Problem 4 Time Based Billing: Client gets under serviced
POGO Physio has moved beyond the traditional session to session physiotherapy delivery of care with the introduction of our industry and Australian first first fixed fee unlimited access Finish Line™ physio programs.
I believe there are 30 problems that result when practices and practitioners ‘sell their time’ by offering a session to session only model of physiotherapy care.
In this post I will introduce the fourth problem that can arise when clients work with their physiotherapist on the traditional session to session model of care.
The fourth problem of a session to session only physiotherapy service delivery model is the client potentially being under-serviced of their optimal treatment requirements.
What is Under Servicing?
Under servicing is when the client receives less than the treatment they would most benefit from for their given condition or injury.
Instead of receiving the optimal treatment recommendations to assist in the most complete and rapid recovery from injury or pain, the client receives less treatment than what they would most benefit from, as their treating physiotherapist prescribes less than optimal treatment recommendations. To be specific this is normally due to there not being enough treatment sessions administered (not enough consultations/treatment), or the treatment sessions occurring too far apart (too much time between consultations/treatment).
In contrast to Problem 3 (Client Drop Outs) under servicing is not the choice of the client. The client follows the recommendations of their physiotherapist, it’s just that the recommendations are ‘diluted’ from what they need to be to give the best outcome. In other words the physiotherapist has let the client down by not providing the client with appropriate treatment scheduling of their appointments.
An example of Optimal Servicing
To best explain under servicing think of your favourite sporting team or your favourite athlete. In Australia it will often be a rugby league or AFL team, or it could be an athlete of any sport that you admire or enjoy. Now imagine that your favourite player or athlete gets injured.
In terms of physiotherapy treatment the injured athlete may receive daily treatment, on some occasions even bi-daily treatment. The treatment is administered in this manner to expedite the player’s recovery process and return the player back to their physical best as quickly as possible.
The therapist in charge of the athlete knows that if they can get frequent contact with the player including hands on manual therapy, the prescription and supervision of rehabilitation exercises, and return to activity planning, than getting the athlete back to their best will occur much more rapidly than if that contact were not as frequent. Added to this the treating physiotherapist is likely under pressure from coaches to see that the player or athlete makes a complete and rapid return to their best, combined with the athlete’s strong drive to ‘get back out there’.
An example of Under Servicing
Now in contrast think about the last time that you attended private practice physiotherapy for an injury or condition. What sort of treatment recommendations did you receive? At most you were likely recommended to see your physio twice per week for a two week block. You then potentially attended once per week for several weeks. Perhaps you then stuck with the prescribed rehabilitation process long enough to attend a review every fortnight, followed by a monthly ‘check in’ appointment. If you persisted with your rehabilitation following your therapist’s recommendations you may have been informed that your treatment was over and that you do not need to return.
If we leave aside the professional athlete’s requirement for rapid return to optimal function, and contrast the treatment received by the above mentioned athlete and the treatment received by private fee paying physiotherapy consumers, we will typically note profound differences in the treatment scheduling and clinical outcomes. Contrasting the two raises the question why private physiotherapy patients (who in many instances have the same desire for rapid and excellent treatment outcomes as the athlete) so often receive less treatment than what would be most beneficial? Perhaps the more concerning question is why are such private physiotherapy clients at least given the option of receiving optimal treatment scheduling, aligned to that of a professional athlete. Irrespective of what pathway the client chooses for their rehabilitation, I believe the client’s right is to be informed of what the best treatment scheduling would look like.
Additionally consider the client with an injured knee who is trying to run a marathon several weeks. The client’s condition may very well warrant hands on manual therapy and progressive exercise programming performed on a daily basis. However the industry norm with such a client would be to recommend and administer as an example two treatments per week for 2-3weeks. The physiotherapist would typically make such a treatment recommendation as a single treatment will obviously not be enough to achieve time effective complete rehabilitation. Furthermore receiving more than two treatments in a given week may be viewed as cost prohibitive for many clients, hence the client receives two sessions for the week.
What has happened in the above example? The physiotherapist has succumb to the conflict of interest whereby the client could really benefit from ‘x’ recommendation (truth), such as ‘come every day this week so we can get on top of this quickly’, but they have been advised of a lesser treatment schedule, and hence under-serviced.
Private practice vs professional sports
In my 11 years as a physiotherapist the vast majority of my clients have shared a common goal: to get back to their physical best and doing what they love to do physically, as quickly as possible. At POGO we recognise that our ideal clients have three key attributes: they value being their physical best, they have a date for an upcoming event in their diary, and they engage in physical activity regularly (they sweat more than 5x per week). Wouldn’t such clients at least welcome the opportunity to receive the best care possible as a result of the best treatment scheduling recommendations being given?
The answer is obviously yes, however sadly client’s attending private practices Australia wide so often will not be informed of the optimal treatment schedule that could best help them get back to their physical best.
