Objectiveswpta.org/events/conference/2015/spring/handouts/pdfs... · 2017. 4. 19. · 3/30/2015 13...

3/30/2015

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Jennifer M. Gamboa, PT, DPT, OCS

Objectives Business/Policy Context

Disrupting the Status Quo Therapeutic versus co‐dependent relationships.

Lifetime client engagement

Spheres of influence for lifestyle medicine

Differentiate among models of engagement

Define and characterize retainer‐based medicine, retail medicine, and the health club industry.

Develop lifestyle medicine programs at both a consumer level and a community level

Build/present a business model

Copyright 2015, JM Gamboa All Rights Reserved.

3/30/2015

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8 to 8:30 AM

Jennifer Gamboa, DPT, OCS


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0

1

Small PrivatePractice

Corporate PT HospitalSystem/Outpatient

Other

Who is in the audience?

TBA


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0

1

Why are you here?

TBA


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Business/Policy Context

8:30 to 10:00 AM


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HEA

LTHCAREREFO

RM

INANUTSH

ELL

• Inconsistent Practice Patterns

• Varied Practice Settings• Inefficient Health

Delivery Systems

• Declining “Population Health” • Escalating costs of managing Chronic Disease• 75% of the $2.47 trillion in annual U.S. healthcare costs stem from chronic diseases, many of which can be prevented or delayed by wise lifestyle choices

Expensive Health Care(17% of GDP)

&

Affordable Care Act

• Vertical Integration of Healthcare Services

• Institutionalized the Consolidation of the Market

• Mandated Increase in Insured Patient Population

Pitfalls

Insufficient Providers

No relief from declining reimbursements

Financial penalty to health delivery systems if population health does not improve

No incentives/disincentives to drive wise individual lifestyle choices (which dictates population health)

Vertical Integration Reward providers for reducing total cost of care for patients through prevention, disease management, coordination.

Bring care to larger numbers of people

Long‐range goal of CMS to migrate to risk contracting

spark industry‐wide investment in primary care infrastructure

establish narrower networks


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©2014 The Advisory Board Company • advisory.com

Where the Medicare ACOs Are

23 Pioneer and 343 Shared Savings Program ACOs

Source: Centers for Medicare and Medicaid Services; Health Care Advisory Board interviews and analysis.

Update on Accountable Care Organizations

April 2014

Shared Savings ACOs 2013 Cohort

Shared Savings ACOs 2014 CohortShared Savings ACOs 2012 Cohort

Pioneer ACOs

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Number of ACOs Continues to Grow

Source: Oliver Wyman, “ACO Update: Accountable Care at a Tipping Point,” April 2014; Leavitt Partners, “Growth and Dispersion of ACOs,” June 2014; Marketing and Planning Leadership Council interviews and analysis.


1) As of April 2014.

Total Number of Operating ACOs

May 2014

Widening Reach of ACOs1

67%Portion of U.S. population living in a primary care service area with an ACO

17%Portion of U.S. population treated by an ACO

5.3MMedicare FFS beneficiaries treated by an ACO

23

306

210

74 13 626

MSSP CohortPrivate Sector ACOs

ACOs without announced contracts

Pioneer ACO Model

TotalPrivate &PublicACOs

14


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Performance, Persistence Closely Correlated


Source: Centers for Medicare and Medicaid Services, http://innovation.cms.gov/Files/x/PioneerACO-Fncl-PY1PY2.pdf; “San Diego-Based Sharp HealthCare Pulls Out of Pioneer ACO Program,” California Healthline, August 28, 2014; Health Care Advisory Board interviews and analysis.

1) Dropped out after second year; second-year performance not reported

Some Pioneers Dropping Out of the Program

Pioneer ACO Performance

First-year performance

Second-year performance

Dropped out after first year

Gross Savings as Percentage of Benchmark

1

-5.6% (min)

7.1% (max)

Dropped out after second year

15


McClellan M, Kocot SL, White R., Early Evidence On Medicare ACOs And Next Steps For The Medicare ACO Program (Updated), Health Affairs Blog. Accessed March 20, 2015.


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Volumes Continuing to Shift Outpatient

18

Source: “Report to the Congress: Medicare Payment Policy,” MedPAC, March 2014, available at: www.medpac.gov; Marketing and Planning Leadership Council interviews and analysis.

1) Outpatient services represent entire market regardless of site of service (includes hospital-based settings, ASCs, other freestanding providers and physician offices)

Medicare Volume Growth

Cumulative Percent Change

All Payer Volume Growth Projections1

2013-2018

Outpatient Services per FFS Part B Beneficiary

Inpatient Discharges per FFS Part A Beneficiary

28.5%

(12.6%)

2006 2012

14.0%

5.0%

(3%)

(11%)

Inpatient Oupatient

11%

16%

15%

17%

Cardiac Services

Vascular Services

Orthopedics

Neurosurgery

Volume Performance


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Volume Performance

Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf; Health Care Advisory Board interviews and analysis.

