Health Models and Health Systems in Physical Therapy Practice

Significance of Health Models in Physical Therapy Practice

• Scope of Practice: Health models determine whether a practitioner treats only physical impairments or addresses broader activity limitations and participation restrictions.

• Treatment Philosophy: These models dictate whether the focus remains on curing a specific condition or promoting overall wellness.

• Patient Access: Models influence whether patients have direct access to services or must be referred by a physician.

• Reimbursement: Health models shape what services are covered and the total number of allowed visits.

• Interprofessional Roles: They define how physical therapists (PTs) collaborate with physicians, nurses, and other healthcare providers.

• Prevention vs. Treatment: The prevailing model determines if PTs are expected to provide preventive services or only treat existing conditions.

Defining Health Models

• Definition: A health model is a conceptual framework that defines:

  • What health means.

  • What causes health and illness.

  • Who is responsible for health.

  • How health should be measured.

  • What interventions are appropriate.

• Stakeholder Influence: Which model predominates is determined by factors including the distribution of power between stakeholders and the particular circumstances of an individual case.

• Professional Identity: Documentation, treatment choices, and professional identity reflect the health model a therapist adopts.

Theoretical Models of Health

The Positive Model of Health

• Definition (WHO, 1948): Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

• Merits:

  • Recognizes physical, mental, and social dimensions.

  • Acknowledges that health affects every sphere of life.

  • Incorporates subjective elements, such as how patients feel.

• Limitations:

  • Too idealistic, as complete well-being is often unattainable.

  • All-embracing nature implies every positive aspect of life is health.

  • Too generalized and does not account for individual differences.

Health as a Resource for Living

• Definition (Ottawa Charter for Health Promotion, 1986): Health is a resource for everyday life, not the object of living.

• Key Shifts:

  • Health is a capacity to function rather than a state to achieve.

  • Health is a means to achieve desired goals.

  • Measurement spans physical, mental, and social dimensions.

The Negative Model of Health

• Definition: Health is the polar opposite of disease. People are considered healthy if no disease is found, regardless of behavior or subjective feelings.

• Characteristics:

  • Objective and based on scientific investigation.

  • Subjectivity is dismissed; patient reports are less important than test results.

  • Relies on sophisticated technology for disease detection.

• Contextual Dominance: Negative models often predominate in hospital settings, while positive models are more common in community settings.

Comparison of Biomedical and Biopsychosocial Models

Biomedical Model Analysis

• Strengths:

  • Provides clear, measurable outcomes.

  • Effective for acute conditions and specific pathologies.

  • Supported by strong scientific evidence.

  • Useful for surgical and pharmacological interventions.

• Limitations:

  • Does not explain why not everyone exposed to a causative agent develops disease.

  • Fails to explain variations in patient recovery.

  • Ignores psychological and social factors.

  • May lead to over-treatment or unnecessary interventions.

Biopsychosocial Model Analysis

• Definition: The health of individuals and communities is the result of complex, interacting social, economic, environmental, and personal factors.

• Implications for PT Practice:

  • Optimal health is equivalent to fulfilling realistic chosen and biological potentials.

  • Health is primarily the responsibility of society as a whole.

  • Society has a collective responsibility to ensure opportunities for healthy lifestyles.

• Addressing Systemic Responsibility vs. Victim Blaming:

  • Victim Blaming: "The patient is unhealthy because they make poor choices" or "They should exercise more/quit smoking."

  • Systemic Responsibility: "The patient lives in a food desert with no access to healthy options" or "The neighborhood has no safe places to exercise."

Curative vs. Preventive Models

The Curative Model

• Focus: Curing disease after it occurs.

• Measures: Drugs, surgery, and medical interventions.

• Settings: Hospitals and clinics.

• Responsibility: Primarily clinicians.

• Timeframe: Immediate or short-term outcomes.

• Strengths: Successful treatment of many conditions through science; effective for acute conditions.

• Challenges: High costs; risks of iatrogenesis; limited contribution to overall population health; many causes of morbidity (e.g., lung cancer) remain difficult to cure.

