Long before there was even the idea of value-based care, I approached every patient encounter with this question as a physical therapist: “So what?” Why was I recommending this treatment plan? What impact, or lack thereof, would it have on this person’s life?

It wasn’t like this was a philosophy I’d read somewhere. As time went on, it felt like it was actually more like a compulsion. I needed every encounter, every activity, every element of a plan of care to have a purpose. No filler. And I needed the patient to understand and internalize that purpose and agree with it.

Did they understand my reasoning?

Did I have their buy-in?

Was I motivating them in ways that actually resonated with them based on the reality of their life, their personality, what was genuinely achievable for them? Every visit was a chance to build an alliance, and everything I did, or deliberately chose not to do, was something I was aware of, whose consequences I knew, and the patient knew, too.

Sometimes I wondered if I was the only one who thought this way. Was I the only one designing care plans around the long-term impact of treatment rather than around the visit in front of me? It wasn’t how we were trained to document, and it certainly wasn’t what anyone was paid for.

Waste 15 minutes on “warming up” a patient who was perfectly capable of coming into the clinic already warmed up? No way. I reminded everyone who could warm up beforehand to do exactly that. We wouldn’t spend their valuable time on activities they didn’t need me for, so they should make sure to come in after warming up. Or they could come into the clinic 15 minutes early and choose one of a few options to warm up on their own before their scheduled treatment time, if warming up independently was needed.

I didn’t know it then, but I was already practicing value-based care.

That phrase makes a lot of therapists bristle, and I understand why. It arrives sounding like something invented in an office, or it sounds like policy jargon, or maybe a threat to how we practice and how we’re paid. But strip away the acronyms and value-based care is just the “so what?” test asked at scale. Instead of one clinician insisting that every intervention justify its impact on one patient’s life, it’s a care team insisting on the same thing across a whole population, with clinicians having some financial accountability for the answer.

Nobody invented value-based care. It was formalized from what good clinicians were already doing.

The thing is, fee-for-service has never paid for any of it. It pays for transactions. The alliance you build, the reasoning you walk a patient through, the prognosis and goal-setting shaped to how that specific person will actually engage in their care and in consideration of the entirety of their health, the work that changes outcomes, is invisible to the fee schedule. If you’ve ever felt that the best things you do for patients don’t show up anywhere on a claim, you’ve already diagnosed the problem. You just aren’t naming it “value-based care.” The system so many of us are still defending pays us in spite of our best work, not for it.

I lived this. The parts of being a physical therapist that felt most true to me were the parts I was never technically paid to do. They didn’t correspond to any of the few billable codes at a PT’s disposal, but I couldn’t have been the professional I needed to be without them.

Taking the time to engage and re-engage patients,

pacing treatment frequency to match their progress and their ability to internalize what we worked on together…

…to turn it into a habit that would carry over long after I was gone.

This is what I keep trying to re-orient clinicians toward, and I’ll be honest that I struggle to convey it. We’re taught to defer to and to track “outcomes,” but most of the time what we mean is the outcome of a short-term plan of care, measured the week we “discharge” and rarely asked about again. That’s a lower bar than it sounds. It’s a bar that keeps us working below the top of our license.

A plan of care, regardless of the clinician type developing it, should have to clear a higher bar: will this lead to a change that holds long after I’m gone? If the honest answer is no, I have to ask what we’re really doing, and how it’s making anyone healthier. If the answer is no, who is that plan really for?

I don’t say this to diminish anything. I know I may ruffle feathers with this perspective. But if our care only feels good in the moment and fades once the visits stop, how is it different from a massage?

A facial?

Botox?

Those may be good things, they may be things people want,

and people are right to enjoy them.

No one calls them medicine, though, and no one is accountable for whether they impact a life. When we call something a plan of care, we’re claiming more than that. I’d like us to be worthy of the claim.

Providing a high-value plan of care was never, to me, a matter of what was reimbursed. I simply wasn’t wired to be okay with care that filled time, or that made a patient happy in the short term, or that followed an order, or that was good for an employer wed to fee-for-service. If a plan didn’t earn its place in someone’s life, I couldn’t defend it.

Home health made this concrete. Back when home health’s reimbursement amount (determined by the case-mix classification system called the Home Health Resource Group, or HHRG) was heavily influenced by the number of therapy visits made, I still never planned care around visit volumes. That wasn’t what was best for patients. It didn’t let me dose in a patient-specific way. Instead, I planned care so that the impact of the expert care I delivered as a physical therapist didn’t “end” when I transitioned them off the episode. I was known to sometimes front-load frequency early and then wean patients off of care, building their independence into the plan itself.