Medicare to Become Majority of Volume by 2022

Projected Number of Medicare Beneficiaries

Millions of Beneficiaries

54.0

55.6

57.3

59.0

60.7

Average Inpatient Case Mix By Volume

n = 785 Hospitals

42%

58%

19%

15%

33%

25%

6% 2%

2012 2022

Medicare

Medicaid

Commercial

Self-Pay

2014 2016 2018 2020 2022

19


65

89 95 98

2010 2011 2012 2013

Mergers and Acquisitions Continue to Rise

Source: AHA Hospital Fast Facts, available at www.aha.org; GE Capital Survey, available at: www.gehealthcarefinance.com; Kaufman Hall, “Number of Hospital Transactions Grew in 2013,” available at: www.kaufmanhall.com; Advisory Board interviews and analysis.

Mergers and Acquisitions

1) September 2013.

Hospital Mergers and Acquisitions M&A Plans for the Next 12 Months1

Number of Hospitals Part of a Health System

2000-2012

2000 2003 2006 2009 2012

25422626

27752921

3100

88%

12%

n=189

No M&A Activity Planned

Planning to Pursue M&A Within the Next 12 Months

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A Growing Network of Immediate Access Choices

Markets Responding to Unmet Needs

Source: Mehrota A et al, "Visits To Retail Clinics Grew Fourfold From 2007 To 2009, Although Their Share Of Overall Outpatient Visits Remains Low," Health Affairs, August 2012; Health Care Advisory Board interviews and analysis.

Primary Care Network

Traditional Access Points

Consumer-Oriented

Access Points RetailClinic

Urgent Care Center

Virtual Visit

Primary Care Office

Low Acuity High Acuity Emergency Department

Consumer-Oriented Service Delivery Sites Filling the Gap

Driving Provider Questions:

• Should we partner to establish retail clinics?

• Should we build or expand our urgent care footprint?

• Is virtual care something that we should provide?

• When should we enter into partnerships to meet patient demands?

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Major Opportunity to Shift Primary Care Volumes

Redistributing Non-emergent Care to Appropriate Lowest-Acuity Sites

Source: CDC/NCHS, "National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey," 2009-2010; “Primary Care Physician Shortages Could be Eliminated Through Use of Teams, Nonphysicians, and Electronic Communication,” Health Affairs 32:1. Jan 2013. Health Care Advisory Board interviews and analysis.


Annual Visitsto PCPs

AnnualED Visits

Visits Eligible for NP-Led Care

103M

47M

132M

Non-urgentED Visits Shifted

to Other Care Sites

573M 18% of PCP visits could be handled by NPs at convenient care sites

Non-urgent ED visits could be treated at urgent care, retail or primary care

Visits At Risk of Shifting to Other Sites of Care

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Retail Clinics Expected to Continue Growing


1) As of Oct. 2014.Source: Accenture, "Retail medical clinics: From Foe to Friend?," 2013; Ritchie J, "After a stall, Kroger could add clinics," Cincinnati Business Courier, July 5, 2013; Robeznieks A, "Retail clinics at tipping point," Modern Healthcare, May 4, 2013; Health Care Advisory Board interviews and analysis.

2000-20151

Estimated Total Number of Retail Clinics in the US

202

868

1135 1172 12201355 1418

1743

2243

2868

2000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Growth trajectory depends on preferred payer relations, PCP capacity, and health system partnerships

Retailer

Operational Retail Clinics1 900+ 400+ 135 14 75+

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Catalyzing a Shift in Network Demands

Patients

Source: Health Care Advisory Board interviews and analysis.

Market Forces Turning Patients into Consumers

Traditional Market Retail Market

Growing number of buyers

1

Proliferation of product options

2

Increased transparency

3

Reduced switching costs

4

Greater consumer cost exposure

5

Passive employer, price-insulated employee

Activist employer, price-sensitive individual

Broad, open networks Narrow, custom networks

No platform for apples-to-apples plan comparison

Clear plan comparison on exchange platforms

Disruptive for employers to change benefit options

Easy for individuals to switch plans annually

Constant employee premium contribution,

low deductibles

Variable individual premium contribution, high deductibles

Characteristics of a Traditional vs. Retail Market

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Primary Care NetworkProviders Expanding the Applications of Virtual CareFrom Administrative Transactions to Real-Time Care Delivery

Source: Wang H, “Virtual Health Care Will Revolutionize The Industry, If We Let It.,” Forbes, 3 April 2014; available at: http://goo.gl/oOJOCG, accessed May 9, 2014; Health Care Advisory Board interviews and analysis.

Virtual Care Platform Function

A Fast-Emerging Market Segment

Estimated revenue fromvirtual visits in 2018, up from $100M in 2013

$13.7B Projected increase in households using virtual care between 2013-2018

220%

Impact on Access

Automate Administrative Functions

Streamline Clinical Transactions

Virtualize Care Delivery

• View medical records

• Schedule in-person appointments

• Refill existing prescriptions

• Pay bill

• Prescribe new medications

• Receive lab results

• Asynchronous, message-based visits

• Live, video-based visits

• Deliver online education, shared decision-making tools

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Commercial Payers

Source: Mathews AW and Kamp J, “Another Big Step in Reshaping HealthCare,” Wall Street Journal, February 28, 2013, available at: www.online.wsj.com; Health Care Advisory Board interviews and analysis.