My frustration with the under servicing scheduling patterns of many physiotherapists was recently highlighted when I attended a weekend professional development course on sporting shoulders.. The therapists in attendance were all advanced in their practice and skills. We were given the task of advising how many sessions a case study client (with complicated shoulder pathology and markedly reduced function) would likely need to rehabilitate their extensive shoulder pathology. To my frustration all five of my colleagues suggested a version of the below treatment schedule:
- bi-weekly for 2 weeks
- weekly for 4 weeks
- fortnightly for 4-6 weeks
- monthly for 2-3 months.
I was frustrated by the consistency in what I deemed to be under servicing based treatment recommendations between my colleagues ,so I challenged my colleagues’ recommendations by asking them ‘who said that this is the best treatment plan for the client?’’. When I highlighted that we would all likely see the client more for the shoulder injury if we were based inside a professional sporting organisation looking after professional athletes, my colleagues’ interest was piqued. When I posed the question what if there was a way (Finish Line™ Programs) that private clients could get the same care as professional athletes, by providing the client with the treatment that they would most benefit from as opposed to the treatment that they could afford to receive-I had everyone’s full attention.
They just want me to keep coming back
Reading this the thought of a health practitioner letting a client down through under servicing might seem foreign to you and you may perceive that it would be unlikely to occur. After all aren’t health care consumers bound by the Hippocratic Oath of doing no harm?
If you are reading this and like some health care consumers I hear from, you may have in the past seen practitioners who you perceived to ‘over service’ you. That is you felt that they ‘just wanted you to keep coming back’ and recommended return visits for seemingly no purpose other than keeping the practitioner busy. On occasion I have even heard disgruntled physiotherapy consumers tell me that the therapist they were seeing just wanted them to keep returning to (in the client’s eyes) pay their mortgage or fund a new car!
If the above has been your experience than grasping what I am about to share may be difficult.
Fundamentally I believe that inside the under servicing of clients inside the Australian physiotherapy industry is perhaps the greatest challenge facing the physiotherapy ‘brand’. I believe the deeply ingrained and habitual act of providing clients with under servicing through diluted treatment scheduling is resulting in physiotherapy consumers more often than not being overall dissatisfied with their servicing. The client being dissatisfied with their progress, or with expectations not being met, elects to drop out of care, and change direction. In doing so damaging the ‘brand’ of physiotherapy, let alone the local practice they were attending.
To read more about the impact of client drop outs and how we solved the problem click HERE>>.
Before we explore the main problems and resultant outcomes of a client being under serviced, let’s take a moment to better understand what the drivers are for many therapists Australia wide under servicing their clients.
What are the reasons for clients being under serviced?
- A fear of over-servicing.
I find it ironic that many physiotherapists are more concerned about over-servicing than they are aware of how their under-servicing habits can negatively impact the results of their clients.
Dig deep enough with any physiotherapist and you will discover a genuine concern that they would ever be perceived by a client to be over-servicing their needs. Over servicing is advising a client that they require treatment beyond what is actually needed to deliver the optimal care. To be known as an over-servicer in an industry that as previously outlined in a previous blog (click HERE>>) is comprised of genuine carer-nurturer people, strikes fear into the heart of every physiotherapist. The thought of anyone questioning the client care that they have for their own gain with excessive treatment recommendations, is a horrible one for well-intentioned physiotherapists. The great news for physiotherapy consumers is that I believe over-servicing clients rarely happens inside the physiotherapy industry.
Yet despite the desire to not be unethical by over servicing client needs many physiotherapists are unaware of the damage that under servicing client needs can create. Under servicing is a therefore I believe a far greater physiotherapy industry challenge than over servicing.
- The session to session model is prohibitive for clients getting the care they need or would most benefit from.
Physiotherapy is a professional service, and therefore an expensive service. The traditional model of care with high session to session fees means that even if optimal treatment recommendations were given the client would likely not be able to attend that frequency due to the cumulative cost of receiving treatment.
After 12 months of offering clients access to our industry first fixed fee unlimited access 2, 6, and 12 week Finish Line™ Programs (alongside the option to receive session: session care) we have been delighted to discover that our clients have been on average receiving 33% more in value from services received than the fee paid for their respective program. The result being that our Finish Line Program clients can access the treatment they truly need and will benefit from. Needless to say the results we have been assisting our clients to achieve have been wonderful.
- The physiotherapist is more concerned about what the client will think of their recommendations and their character if they tell you what you need or will most benefit from.
Will the paying client think that the physiotherapist making recommendations are greedy, excessive, self serving, or ‘money hungry’? As aforementioned, physiotherapist’s tend to be wired to be carer-nurturers, hence of great importance to the physio is the client’s perception of them as practitioners, the need to be liked, and the need to be pleasing. These drivers tend to be deeply ingrained in the therapist. So deep is this desire to please clients that a physiotherapist may even inadvertently (through their diluted treatment recommendations) place their self preservation ahead of their client’s outcomes. When put in these terms under servicing makes no sense!
- Traditional based physiotherapy graduate training.
Traditionally the bulk of undergraduate and masters physiotherapy practical training occurs in public health settings such as hospitals. If a student is fortunate enough to secure a training rotation inside a private physiotherapy practice the time spent in such a setting is typically disproportionate to the time spent in public training environments. Despite my deep satisfaction with the standard of undergraduate training I received as an undergraduate I recall no training being given to myself or my classmates around optimal treatment scheduling practices.