Did that mean I didn’t always hit the higher visit thresholds that would have brought more revenue to the agency? Yes.

Was I practicing value-based care? You bet I was.

That’s true even if you, personally, have never once provided care that wasn’t medically necessary. That’s the point.

The poor return on all that spending isn’t a knock on healthcare professionals as much as it’s a symptom of a reimbursement system that was never set up to meet patients’ needs at the individual or population level.

It’s easy to believe that if we just advocate hard enough, fee-for-service rates will rise to meet inflation and beyond. But math doesn’t allow it. There is no way to keep up with a medical cost trend approaching 9% per year — the highest in nearly two decades — and no amount of advocacy changes that arithmetic. [1]

The way I see it, there are really only two levers available to fight that trend:

First, full-risk, fully delegated value-based arrangements, and second, greater use of biosimilar drugs. [2]

That’s the toolbox. And the path to full risk takes years and often necessitates baby steps, early wins for patients and providers, with trust built slowly. Which is exactly why the transition is happening now, whether or not any of us are ready for it.

I said a version of this on a panel recently, and I used the word “deflation.” The point I made to this audience of physical therapists was that advanced primary care teams who invest in upstream, proactive patient care can, at scale and with the assistance of new technology and interoperability, have a chance to be a deflationary lever. I noted that physical therapists could be a powerful additive to primary care teams to address the as many as one-third of patients who present to primary care with musculoskeletal pain, movement impairment, imbalance, gait abnormalities, etc. [3]

I later heard that for some in the audience, it landed as the opposite of what I intended. I sense that some thought “why should we be the ones to fix a problem we didn’t create?” and as one more reason to dig in and defend fee-for-service.

But nobody is asking physical therapists or any individual clinicians to “fix” American healthcare. The ask is much smaller and much better: stop staying locked out of the models that finally reward what you already do. Don’t expect immediate upside, but a chance to build trust and partnerships as peers of other clinician types.

The point I was making to this audience of physical therapists was that clinicians taking on accountability for cost and quality like advanced primary care teams, focused on reaching patients even before they need it, sharing in the savings when populations get healthier, need exactly what we offer. And right now, we’re not in the room.

I’ve described advanced primary care as a three-legged stool consisting of primary care physicians (along with NPs and PAs), behavioral health providers, and physical therapists (and OTs belong here, too). Today, that stool is missing its third leg. Musculoskeletal (MSK) conditions drive an enormous share of cost and disability, and the practitioners best equipped to manage them longitudinally are standing outside the model.

With MSK conditions driving nearly $381 billion in annual U.S. medical costs, embedding a physical therapist directly into the primary care team, as the U.S. military and VA has successfully done for years, provides the stabilizing leg of the stool that simultaneously reduces systemic waste and immediately elevates the patient experience. They get the frontline care they need. The friction is removed. [4]

So what does the first step actually look like? It’s not a policy campaign. It’s simply a conversation.

Speaking to therapists, as you may be the least mainstream healthcare professionals involved in value-based care, find the practices in your area that have taken on risk. These include accountable care organizations, or ACOs (listed on CMS.gov via the MSSP program and ACO REACH), especially the advanced primary care groups, and ask how you can be a partner to help them succeed. And bring tangible suggestions. And shift one perspective that may feel hardest of all: think of these groups as partners and peers, and you are offering to help them transform care.

It will take humility, too. We shouldn’t assume the broader healthcare community or policymakers understand our capabilities, our level of education, or the fact that, like traditional primary care providers, we aren’t paid for much of the work we do and can do more of that moves the needle on improving health. Our perception isn’t always what we think it is. Addressing that honestly is necessary foundational work.

Here’s what’s waiting on the other side of it: a profession elevated from “physical therapy,” a service that gets ordered and billed, to “physical therapist,” a doctoring professional working alongside physician and behavioral health peers in primary care, in urgent care, and in the emergency room doing the good, hard work of managing patients longitudinally and with their long-term health ever in our minds.

If you’ve ever felt the need for the treatment you deliver to have a long-term impact, and needed your patients to know that purpose and agree and form a therapeutic alliance with you, for them, you answered that question of whether you “believe in” value-based care a long time ago. The only question left is whether we help build the payment system that finally pays for the answer, or keep defending the one that ignores it. When we finally strip away the noise of the old system, what remains is the only thing that ever mattered: a clinician and a patient, working together toward a better outcome.