Seeing Price Cuts On Most Exchange Plans

Anticipated Provider Reimbursement Rates for Exchange Plans

Catholic Health Initiatives Modest discounts from commercial rates

Tenet Healthcare Up to 10% below commercial rates

Meriwether Hospital1

5% below commercial rates

WellPoint Inc.Between Medicare and Medicaid rates

Meyers Health1

10% above Medicare rates

Millern Medical Center1

20% below commercial rates

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40%

46%50% 49%

58%

13%17%

22%26%

28%

2009 2010 2011 2012 2013

Small Firms (3-199 Workers)

Large Firms (200+ Workers)

Particularly Severe for Out-of-Network Care

Commercial Payers

Source: Kaiser Family Foundation and Health Research & Educations Trust, “Employer Health Benefits 2013 Annual Survey,” August 2013; PwC, “Medical Cost Trends: Behind the Numbers 2014,” June 2013, available at: www.pwc.com; Health Care Advisory Board interviews and analysis.

Employer Shifting Risk by Increasing Cost-Sharing

$680$760

$1,010$940

$1,230

$1,000

$1,380

$1,750

$1,570

$2,110

2009 2010 2011 2012 2013

In-Network Out-of-Network

Average In- and Out-of-Network Deductibles for Group Plans

n = 1,100 employers

Percent of Covered Workers Enrolled in a Plan with a $1,000+ Deductible by Firm

SizeSingle Coverage

27


Commercial Payers

Source: Breakaway Policy Strategies, “Eight Million and Counting: A Deeper Look at Premiums, Cost Sharing and Benefit Design in the New Health Insurance Marketplaces,” May 2014; eHealth, “Health Insurance Price Index Report for Open Enrollment and Q1 2014,” May 2014; Health Care Advisory Board interviews and analysis.

Public HIX Participants Choosing High Deductibles

Annual Deductibles of Individual Plans Selected on eHealth

13%

3%

11%

5%

30%

39% $6,000+

$3,000-$5,999

$2,000-$2,999

$1,000-$1,999

$500-$999 < $500

October 2013 – March 2014

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Payers Responding to Anticipated Premium Sensitivity

Source: Gottleib S, “Hard Data on Trouble You’ll Have Finding Doctors in Obamacare,” Forbes, March 8, 2014, www.forbes.com; McKinsey & Company, “Hospital Networks: Configurations on the Exchange and Their Impact on Premiums,” December 2013; Medical Group Strategy Council interviews and analysis.

Public Exchange Plans Mainly Narrow Network

Majority of Public Exchange Plans Exclude >30% of Largest Hospitals

20 Urban Markets, December 2013

Excludes 30% of 20 largest hospitals

38%

32%

30%

“Ultra-Narrow”

“Narrow”

Broad

Excludes 70% of 20 largest hospitals

Commercial Payers 29


Will Employers Maintain Coverage, and How?

Employers

Traditional Employer Coverage Eroding

“Activation”“Abdication”

Convert to Self-Funding

Pros:

• Close control over network design

• Exemption from minimum benefits requirements

Cons:

• Greater financial risk

• Network assembly challenging

Shift to Private Exchange

Pros:

• Responsiveness to employee preference

• Predictable, defined contributions

Cons:

• Disruption to benefit design

• Risk employees may underinsure

Spectrum of Options for Controlling Health Benefits Expense

Drop Coverage

Pros:

• Escape from cycle of rising premium costs

Cons:

• Employer mandate penalty

• Labor market disadvantage

Source: Health Care Advisory Board interviews and analysis.

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Low-Wage Employers Most Active Today, but Skilled Industries in the Wings

Employers

Source: Accenture, “Are You Ready? Private Health Insurance Exchanges are Looming;” privatehealthexchange.com; Health Care Advisory Board interviews and analysis.

Huge Growth Forecast for Private Exchanges

3M

9M

19M

30M

40M

2014 2015 2016 2017 2018

Potential Growth Path for Private Exchange Enrollment

Prominent Employers Using Private Exchanges

For Active Employees: For Retirees: (Medicare Advantage, Medigap plans)

Private exchange operators as of October 2014

172

31


Medicare

Source: CBO, “Letter to the Honorable John Boehner Providing an Estimate for H.R.6079, The Repeal of Obamacare Act,” July 24, 2012; CBO, “Estimated Impact of Automatic Budget Enforcement Procedures Specified in the Budget Control Act,” September 12, 2011; CBO,“Bipartisan Budget Act of 2013,” December 11, 2013, all available at: www.cbo.gov; Health Care Advisory Board interviews and analysis.

1) Includes hospital, skilled nursing facility, hospice, and home health services; excludes physician services; annual reductions rounded.

2) Disproportionate Share Hospital.

Medicare FFS Payment Cuts Continue

($4B)

($14B)($21B)

($25B)($32B)

($42B)

($53B)

($64B)

($75B)

($86B)

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

ACA’s Medicare Fee-for-Service Payment CutsReductions to Annual Payment Rate Increases1

$415B in total fee-for-service cuts, 2013-2022

$260BHospital payment

rate cuts, 2013-2022

$56BReduced Medicare and Medicaid DSH2

payments, 2013-2022

$151BReduced Medicare payments

due to sequestration and 2013 budget bill

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Patient Preferences for Online Care Growing

Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis.

Patients

1) Based on proportions of respondents interested in teleheatlh.

