Effective Efficient Satisfied Leveraging Outcomes for Your Practice

Effective · Efficient · Satisfied Leveraging Outcomes for Your Practice David Grigsby MPT, Cert MDT FOTO Conference Knoxville, TN April 19, 2015

David Grigsby MPT, Cert MDT David graduated with his Master of Physical Therapy degree in 2002 from the University of Tennessee Health Science Center (UTHSC). In August 2006, he achieved Mechanical Diagnosis and Therapy (MDT) credentialing with the Mc. Kenzie Institute, an international institute specializing in assessment and treatment of musculoskeletal spine and extremity disorders. Co-owner of Mid. South Orthopaedic Rehabilitation since October 2007 with Jason Ward. They are actively involved with the Practice Based Evidence Research Network which has published 3 studies on the assessment and treatment of low back and neck pain. Their papers have been published in the Journal of Orthopaedic and Sports Physical. Therapy (JOSPT) and the Journal of Manual and Manipulative Therapy (JMMT). Winner of the John Medeiros Award in 2010 from JMMT for the paper with the most impact, that is felt will most influence clinical practice, and that has the greatest opportunity for citations. Finalist and Favorite in the Commercial Appeal’s Memphis Most Contest for Best Sports Medicine Clinic 2011, 2012, 2013. David is nationally ranked in the top 5% of efficiency and effectiveness for pain and movement outcomes. (FOTO®)! Contact Information: Work: 901 -522 -6671 Email: dgrigsby@midsouthorthopaedic. com Twitter: @midsouthortho 1 and @PTDavid. G Facebook: facebook. com/midsouthorthopaedic 256 Germantown Bend Cove Cordova TN 38018 901 -522 -6671 www. midsouthorthopaedic. com

Quick Show of Hands

Customer’s desired result Value = Outcome Cost Price, Time or Energy David Grigsby ‘ 15

David Grigsby

Data! David Grigsby ‘ 15

Data… Will no longer reflect who we are – it will help determine it. Andrew Levina Common currency within leading organizations. Becoming the central driver of Customer Value Creation making it the biggest propellant for innovation companies large and small has ever seen. Identifies new sources of revenue, retain and acquire new customers, developing new products and services, winning and keeping customers and enhancing the customer experience. Sara Miller Caldicott David Grigsby ‘ 15

Current Healthcare Market • Healthcare Expenditure – 3 trillion spent in ’ 14 – 1 out of every 5 dollars spent on healthcare – $765 billion was lost to waste according to Medicare and Medicaid services – Drug costs in 2018 >$1. 3 trillion dollars Bloomberg David Grigsby ‘ 15

Current Healthcare Market • Cost – Diabetes $245 billion – Cardiac $444 billion – Musculoskeletal $870 billion • >$86 billion in direct costs Martin ’ 08 • 126 million adults (1 in 2 individuals over 18) • 20% of the 1. 3 billion medical appointments Boneandjointburden. com David Grigsby ‘ 15

Current Healthcare Market • Musculoskeletal Cost David Grigsby ‘ 15 Healthcare Bluebook

Current Healthcare Market • High costs – Average deductible $2, 500 per family, $1, 250 per individual – Can reach $13, 200 for family and $6, 600 for individual Kaiser Foundation – Some copays as high as $100 – $1, 500 to $2, 000 average direct cost per individual just for LBP Fritz ‘ 12 • Skipping care – 30% of privately insured working age Americans David Grigsby ‘ 15

Current Healthcare Market David Grigsby ‘ 15

Current Healthcare Market • Trends – VIP care – Expansion of digital medicine • Telemedicine – Physician ownership changes/ACO • Referral patterns changed – Pay for performance David Grigsby ‘ 15

David Grigsby ‘ 15

Current PT Market • Industry at a Glance: 2010 -2015 – Revenue $32. 7 billion (projected 41. 6 in ‘ 20) – Wages $13. 3 billion – Profit $3. 9 billion (expected to decline ’ 20) – Businesses 95, 816 (103, 679 in ’ 20) – Annual Growth 5. 1% (1. 2% projected ‘ 15) – Unemployment 0. 2% IBISWorld David Grigsby ‘ 15

Current PT Market • Growth Stage – By 2020 value added to overall economy is expected to grow at a rate of 3. 9%. – GDP is only 2. 5% • Shortage – By 2020 expected 9, 000 -40, 000 PT shortage due to retirements, expanded health coverage and increase in Medicare patients. IBISWorld David Grigsby ‘ 15

