make sure they're not just publishing some kind of foregone conclusion.

[00:08:36] This is an area that I've felt strongly about.

[00:08:39] And, you know, I could happily just believe what I want to believe, or I could try to figure out something about it, which is why I've started a PhD program in epidemiology.

[00:08:50] It's difficult to get legislators to listen to data.

[00:08:55] They glaze over pretty quickly.

[00:08:57] They don't get elected because they're good at data.

[00:09:01] Having those conversations without data, you're dead in the water when you're trying to perform advocacy work.

[00:09:08] So we need that as a springboard for any conversations to affect any change that can help our citizens get access to our care.

[00:09:17] We need to really consider things from other perspectives, which is challenging for all of us in healthcare because we've got our healthcare lens on all the time.

[00:09:27] Definitely.

[00:09:28] And you mentioned your PhD work, Roy.

[00:09:30] We'll get to that in a moment because that is very much getting into the data.

[00:09:34] And I think it's that careful balance when you're speaking with policymakers and legislators between the story, the hook is around the story of the individual or the group, and I think balancing that with the data.

[00:09:47] As you say, having the underlying data to show that you really do know what you're talking about and you have the flexibility to weave the data in with the compelling story.

[00:09:56] Before we get to the data, I do want to talk about protecting yourself or being kind to yourself because when you're doing a lot of this work as an advocate, it can feel like you're running around doing lots of things.

[00:10:11] And as a PT, perhaps you might be trying to help people get access to housing or access to good nutrition.

[00:10:20] Roy, how do you balance being kind to yourself and taking care of yourself?

[00:10:25] Because you can't do a good job as an advocate if you're burnt out and exhausted, nor can you do a great job as a PT either.

[00:10:32] And yet, there's a lot of work that individuals need to do as well.

[00:10:36] Yeah, well, you asked probably one of the hardest questions you could ask me because I don't balance very well.

[00:10:42] Over the years, one of the things I've realized is if you feel alone in doing this work, it is really something that's demoralizing because it looks like this bear that you're trying to tackle and you've got no hope of really doing anything significant, especially as an individual.

[00:11:01] So if you can link up with like-minded therapists and then get those folks to maybe pursue something together, then it makes it smaller for each individual.

[00:11:13] You know, there are a lot of people who get involved with APTA because they like to help with the state conference or help with legislative issues.

[00:11:21] There are a lot of people who aren't necessarily interested in those kinds of traditional things.

[00:11:26] In our chapter, we've been really lucky to try in an effort to make more space for people to come into the chapter.

[00:11:34] We got a lot of people who traditionally just haven't even been members.

[00:11:38] Even if they were members, maybe haven't been involved with the state chapter very much.

[00:11:43] So working together, we've kind of formed a community engagement group.

[00:11:49] We have a DEI group now, and they've been going for a couple of years.

[00:11:54] But when we started those things, all of a sudden, we got 33 people to come out who wanted to volunteer with us who had never, ever done so before.

[00:12:04] And prior to that, we had maybe 15, 20 people total in the chapter.

[00:12:09] So we got all this new energy.

[00:12:11] That sense of not feeling alone is so important.

[00:12:14] So I'm glad you bring that up, Roy.

[00:12:16] And the sense of we're working together as a collective towards something that we all believe in is also really powerful.

[00:12:23] So absolutely get involved, folks.

[00:12:25] There's lots of different ways to do so.

[00:12:28] Let's come back to the data, Roy.

[00:12:29] And I want to focus specifically on a new paper of yours that has just been published in JOSPT.

[00:12:37] And it's highlighted disparities in outpatient PT use after hip fracture.

[00:12:42] So we're coming back to this where we started with access to care for people with musculoskeletal pain.

[00:12:48] What were the main findings of your analysis?

[00:12:51] And then what are the implications of those results for patients and for clinicians?

[00:12:56] Thanks.

[00:12:57] So I'm really excited about this.

[00:12:59] This is the first paper from my PhD work.

[00:13:01] And I was really lucky that some pretty big authors collaborated with me on this.

[00:13:09] Dr. Julie Fritz and Dr. Tiffany Adams, Dr. Jason Falvey, who's my PhD mentor here at the University of Maryland.

[00:13:18] It's been just incredible being able to work at a high level with these folks so early in the process.

[00:13:25] Our primary findings were, first off, that only about three out of every 10 patients who've had a hip fracture,

[00:13:33] who are Medicare patients, end up ever using outpatient physical therapy.

[00:13:37] They almost all get inpatient physical therapy.

[00:13:40] And that was kind of surprising to me because through my bias, my clinical bias,

[00:13:46] it seemed to me that a lot more people should be getting outpatient PT.

[00:13:50] And then within that, we found significant racial disparities.

[00:13:53] And it was about, in the raw data, it was about 50% lower odds if you were a black Medicare recipient

[00:14:02] who had a hip fracture that you would ever use physical therapy.

[00:14:06] Now, that's really, really large.

[00:14:09] That's a really large disparity.

[00:14:10] And I expected a disparity.

[00:14:13] I did not expect anything that large.