Survey Finds Email Visits Preferred to Clinic Near Errands or Work

Increasing Consumer Preference

Emailing provider with symptoms

Preference for Location of Services

Clinic located near work

Clinic located near errands

Clinic located near the home

Young, Wealthy, Busy—Strongest Potential Telehealth Targets1

Of 18-29 yrs olds

54%Of those making >$71K per year

49%Of those working >35 hours per week

53%

33


Consumers Seeking Accurate Estimates

Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis.

Patients

Compared to Not Knowing How Much the Visit Costs Until Receiving the Bill:

Would rather have to go to another clinic for lab

tests, x-rays, or pharmacy

Would rather drive 20 minutes to the clinic

Would rather pay $50 out of pocket

Would rather pay $100 out of pocket

92%

76%

74%

38%Primary Care Consumer Survey Results

Rank, out of 56 attributes, of “not knowing how much the visit would cost until receiving the bill”

55th

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Counterpoint: ACA Analysis Accelerating pernicious growth of market consolidation

Sanctions monopolistic hospital markets

Introduces new rules to reduce competition in the insurance market.

Hope is that dominant providers will use higher revenues to cross‐subsidize indigent and emergency care

Pope CM, How the Affordable Care Act Fuels Health Care Market Consolidation. Backgrounder #2928, Heritage Foundation, August 2014


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Counterpoint: Recommendations Government regulation and spending should not shield dominant providers from competitors.

Monopolies are irresponsive to the needs of patients and payers.

They are an unreliable method of subsidizing care that tends to both lower quality and inflate costs.


Counterpoint: Recommendations Repeal certificate‐of‐need laws.

Innovative providers should be allowed to expand or establish new facilities that challenge incumbents with lower prices and better quality.



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Counterpoint: Recommendations Repeal ACA mandates.

Forcing individuals to purchase standardized health insurance establishes a captive market, making it easier for providers, insurers, and regulators to degrade services and inflate costs with impunity.

Repealing purchase mandates is essential to creating a market in which suppliers have the flexibility to respond to consumer demands for better value for their money.


Counterpoint: Recommendations Subsidize patients, not providers. Public policies should be provider‐neutral.

Policymakers should subsidize such needy individuals directly.

Allow patients to shop around.

Wherever possible governments and employers should put patients in control of the funds expended on their care, and permit them to keep any savings they obtain from seeking out more efficient providers.



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Who else is concerned? Federal Trade Commission

As hospitals merge and buy up physician practices, creating new behemoths, consumers may be victimized by the trend toward consolidation.

Hospitals often say they acquire other hospitals and physician groups so they can coordinate care, in keeping with the goals of the Affordable Care Act.

FTC says mergers tend to reduce competition,

FTC is using the Clayton Antitrust Act of 1914 to challenge mergers and acquisitions,

Principles of Microeconomics, v. 1.0. by Libby Rittenberg and Timothy Tregarthen


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Government Response to Monopolies Depends on perception of Good V. Bad

International Harvester (1902 – 1985) Produced cheap agricultural equipment for a largely agrarian nation

Considered untouchable (avoid voter wrath)

American Tobacco (1890 – 1911) Among the original 12 members of the Dow Jones Industrial Average (1896)

Suspected of charging more than a fair price for cigarettes ‐then touted as the cure for everything from asthma to menstrual cramps

Legislators’ wrath in 1907 and broken up by 1911

1870 – 1911…


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1921‐1984…


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Consumer Responses to Monopolies Elite, quality conscious consumers

Most sensitive to product/service quality

Most likely to police the market

Most likely to exit the market leaving sellers to deal with the relatively voiceless mass of consumers

Rare entity?

Remember rise in activist consumer (The Advisory Board)

Andreasen AR, Consumer Responses to Dissatisfaction in Loose Monopolies. Journal of Consumer Research. Vol. 12, No. 2 (Sep., 1985), pp. 135‐141


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Consumer Responses to National Health Care

While majority are passive consumers, others will dynamically manage their health care

Some will seek faster, better care outside their locality (in‐country or out‐of country medical tourism)

World‐wide medical tourism market growing at a rate of 15 to 25% (to either save money or avoid wait times)

Private Practice market continues to grow in Canada and England (precise estimates unknown)

But is it Ethical?


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Our Conundrum

Benevolent Capitalism

A Professional Obligation


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Break time


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10:15 to 11:15

Objectives Business/Policy Context

Change the Status Quo Therapeutic versus co‐dependent relationships.

Lifetime client engagement

Spheres of influence for lifestyle medicine

Differentiate among models of engagement

Define and characterize retainer‐based medicine, retail medicine, and the health club industry.

Develop lifestyle medicine programs at both a consumer level and a community level

Build/present a business model


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IllnessHealth

$ Healthcare $$$

$ Medicine $$$

$ Lost Days $$$

$ Delivery Systems $$$

+++ Wellbeing +

+++ Productivity +

+++ Leisure/Recreation +


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Spheres of Influence

Traditional Healthcare Delivery

Consumer‐driven

Community Driven

©2014, JM Gamboa

“If you can’t think outside the box; find a new box” Andrew A. Guccione


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Retainer Medicine

Retail Medicine Health Club Industry

Retainer Medicine Relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges.

Models

Fee for Care

Fee for Extra

Hybrids

Retainer Medicine


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Retainer Medicine Annual fees

$195 to $5,000 per year for an individual with incremental savings when additional family members are added

Higher priced plans generally include most “covered” services where the client is not charged additional fees for most services (labs, xrays, etc).