Current PT Market • Segmentation of Services – Orthopedic 48. 1% – General 9. 0% – Geriatric 8. 7% – Pediatric 8. 1% – Sports 6. 7% – Neurological 6. 5% – Other 2. 0% IBISWorld David Grigsby ‘ 15

Our Customers • Conditions – Musculoskeletal 63. 4% • 35. 4% female • 28. 0% male – Neurological 25. 9% • 14. 5% female • 11. 4% male – Cardiopulmonary 7. 4% • 4. 1% female • 3. 3% male – Integumentary 3. 3% • Diagnosis – Degenerative joint disease 81. 0% – Back, neck, connective tissue and chronic pain – Stroke David Grigsby ‘ 15 APTA

Our Customers • Arthritis – 46 million – 60% female • Arthritis disability – 24. 4% women – 19. 1% men • At any given time – LBP 40% – Neck pain 20% – Knee and shoulder 15% IBISWorld David Grigsby ‘ 15

Why Us? David Grigsby ‘ 15

Why Us? • Pain - 98% of low back pain can be classified as mechanical. Cleveland Clinic • Visits - 1 in 17 primary care visits Licciardone ‘ 08 • Referral - Only 7% make it to us! Fritz ‘ 12 David Grigsby ‘ 15

Why Physical Therapy? Virginia Mason’s “lean” approach cuts costs and improves quality • ½ the visits of therapy needed compared to region • Reduced MRI’s by 33% • Back to work in 4. 3 days versus prior avg 9 days • While achieving satisfaction of 4. 9 on 5. 0 scale David Grigsby ‘ 15

Why Physical Therapy? University Health System Express Med Clinic San Antonio • 1 -3 days of showing to clinic • 8 visits vs 14 • $1500 savings on medical charges • 50% reduction of x-rays, MRI and CT scans Walk and Du ‘ 13 David Grigsby ‘ 15

Early Treatment by a Physical Therapist Associated with Reduced Risk of Health Care Utilization and Reduced Overall Health Care Costs • 32, 070 patients to PT within 90 days of symptoms. • Patients categorized based on timing (early or delayed) and content (adherent or non-adherent) • LBP related healthcare costs and utilization examined after 18 months. Results • Early initiation of physical therapy within 14 days of onset as compared to delayed PT was associated with a decrease likelihood of: 34% - physician visits by 26% - surgery by 45% - injections 42% - opioid medication 78% - imaging by Total medical costs for patients receiving early therapy (<14 days)= $2736. 38 Fritz David Grigsby ‘ 15 ‘ 12

Management patterns in acute low back pain: the role of physical therapy. • 20% sample of Center of Medicare and Medicaid Services (439, 195) • Excluded if previous visit for LBP, injection, surgery in the past year. Results • Early intervention of physical therapy within 30 days of onset compared to 90 days – Reduced likelihood of surgery 38% – Injection 46% – Physician office visits 47% – Underutilization of PT’s with potential cost savings now and downstream Gellhorn ‘ 10 David Grigsby ‘ 15

Comparative Effectiveness • PT vs… – Cervical Fusion (ACDF) – Shoulder Arthroscopy – Acromioplasty – Rotator Cuff Repair – Lumbar Fusion – Knee Arthroscopy – ACL reconstruction – Achilles repair – Injection – Advanced Imaging David Grigsby ‘ 15

Surgery for Cervical Radiculopathy vs PT • Spine June 2013 – Compared 2 approaches • 31 subject underwent ACDF and physical therapy • 32 subjects had physical therapy only – Outcomes demonstrate significant improvement in NDI, neck and arm pain in both groups at 24 months – Side effect surgery > PT – Cost $15, 000 vs $1, 200 Enquist et al. David Grigsby ‘ 15

Shoulder Arthroscopy vs PT • Bone and Joint Research January 2014 – 180 shoulders, 55 years or older with supraspinatus tendon tears – 3 groups: 60 in each • PT only • Acromioplasty and PT • Rotator cuff repair, acromioplasty and PT – Constant scores for all 3 groups at 3 months, 6 months and 1 year the same and patient satisfaction for all 3 were the same – Cost $6, 200 Kukkonen et al. David Grigsby ‘ 15

Rotator Cuff Repair vs PT • Journal of Shoulder and Elbow Surgery Oct 2013 - 452 patients with FULL thickness rotator cuff tears. • Patient reported outcomes improved significantly at 6 and 12 weeks and elected to undergo surgery < 25% of the time. - 75% spared from surgery after 2 year follow up - Side effects of surgery > physical therapy - Cost $10, 000 surgery Kuhn et al. David Grigsby ‘ 15

Lumbar Fusion for DDD vs PT • World Neurosurgery November 2014 – 96 patients responded to follow up. • 53 lumbar fusion • 43 non operative – 5 year follow up • Both showed improved significantly in pain while there was no difference in Oswestry, short form 12 or satisfaction – Cost $40, 000+ David Grigsby ‘ 15 Smith et al.