Hence when I commenced work as a private practitioner fresh out of university my recommendations were woefully inadequate. They were ‘woeful’ in the sense that they were far towards the under servicing spectrum. For example I would suggest to a client with acute lower back pain to return in one week’s time. Or I would advise a client who had a non acute injury to return in two weeks, when they really needed to be seen that same week in several days time. As a result the client had very little likelihood of achieving a great outcome because of my inadvertent treatment negligence and under servicing with the client not being seen enough or at appropriate intervals.
I do not believe much has changed in the university teaching curriculums, at least on this front in terms of preparing physiotherapy graduates for providing clients with optimal scheduling and therefore optimal treatment.
Hence the physiotherapist is handicapped in their endeavour almost immediately upon commencing their career, as are the clients in their care.
- Mirroring of peers and colleagues professional activity
There exists a professional fear to put your ‘head up’ and do anything different too different inside the physiotherapy industry. I do not believe that this fear of being critiqued by your peers or colleagues is isolated to just the physiotherapy profession. I’m sure it extends into the majority of professional services. Inside the physiotherapy industry the majority of physiotherapists do not want to be ostracized or misunderstood amongst their peers or colleagues.
Hence the reluctance to entertain a model of care that differs from the traditional session to session model of care has pervaded the physiotherapy industry since inception. Yet all positive change is precipitated by someone going first and challenging the status quo and that is exactly what we did in July 2016 with the release of our Finish Line™ Programs. To read more about the Finish Line Program origin click HERE>> (How Brad Solved his Greatest Physiotherapy Conundrum)
- The treating physiotherapist lacks confidence in their abilities
While no practitioner would like to admit to this, I believe that quite often a therapist will advise a client to return for treatment in a time-frame that is far from best care, because they lack the confidence to create change more quickly. That is by advising a client to return in say 7 days when the client would have best benefited from a treatment in say 2-3 days, the practitioner removes themselves from some of the pressure of needing to deliver results and move treatment forward if the client was to see them in just a few days time (or even the next day where appropriate).
Underneath this confidence deficit the therapist may feel is often either a deficit of professional skill set, and/or a reduction in belief for what they can help clients achieve. Until the practitioner improves their skillset or garners more belief in their abilities clients under their care will likely continue to receive diluted treatment recommendations and in effect be under serviced.
How does POGO ensure that our clients are not underserviced?
In addition to the release of our fixed fee unlimited access Finish Line™ Programs which removes the barrier of clients being under serviced by their physiotherapist, at POGO we also:
- Believe in the treatment adage to ‘treat everyone like family’. That is when it comes to giving best practice treatment recommendations for our clients we base it around what we would do if we were responsible for administering care to our own family members. You will often hear POGO physiotherapists say ‘if you were my own mother, I would recommend that you….’. Adopting this simple way of thinking ensures that our clients are not given diluted treatment recommendations that will negatively affect their desire to get back to their physical best.
- Think like professionals, not amateurs, and certainly not like a physiotherapy students. While we recognise that graduate physiotherapists need to mature in their skills and abilities including being able to advise a client around best practice treatment scheduling, we do not accept that a client’s outcome may be compromised through ‘university born’ treatment scheduling. Our physiotherapists particularly our more junior therapists are trained and mentored around how to service a client to ensure the client will get back to their physical best and cross their Physio Finish Line™.
- Insist that our physiotherapists believe in what they do. We are very selective with which therapists we onboard. One of the criteria for our physiotherapist selection is a robust belief in both their own clinical skill and ability and also a strong belief in the physiotherapy profession and how physiotherapy can benefit health care consumers. Our clients are the beneficiaries of our team being comprised of competent and confident practitioners who can lead a client from their initial consultation (Discover Recover™ Session) through to crossing their Physio Finish Line™.
In the next post we will look at the fifth problem of session to session time based billing in the physiotherapy industry: a reduced client commitment to completing rehabilitation.
For more information around the journey we underwent to launch our Finish Line™ Programs click HERE>> (Challenging the Way the Physiotherapy Industry Charges) to listen to a podcast interview.
For an example of how POGO’s Finish Line™ programs achieve great client outcomes click HERE>> (Finish Line™ Case Study-Tom Bowie) to read Tom’s story of overcoming debilitating lower back and sciatic pain.
In the meantime if you are physiotherapy practice owner looking to get more respected results through heightened trust levels with your clients be sure to subscribe for our POGO Partners™* updates HERE>> POGO Partners™ Program
If you are a physiotherapy consumer looking to benefit from the best in treatment outcomes schedule your initial appointment (Discover Recover Session) HERE>>.
*From July 2017 our industry first Finish Line™ Programs will be available at select Australian physiotherapy practices.
Physio With a Finish Line™,
Brad Beer (APAM)
Author ‘You CAN Run Pain Free!’
Founder POGO Physio
Host The Physical Performance Show
Featured in the Top 50 Physical Therapy Blog