Retainer Medicine

Retainer Medicine Benefits:

same day access to your doctor;

immediate cell phone and text messaging to your doctor

unlimited office visits with no co‐pay

little or no waiting time in the office

focus on preventive care

Marketplace Profile (2/2010)

>66% internal medicine specialists

family practice>dental>pediatric

Retainer Medicine


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Retainer Medicine MD Private Practice Adoption Rate: 16% in next 3 years

Participating Consumer Profile

40% earned a combined household income of between $100K ‐$200K

33% earned less than $100KRetainer Medicine

A Virtuous Cycle of Retainer Based Medicine

High Touch Access for Members

Higher Volume

Income Stabilization

Higher Margins

Increased Patient Contact Time

Increased Focus on

Comprehensive Wellness

Increased Patient

Engagement

Lower Volume

Increased Provider Morale


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Retail Medicine Small healthcare facilities

located in high‐traffic retail outlets associated with pharmacies, supermarkets, or big‐box retailers

Staffed by nurse practitioners and physician assistants

Treat minor ailments (e.g., strep throat, minor wounds, vaccinations, physicals)

Some manage chronic conditions (e.g., diabetes, high blood pressure, asthma)

Retail Medicine

Retail Medicine Since first retail clinic opened in 2000, more than 3.5 million patients have been treated in the more than 1,000

Average cost of treatment is $60, and most participate with major insurance plan

Key site for many uninsured clients who pay out of pocket

Retail Medicine


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Retail Medicine Benefits:

Immediate Access

Virtual Health Consult

Lower Costs

Marketplace Profile

700% growth from 2000 through 2014

Retail Medicine

A Virtuous Cycle of Retail Based Medicine

Immediate Access

Higher Volume

Deep Pocket Funding/Lower Cost Structure (overhead and

provider)

Higher Margins

Increased Virtual/

Telehealth

Increased Patient

Convenience

Mission Matches Volume

High Volume


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Increased Membership

Boomer focused

Youth focused

Social Engagement

Small Group Personal Training

Technology

Convenience

Corporate Wellness

Medically Prescribed Exercise

Health Club Industry

$21.8 Billion Industry (PT: $17.7 B Industry)

Average monthly cost: $58/month

Percent of members who purchase but do not use membership: 67%

Percent Attrition: 60%



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Prefer flat rate contracts over pay per visit options (even if pay per visit option is less expensive);

Monthly contracts that automatically renew, but can be canceled at any time have a higher share of consumers renewing the contract, even though a long‐term annual contract may be a cheaper option;

The share of consumers enrolled after 12 months is higher under monthly contracts than under annual contracts


A Vicious Cycle of the Health Club Industry

Unlimited Access/ Low

to moderate price point

Higher Volume

Significant Growth

Significant Attrition

Low Margins

Virtuous Pearls

Membership Sells

Social construct of group exercise and belonging is strong

Retention relies on perceived value and outcomes not on number of visits utilized


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High Touch Access for Members

Lower Volume

Increased Patient Contact Time

Increased Patient Engagement

Increased Focus on Comprehensive Wellness

Increased Provider Morale

Memberships Sell (Need multiple price points of entry)

Social construct of belonging is strong

Dating is expensive

Retention = increased margin

Retention related to perceived value and outcomes NOT number of visits utilized


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Spheres of influence


Consumer‐driven

Community Driven

©2014, JM Gamboa

Managing Long Term Health and WellnessAn Evolving Model

©2014, JM Gamboa


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PhysicalTherapy

Health Promotion & Fitness

Long‐term Clients

(Informal Membership)

At the intersection of injury and health

©2014, JM Gamboa

Productiveand Healthy

Lifestyle

UnencumberedExercise

Prevention and Maintenance

Healthy Movers:Support and Augmentation

Elite Movers:PerformanceEnhancement

Clinical Intervention

Injury/ Trauma/Post-surgical

Deconditioned

Chronic Condition or Disease Metabolic Syndrome Complex PainRehab

Fitness

©2014, JM Gamboa


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Performance

Chronic Disease Risk and Impact Reduction

Stress Tolerance

Movement

Quality

Four Cornerstones of Health

©2014, JM Gamboa

Fit

CDREmW

MQ

Fit

CDREmW

MQ

Fit

CDREmW

MQ

©2014, JM Gamboa


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Fitness

PT

Counseling

©2014, JM Gamboa

PT

Personal Training

Group Classes

©2014, JM Gamboa


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Massage

PT

Sports Enhancement

©2014, JM Gamboa

PhysicalTherapy

37% Clients


41% ClientsLong‐term Clients


22% Clients

©2014, JM Gamboa


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Impacts of an annual fitness physicalOur Vision

To introduce NEW clients to our independent physical therapy and wellness center.

To achieve a 15% mid to long-term retention rate of new clients

To shift clients from more expensive, dependent care to less expensive, independent care as

quickly as possible.