Lumbar Surgery vs PT • Spine Journal December 2008 • Low Back – stenosis – 8 years SPORT (Spine Research Outcomes Research Trial) – Similar outcomes in either study although surgery gave more immediate relief and both better than no treatment – 18% had another surgery however – $15, 000+ Weinstein et al. David Grigsby ‘ 15

Knee Arthroscopy vs PT • NEJM March 2013 – 7 universities and orthopedic surgery centers • 351 pts, 45 years or older with meniscal tear and mild to moderate osteoarthritis – Outcomes regarding functional status and pain same at 6 months and 12 months – 70% remained with therapy – Side Effects Surgery > PT – Cost $4 -7 K Katz et al. David Grigsby ‘ 15

ACL Reconstruction vs PT • NEJM July 2010 – 121 young, active adults with acute ACL injury – 2 options • Structured rehab plus early ACL reconstruction (62) • Structured rehab with option of ACL reconstruction (23 had reconstruction; 36 rehab only) – Outcomes for function, quality of life and pain virtually identical (KOOS) – ACL repair plus rehab not superior to rehab alone – Cost $11, 500 Frobell et al. David Grigsby ‘ 15

Achilles Repair vs PT • Journal of Bone and Joint Surgery December 2013 – Review of 10 studies • 418 pts that underwent surgery • 408 pts that did not have surgery – Functional rehab incorporated into both groups showed same outcome as surgery without the side effects – Cost $6 -12, 000 Glazebrook et al. David Grigsby ‘ 15

Injection vs PT • Annals of Internal Medicine August 2014 – 104 pts with impingement syndrome for > 1 year – 6 PT visits versus 3 injections in one year. – Outcomes the same at all points – Those with injections used more sources of healthcare • • Injection group sought more care 60% PT 37% Additional injection 38% for injection group, 20% PT Additional PT sought 19% by injection group, 9% PT – Side effects of injection weakened cuff, etc… – Cost $120 -140 Rhon et al. David Grigsby ‘ 15

Advanced Imaging vs PT • Health Services Research – 406 EMR and insurance claims data assessed – For LBP, early advanced imaging resulted in $4, 793 more charges and higher health care utilization compared to physical therapy first. Fritz ‘ 15 David Grigsby ‘ 15

Customer’s desired result Value = Outcome Cost Price, Time or Energy David Grigsby ‘ 15

Why You? • Business! • Opportunity! – Lead healthcare in quality, effectiveness and efficiency measures – FOTO research – Payment for services! – Start a movement! David Grigsby ‘ 15

How do we leverage outcomes? • • • Contracts Research Expertise Direct Access Special projects David Grigsby ‘ 15

Contracts David Grigsby ‘ 15

Contracts • Insurance Companies • Worker’s Compensation • Business relationships David Grigsby ‘ 15

Research David Grigsby ‘ 15

Expertise • Visibility leads to Credibility – People on the move, newspaper recognition – Speaking opportunities • Locally • Nationally – Networking • Other professions want outcomes • Pay for outcome not procedures – Writing David Grigsby ‘ 15

Direct Access David Grigsby ‘ 15

Online/Social Media David Grigsby ‘ 15

Online/Social Media David Grigsby ‘ 15

Special Projects David Grigsby ‘ 15

Quality

Why Your Best Choice is Credentialed MDT clinicians: MDT is the most researched method of physical therapy assessment and treatment and has been shown to be both reliable and valid in the care of musculoskeletal problems. Efficient and Effective: Fewer visits needed to achieve greater outcomes. We average 7 visits for all conditions compared to national average of 11. In those 4 fewer visits, MOR achieves >73% more improvement than the national average in patient’s functional outcome. That means more improvement in fewer visits Nationally ranked, right here in the Mid. South: MOR is ranked in the top 10 of over 8000 clinicians nationally for treatment of spine conditions and is in the top 6% of clinics in all categories nationwide (FOTO, Inc). Research: Three current publications in well respected scientific journals, JMMT and JOSPT on assessment and treatment of low back and neck pain. Winner of the prestigious John Medeiros Award in 2010 for the paper felt to have the most influence and impact on clinical practice. Best Sports Medicine Clinic: As voted by the readers, locally recognized in the Commercial Appeal’s Memphis Most contest as one of the top 3 “Best Sports Medicine Clinic” three years running!

Thank You!