[00:14:15] But there are a lot of possible reasons for this.

[00:14:18] So we controlled for several things.

[00:14:20] We controlled for demographics and medical complexity and socioeconomic factors.

[00:14:25] And even after adjusting for all those things, black Medicare beneficiaries were still,

[00:14:32] but still had 42% lower odds of ever using outpatient physical therapy.

[00:14:38] So all those things that we controlled for are things that have been traditionally used as explanations

[00:14:45] for why we might have health outcomes disparities in the United States.

[00:14:50] So controlling for all of them still left the majority, the vast majority of this disparity remaining.

[00:14:58] If that's the case, then what is it?

[00:15:01] And that really kind of got us, you know, gets us thinking more so.

[00:15:05] Beyond just whether or not they went to physical therapy,

[00:15:08] we also looked at the number of visits that people went to physical therapy for.

[00:15:13] And within that, there was also a significant disparity.

[00:15:16] Not as large, but if you were a black Medicare beneficiary who had a hip fracture,

[00:15:21] within the first six months, you used 15% fewer ET visits if you did start at all.

[00:15:30] So there's a lot of potential reasons for that.

[00:15:34] And even after controlling that, that disparity really remained largely unchanged.

[00:15:39] So that was really kind of surprising, spurs a lot of potential future research as well.

[00:15:46] And you mentioned this was the first paper of your PhD.

[00:15:50] Congratulations.

[00:15:51] Thank you.

[00:15:52] What are those next steps?

[00:15:54] Where do you take this analysis?

[00:15:55] And what are you looking at with the following papers in your PhD?

[00:16:00] So my plan, whether or not my plan actually goes according to plan,

[00:16:06] is to look at opioids and mitigating the use of opioids by using physical therapy for pain management

[00:16:13] and specifically outpatient physical therapy.

[00:16:16] That's my background.

[00:16:18] I was a private practice owner for several years before I got involved in academia.

[00:16:23] You know, I noticed a significant, you know, disparity in the population that I was treating.

[00:16:30] My clinic was in an area that wasn't necessarily as diverse as Baltimore City.

[00:16:36] I was out west in the suburbs.

[00:16:38] Once I started to realize this, I kind of thought, well, you know,

[00:16:42] maybe there's something that I'm doing that's fostering some of this problem.

[00:16:46] I should really, you know, reflect on that and look at, you know, what I'm doing as a clinician,

[00:16:51] how I've set up my business practices.

[00:16:54] Everyone's trying to move towards cash-based practice and outpatient therapy these days

[00:16:59] because reimbursement rates aren't increasing, but our costs are increasing.

[00:17:06] So a lot of people are creating these business models that now foster more inequity.

[00:17:14] If you have a cash-based program, well, then you're excluding lots of people from coming into your clinic.

[00:17:20] You're making it harder for access to care, which at the time I didn't think about at all.

[00:17:25] I was just thinking, how am I going to make this clinic work?

[00:17:28] Really getting to the point where in my PhD, I could utilize this to try to investigate disparities more

[00:17:38] was really my primary aim, but not, I wasn't particularly thinking about racial disparities.

[00:17:44] I was just thinking in how we can demonstrate the value and quantify the value of outpatient physical therapy.

[00:17:53] If we can't get insurers to recognize, you know, the ethical reasons for improving access to care,

[00:18:00] hopefully we can rely on, you know, on their desire to increase the bottom line

[00:18:06] and improve things for their stock price and things like that.

[00:18:10] But this seems to be improving access to care to PT to me seems to be a no-brainer

[00:18:16] and I want to kind of investigate that and see if we can make that point better.

[00:18:21] The challenges that I've gotten back from reviewers of my, of my work, although really uncomfortable

[00:18:30] and challenging to figure out and to wrestle with, it's helped me so much to really try to recognize

[00:18:36] how I need to frame things to make some of these cases that are airtight.

[00:18:44] If we, if we try to go into state capitals around the country with data that has holes all over the place,

[00:18:51] you know, we will totally shoot ourselves in the foot.

[00:18:54] We won't be able to, to achieve any greater goal of improving access to care, helping our patients.

[00:19:00] And ultimately we all, legislators included, they want to improve the lives of the people that put their trust in them,

[00:19:10] just like our patients put their trust in us.

[00:19:14] Roy, thank you so much for joining us today and particularly thank you for all of your work as an advocate for our profession

[00:19:21] and for the patients for whom you clearly care so deeply.

[00:19:25] I think that's going to resonate with many of our listeners.

[00:19:27] If people want to get involved, you've mentioned some, some good ways to get started.

[00:19:32] So I'm, I'm glad that we're able to give people some hope.

[00:19:35] Leaving people with hope is always much nicer than leaving people feeling either cynical or despairing.

[00:19:41] So thanks so much for joining me on JOSPT Insights today.

[00:19:45] Well, thank you so much for having me here.

[00:19:48] It's been really great having the opportunity to talk about some of these issues.

[00:19:55] Thanks for listening to this episode of JOSPT Insights.

[00:19:58] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

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