Our Objectives

To position our independent physical therapy and wellness center as a superior resource for the consumer and medical community alike for long-term management of physical health and well-being of individuals

Getting Started: A Pilot Project

Bi-Annual Fitness Physical Drives

Up to 30 individuals in 1

day

Track conversion and retention

rates

Collect objective baseline data

Establish fitness profile

Develop a specific, matched exercise

prescription

Prescribe for specific change in disease risk

©2014, JM Gamboa

©2014, JM Gamboa


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71% New Clients

29% Existing Clients

©2014, JM Gamboa

Massage

Acupuncture

Physical Therapy

Personal Training

Dietary Counseling

Personal Counseling

Group Exercise Class

©2014, JM Gamboa


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Collectively generated by the members of the 6 AFP cohorts

©2014, JM Gamboa

Aggregate Retention Rates

43%

30%

13.5%

13.5%

1 visit

2‐19 visits

>20 visits

>100 visits

©2014, JM Gamboa


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Additional Services Utilized 2 to 19 visits:

PT, MT, single personal training pack, group classes

> 20 visits:

PT, MT, multiple personal training packs, group classes

>100 visits:

All services:

PT, MT, personal training, group classes, personal and dietary counseling, acupuncture

©2014, JM Gamboa

Revenue Generation$6,500.00 $29,667.00

$88,006.00

$349,860.00

1 visit

2‐19 visits

>20 visits

>100 visits

©2014, JM Gamboa


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Value of Customer Engagement

©2014, JM Gamboa

One and done: $100

Primary Engagement: $800 to $1500

Secondary Engagement:

$ 4500

Lifetime Engagement:

$ 2,400 to $8,400 per year

Engage or Not to Engage?

©2014, JM Gamboa

150 Clients

$225,000

$ 475,836


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Productiveand Healthy

Lifestyle

UnencumberedExercise

Prevention and Maintenance

Healthy Movers:Support and Augmentation

Elite Movers:PerformanceEnhancement

Clinical Intervention

Injury/ Trauma/Post-surgical

Deconditioned

Chronic Condition or Disease Metabolic Syndrome Complex PainRehab

Fitness

©2014, JM Gamboa

PhysicalTherapy

37% Clients31% Revenue


41% Clients21% Revenue

Long‐term Clients


22% Clients

48% Revenue

©2014, JM Gamboa


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Some KEY pointsWhat you have to “sell” must fill a genuine human need

You will earn the loyalty of clients only if you sincerely care about satisfying their needs

You must earn your rewards through serving others

Abraham J, 2001 [Getting Everything You Can Out of All You’ve Got]

©2014, JM Gamboa

Identifying genuine needs What are your patients asking YOU for?

What do your referral sources NEED?

Can you say “YES” instead of “NO”?

©2014, JM Gamboa


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High perceived value creates a client for life

©2014, JM Gamboa

What is Value?

Value = (Outcomes + Safety + Service)

(Cost + Time)

©2014, JM Gamboa

Robert Nesse, CE0, Franciscan Skemp Healthcare ; http://sas‐origin.onstreammedia.com/origin/worldconference/HR08000/HR08000_Nesse_Robert_Podcast.mp3.


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How do others view “value?”

Value is a judgment that people make about the importance of the goods and services at their disposal for

the maintenance of their lives and well‐being

Karl Menger, Principles of Economics, 1873

©2014, JM Gamboa

Collaboration = Parallel Play


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Parallel Play: time consuming and uncertain outcomes

Client Referral or

Recruitment

Physical Therapy (driven by PT evaluation and plan of care) Retail Payment Plans

Customized Membership

Managed Membership (driven by Sustainable Health Index to match membership features to

real needs)

Maintenance Membership (independent exercisers who self‐select from pre‐defined memberships)

A Proposed Membership Model


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Systematic Data Collection in Multiple Domains

Blend Data into a Coherent Picture

Standardized Approach to

Integrated Care

Sustainable Health IndexSM

Based on measurement of four specific domains of overall health to gain a global snapshot of of“Sustainable Health”

Fitness/Performance

Disease Risk Indicators

Stress Tolerance

Movement Quality


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Sustainable Health Index Intake

Acute Episode Physical Therapy

Retail: A la carte or 1 + 4 Plan

Acute Episode Counseling or

Massage

Retail: A la carte or 10 Pack

Short‐term Nutrition Intervention

Retail: A la carte or 1 + 4 Plan

Customizable Membership

Group Class Entry Point (low end)

1:1 Entry Point (high end)

Blended Delivery (Mid point)

$140/mo $741/mo$404/mo


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Timeline

Current• 40 Formal Members

June 2015• 75 Formal Members

September 2015

• 90 Formal Members

December

2015

• 125 Formal Members

Spheres of influence


Consumer‐driven

Community Driven

©2014, JM Gamboa


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Employer‐Based Programs

©2014, JM Gamboa

On‐site Employer‐Based Program

Overview: To identify overall health and injury risks; develop preventative plans; and provide musculoskeletal first aid.

Goals: To prepare workers for their physical workload and reduce the number of musculoskeletal work injuries (OSHA Recordables AND WC Cases)

Key Elements: Annual Wellness Visit to determine scope of program

©2014, JM Gamboa


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ROI Employer‐based ProgramsStakeholder Return on Investment

Employees Easy access to expert knowledge; fewer days off due to injury; potential for “wise choice” related bonuses

Employer Cost‐savings in terms of lower WC insurance premiums; decreased OSHA recordables; and fewer time‐loss hours due to injury.

