Is Individualized Physical Therapy Better Than “Group-based” Therapy?
one-on-one PT versus 2-4 patients per hour
A Happy 4th of July weekend to all my readers and fellow clinicians and managers. With the Holidays upon us, I wanted to kick it off with an interesting topic:
Is treating patients with individualized one-on-one therapy, seeing one patient every 45-60 minutes, superior to treating 2-4 patients per hour as many in-network clinics do?
As MSK clinicians, finding the optimal amount of time to spend with each patient is crucial for achieving the best clinical outcomes as well as a great patient experience.
Within the physical therapy profession, there is a debate over whether therapists should see one patient at a time or manage multiple patients simultaneously. Each approach has its own challenges and advantages, impacting the quality of care, therapist workload, patient satisfaction, and insurance reimbursement. Understanding the nuances of both methods can help therapists, clinic managers, and patients make informed decisions about the best treatment model.
One-on-One
Seeing one patient at a time has several obvious advantages. Many patients enjoy and report greater satisfaction from having the full attention of their therapist. They perceive that they get more thorough assessments, detailed education, and greater individualized treatment plans.
The extra time spent with the therapist often means improved communication facilitating a stronger level of trust and relationship between the two. It also means that therapists can monitor the patient closely and make adjustments to both exercise selection and technique based on the patient’s symptoms.
But it’s not all sunshine and roses. Oftentimes these clinics are very heavily manual-based, which could place a large physical burden on the therapist. Doing 20-30 minutes of manual therapy on every patient may not be necessary or even clinically indicated.
Seeing only one patient at a time obviously limits the number of patients a therapist can see in a given day, thus reducing clinic productivity and profitability. You can’t offer great services if the business isn’t making a profit. As they say…”no margin, no mission”.
Health insurance reimbursement for in-network outpatient-based physical therapy is already on the lower-end in many regions in the United States. Depending on the payer and location, reimbursement per visit can be as low as $50-70. This makes it difficult, if not impossible to stay in business seeing one patient at a time (i.e. one patient every 45-60 mins).
Fewer appointment slots available could also mean longer wait times and delay to treatment. It’s no secret that many of the providers who operate in this model do so on an out-of-network or cash-pay basis.
Seeing Multiple Patients Simultaneously
This is the typical model for outpatient PT (booking 2-4 overlapping patients per hour) and fairly standard across the industry. There are some very obvious problems with this model in terms of care delivery, such as:
Less individualized care to each patient (potentially overlooking details and formulating ineffective cookie-cutter treatment plans)
Improper supervision and lack of timely adjustments to interventions
Patient frustration and decreased satisfaction from inadequate attention
Therapist burnout/turnover and decreased job satisfaction from high volume care
But are there any advantages?
Well for starters, it’s typically more affordable (arguable given increasing co-pays) and accessible for the patient. For the business, this model maximizes clinic resources and increases profitability in an in-network, fee-for-service based system. It also provides better scheduling for patients with more slot availability during peak hours.
Another important but less appreciated benefit is the peer support and encouragement in this type of environment. Anyone who's been to a physical therapy clinic knows that many patients enjoy coming to therapy because they like exercising alongside other patients. They find the social aspect of the experience fun and motivating. This group-based environment creates a bond of solidarity between patients, therapists, and clinic staff.
The ability to form close relationships and friendships between patients and therapists and between staff members can lead to increased job satisfaction. As I always say, one of the best predictors of whether or not a therapist will stay long-term at a company is whether they become good friends with at least one other staff member at the organization (all else being equal).
So Which Is A Better Model?
Many would say more individualized care is better. But I would argue that whether care is individualized or group-based is of secondary importance. The primary consideration should always be whether clinical care provided is safe, effective, and financially feasible (in that order). The method of delivery is- after-the-fact.
Just because clinical care is individualized and a patient works one-on-one with a therapist does not necessarily mean that the care rendered would have been any better or more effective than care delivered in a group setting.
All it means is that the clinician has a greater opportunity and potential to assess, receive feedback, make adjustments, and educate the patient. But without the appropriate training, clinical reasoning skills, or quality assurance, this individualized care is not necessarily better than group-based treatment, and this extra potential may be wasted.
In fact, it could even be more problematic if the therapist is using techniques of questionable scientific evidence. You can provide someone with the best quality tools and kitchen, but if the person doesn’t know how to cook, you’re not getting a Michelin-star meal. Likewise, put Gordan Ramsey in virtually any kitchen and you’ll likely get a pretty good dinner.
The point is that it’s not just about the amount of time spent with the patient. It’s about what is actually being done in that time. A patient can spend an hour with a therapist who performs a dozen techniques and exercises, but only 1-2 of those interventions may actually be providing >80% of the result for the patient.
What Does The Research Say?
Depending on the study you review, each individual orthopedic condition may have different recommendations. But some of the results may surprise you. For example, group physical therapy for shoulder impingement syndrome has been shown to produce similar clinical outcomes to individualized therapy1. Even more surprising, there is evidence that group-based physical therapy is superior to individual rehabilitation in adults following total knee replacement2.
Finding a Balance
So which is better? As always, the answer is context-dependent. Who is the patient? What condition/diagnosis do they have? What does their mobility, function, and medical history look like?..etc
There are some basic principles that are universal. First and foremost, clinics should avoid putting patients at-risk for injury. Therefore, treating multiple patients simultaneously is not recommended if one of those patients is at risk for falling, has cognitive decline, or if they have some condition that requires constant supervision.
Even if they do not have one of these conditions, some patients need more supervision and cues to ensure appropriate technique during therapeutic exercise. These patients are better treated one-on-one. This should go without saying, but clinics need to follow the golden rule in medicine- Do No Harm.
Following “Do No Harm”, clinicians should also be aware of the medicolegal implications of treating multiple patients simultaneously. Despite it being fairly “black-and-white”, legally speaking, there are a lot of clinics that treat (and bill) Medicare patients simultaneously or use PT Aides to render physical therapy services and bill to insurance using CPT codes. We’ve all seen it.
Beyond those two points however, the answer to whether or not to use individualized therapy is largely driven by the patient's needs and the actual clinical intervention. And I can clearly see situations where patients would benefit from either treatment style so long as the interventions themselves are clinically indicated and based on sound reasoning.
Ultimately, these types of operational decisions need careful consideration in terms of scheduling patients and billing appropriately to maximize revenue. By implication this means that a skilled manager will have to look at both clinical safety/effectiveness and make an economic analysis of individual versus group physical therapy when deciding how best to incorporate both types of treatment into the clinic.
Thanks again for reading and I wish everyone a safe and Happy Independence Day!
Resources:
1. Ryans I, Galway R, Harte A, Verghis R, Agus A, Heron N, McKane R. The Effectiveness of Individual or Group Physiotherapy in the Management of Sub-Acromial Impingement: A Randomised Controlled Trial and Health Economic Analysis. Int J Environ Res Public Health. 2020 Aug 1;17(15):5565. doi: 10.3390/ijerph17155565. PMID: 32752234; PMCID: PMC7432922.
2. Krumov J, Obretenov V, Bozov H, Tzachev N, Milanova H, Panayotov K, Papathanasiou J. Is group-based physical therapy superior to individual rehabilitation in elderly adults after total knee arthroplasty? A prospective observational study. Eur J Transl Myol. 2022 Dec 5;32(4):10984. doi: 10.4081/ejtm.2022.10984. PMID: 36533668; PMCID: PMC9830394.