Provider Retainer fee for managing the corporate health and wellness program that is designed to reduce worker’s compensation case rates with a structured prevention and early intervention program

Bonus potential: negotiated as a percentage of WC insurance premium savings.

©2014, JM Gamboa

In‐Clinic Employer‐based Programs

©2014, JM Gamboa


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In‐Clinic Employer‐based Programs

Overview: To identify overall health and disease risks due to lifestyle and exercise habits of the employees of area small businesses and to design a musculoskeletal and fitness‐based employee assistance program

Goals: To provide small businesses in our community the opportunity to offer an otherwise unaffordable benefit to their employees that supports healthy lifestyles, injury prevention and early intervention, as well as fitness.

Key Elements: Annual Wellness Visit to determine scope of services

©2014, JM Gamboa

ROI In‐Clinic Employer‐based ProgramsStakeholder Return on Investment

Employees Access to Physical Therapy, Massage Therapy, Personal Training, and Group Fitness Classes at no cost

Employer Cost‐savings in terms fewer time‐loss hours due to injury; lower health insurance premiums; lower WC case rate; discounted rates on BDI services

Provider Monthly retainer fee for a specified number and type of services developed in response to health profile of employees and company needs.

No insurance paperwork; small business is the client; avg$2500/month/company

Current Enrollment: small modern dance company with part‐time employee dancers; small tai kwon do studio with part‐time instructors

©2014, JM Gamboa


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fitRXSM Medical Gym

©2014, JM Gamboa

fitRXSM Medical Gym

Overview: To partner with at‐risk members of the community, as well as, local primary care physicians and cardiologists to provide a specific and controlled exercise environment for the purposes of decreasing specific disease markers and developing long‐term successful exercisers

Goals: To establish individual exercise prescriptions that are then executed and progressed in a small group environment under the supervision of a physical therapist, athletic trainer, or exercise scientist

Key Elements: AFP to establish medical/injury History, current health profile and disease risk assessment; psychosocial barriers to exercise; and benchmarks functional and aerobic fitness against national norms;membership to the fitRXsm gym located within our facility.

©2014, JM Gamboa


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ROI fitRXSM Medical Gym

Stakeholder Return on Investment

Clients Access to the expertise of PT, ATC, or Ex Sci. in a small group environment (1 to 8 ratio)

MD’s Supports their mandate to be responsible to the population health of their patient base . Scalable from an individual practice to a medical home or ACO level

Provider Monthly gym membership

Marketplace positioning to support emerging community healthcare initiatives

©2014, JM Gamboa

P.aceSM Program

©2014, JM Gamboa


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P.aceSM Program

Overview: To partner with individual clients and sports teams to maximize performance and minimize injuries.

Goals: To establish baseline functional movement and sports performance measures, provide a 6 week intervention program, and retest performance measures.

Key Elements: AFP to establish medical/injury history, current health profile, functional and aerobic fitness, speed, and power metrics.

©2014, JM Gamboa

ROI P.aceSM Program


Athletes Improved fitness and better field performance (increased protection against injury)

Team Improved fitness, better field performance, and more time spent on technique and tactics

Provider $2200 per team (~10 athletes) per 6 week program (12 sessions

Personal training rates for P.ace 1:1’s

©2014, JM Gamboa


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Community Exercise Clinic

©2014, JM Gamboa

Community Exercise Clinic

Overview: To partner with local free clinic to provide graded exercise prescriptions to their at‐risk clientele who are managing diabetes and high blood pressure.

Goals: To provide a realistic, but progressive and specific exercise prescription that can be accomplished with limited resources and time to support; and can be tracked by nursing staff, case managers, and PTs

Key Elements: Significant medical history, increased BMI, increased waist circumference, and/or sedentary behavior

©2014, JM Gamboa


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ROI Community Exercise Clinic


Clients Convenient access to realistic exercise prescription that can be carried out within the course of their lives

Free Clinic Support for managing high cost chronic disease clients with goal of decreasing cost of medication by creating successful, long‐term exercisers

Provider Community Outreach and PR

©2014, JM Gamboa


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11:15 to Noon


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Intake: Annual Fitness (physical therapy wellness) Exam

©2014, JM Gamboa

Preventing Diabetes

54 y.o. non‐exercising pre‐diabetic overweight male

Referred in by his physician under “stress and duress”

Psychosocial Metrics

Current Health Profile

Chair Stand

Push Up

Four Square (Agility)

Bench Test

Case Context KEY Tests and Measures

©2014, JM Gamboa


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Reporting Changes

©2014, JM Gamboa

July 13, 2011

: 128/78 [Pre HTN/Normal]

©2012, FitTEST Solutions

©2012, FitTEST Solutions

Reporting Changes

©2014, JM Gamboa

Four Square Step Test: 50th Percentile

Submax Treadmill Test Took 20 minutes to return to resting heart rate

March 31, 2011

July 13, 2011

Submax Treadmill Test 39.24 HR recovery to 100 bpm at 13 min (stable)


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©2014, JM Gamboa

Medical Impact: Preventing Diabetes

©2014, JM Gamboa

Ideal

Pre-exercise; Diet Alone

Post-Fitness Physical; Specific Exercise

Prescription

1/19/11 4/19/11 7/14/11

Ideal

1/19/11

4/19/11 7/14/11

Pre-exercise; Diet Alone

Post-Fitness Physical; Specific Exercise

Prescription


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Cost of Diabetes DX People with diagnosed diabetes incur average expenditures of $11,744 per year, of which $6,649 is attributed to directly diabetes care and medications [Economic Costs of Diabetes in the U.S. in

2007, American Diabetes Association]

Cost of Annual Fitness Exam: $249

FitRX Gym Membership $140/mo: $1680

Total cost per year: $1929

Cost Savings to the individual over 10 years: $47,200 to $98,150

©2014, JM Gamboa

Lifestyle Medicine/Integrated Care


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Health CoachSouthern Mobile Muscle Unit

• Nurse Practitioner• Social Worker• PT/Exercise/Healt

h Coach• Dietition


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OPPORTUNITY

• Gulf Coast Communities in Louisiana, Mississipi, Alabama, and Florida Panhandle

• Low Socioeconomic status, especially in Baldwin (population: 190,790) and Mobile (population: 413,936) counties (13% and 19% respectively)

• Health Professional Shortage

• In rural areas, may require >= 30 minute drive to get to care (Federally subsidized health center)

• High levels of depression and anxiety

• High levels of hypertension, diabetes, coronary heart disease, and obesity

WHY IS IT IMPORTANT

If we do NOTHING, the underserved population in Baldwin and Mobile counties continue to be underserved and cost of 3 top diseases continue to rise

Cost in Baldwin Cost in Mobile

Hypertension $ 82,570,901 $ 150,250,618

Diabetes $ 241,175,425 $ 483,001,565

CAD $ 8,204,942,178 $ 14,930,170,578

TOTAL $ 8,528,688,505 $ 15,563,422,761


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WHY IS IT IMPORTANT

• If we do SOMETHING, an underserved population has more access to care

• Even modest success will decrease costs signficantly

• If we impact 3% of the “disease bearing” population, our fiscal impact could be:

• Save Baldwin County: $255,860,655

• Save Mobile County: $ $466,902,683


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1. Identify the Opportunity

2. Explain why the issue is important

(If/Then statements)

3. Vision: Best imaginable outcome

4. Customer Benefit

5. Provider Benefit

6. Obstacles (How to Overcome Statements)

7. Strategies (What do you have to do to

implement)

8. Actions (How are you going to do what you have to do to

implement)

©2014, JM Gamboa

Developing Opportunities


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Choose your sphere


Consumer‐driven

Community Driven

©2014, JM Gamboa

1. Identify the Opportunity Community Level

https://www.dhs.wisconsin.gov/chip/index.htm

http://www.cdc.gov/physicalactivity/index.html

http://www.cdc.gov/nccdphp/dnpao/state‐local‐programs/pdf/wisconsin‐obesity‐prevention.pdf

http://www.cdc.gov/chronicdisease/states/wisconsin.htm

Consumer Level Employer Groups

Individual Annual Wellness Visits (FitTEST Solutions Case Studies)

©2014, JM Gamboa


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2. Explain Why it is Important If nothing is done, then…..

If the streets are not safe, then people cannot exercise outside

If I don’t engage consumers directly, my patient flow will diminish significantly

If something is done, then…. If the community has better access to an exercise lifestyle, then the

default decision to exercise is easier

If I a connect with the local running club, then I will have an opportunity to see those clients as patients

What is the COST of doing nothing vs. doing something

©2014, JM Gamboa

3. Vision: Best Imaginable Outcome BE Specific and Quantifiable

Having 10 fully enrolled group classes per week will bring in an additional $48,000 per year of revenue

Having 50 patients enroll in the after discharge gym program will bring in an additional $15,000 of revenue per year

Don’t be Vague

Increase revenue

©2014, JM Gamboa


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4. Customer Benefits What aspect of my clients/customers lives will be improved by this service?

How do the outcomes that I greatly desire for this strategic issue measurable contribute to the target audience’s success?

©2014, JM Gamboa

5. Provider Benefits Describe the benefit to you, the initiator. Be specific.

The company will increase in value by 50% within 3 years

NOT: the company will bring in more revenue

©2014, JM Gamboa


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6. Obstacles to Overcome Define the obstacles

No one knows that PTs do health promotion and fitness

Turn into a “How To” Statement

How to create more end‐user/consumer awareness in my community that I am the best resource for health promotion and fitness

How to statements are actionable; they will define your strategies

©2014, JM Gamboa

7. Strategies For each obstacle identified, what do you need to do to overcome the barrier? These are From/To Statements

How to create more end‐user/consumer awareness in my community that I am the best resource for health promotion and fitness

Move FROM: an annual community wellness event during the month of October (Physical Therapy Month)

Move TO: Weekly Blog/Radio spot on Injury Prevention and Fitness

©2014, JM Gamboa


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8. Actions What do you need to do to implement your strategy.

7 Steps to achieve monthly blog/radio spot

1. Develop blog spot/link to website

2. Develop blog template and topic list

3. Assign topics to staff on rotating schedule

4. Commence blogging on May 1st

5. Contact local radio health spot talk show host

6. Record “blog video”; post to website and send to radio

7. Invite talk show host in for an annual physical therapy wellness visit

©2014, JM Gamboa

Contact:

Jennifer M. Gamboa

[email protected]

©2014, JM Gamboa


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