The Preventive Model

• Focus: Reducing the incidence and prevalence of illness.

• Measures: Promotional campaigns, screening, vaccination, and healthy public policy.

• Settings: Community-based (homes, schools, leisure centers).

• Responsibility: Multiple agencies and professionals.

• Timeframe: Long-term outcomes.

• Strengths in PT: PTs have prolonged contact for education; noninvasive interventions (exercise, education) are highly effective; reduces the need for surgery/drugs.

• Challenges: Outcomes are difficult to measure and justify; requires difficult-to-sustain multi-agency collaboration; potential for unrealistic expectations.

The International Classification of Functioning, Disability and Health (ICF)

• Adoption: Adopted by the WHO in 2001 and the World Confederation for Physical Therapy (WCPT) in 2003.

• Core Shifts: Moves away from the negative connotations of disability toward function and positive abilities (patient-level rather than systems-level focus).

Components of the ICF in PT Practice

• Health Condition: Disorder or disease.

• Body Functions and Structures: Physiological functions and anatomical parts. Example: Rotator cuff tear; Right shoulder flexion AROM $0-90^{\circ}$.

• Activities: Execution of tasks or actions. Example: Unable to comb hair; difficulty reaching overhead.

• Participation: Involvement in life situations. Example: Cannot play tennis; unable to perform job duties.

• Environmental Factors: Physical, social, and attitudinal environment. Example: Home has stairs; supportive family.

• Personal Factors: Individual characteristics. Example: Age $45$; motivated; works as a painter.

The Guide to Physical Therapist Practice

• Definition: An evidence-based resource defining the roles and scope of practice for PTs.

• Foundations: Grounded in the ICF and biopsychosocial model; describes PTs as specialists in movement optimization.

Patient/Client Management Model Elements

1. Examination: Collecting data through history, systems review, tests, and measures (The "O" or Objective in SOAP notes).

2. Evaluation: Clinical decision-making process involving integration and interpretation of data (The "A" or Assessment in SOAP notes).

3. Diagnosis: Classification of the condition amenable to PT.

4. Prognosis: Prediction of outcomes and the timeframe to achieve them.

5. Intervention: Implementation of the plan of care.

6. Outcomes: Results of the intervention.

Health Systems and Global Healthcare Models

• Health System Definition (WHO): All organizations, people, and actions whose primary intent is to promote, restore, or maintain health.

• Role of Rehabilitation: Characterized as an essential health service alongside prevention, promotion, treatment, and palliation.

The Four Models of Health Systems

1. Beveridge Model (Public Model):

   • Features: Government-financed through taxes; low cost per capita; government controls provider charges.

   • Examples: United Kingdom, Spain, Scandinavia, New Zealand.

   • PT Implications: Universal access; no financial barriers; standardized benefits; long waiting lists; government controls covered services.

2. Bismarck Model (Social Health Insurance):

   • Features: Funded by employers/employees via payroll deductions; non-profit; mix of private and public providers.

   • Examples: Germany, France, Switzerland, Japan.

   • PT Implications: Compulsory insurance coverage; flexible service delivery; may only cover the working population; reimbursement caps exist.

3. Private Insurance Model (Independent Customer Model):

   • Features: Funded via premiums to private companies; predominantly private providers.

   • Example: United States.

   • PT Implications: Not universal; access depends on employment/wealth; complex reimbursement; high administrative costs.

4. Out-of-Pocket Model:

   • Features: Patients pay directly; no insurance system.

   • Examples: Many developing countries.

   • PT Implications: The rich receive care while the poor stay sick or die.

Healthcare Delivery Structures

• Tiered System: Regionalized and pyramidal. Access must go through primary care (GPs) before specialists. Examples: UK, HMOs in the US.

• Diffuse System: No clear division between primary care and specialists; patients can approach specialists directly. Example: United States.

• Levels of Care:

  • Primary Care: Outpatient settings for common problems; PTs in direct access or wellness roles.

  • Secondary Care: Hospitalization and specialist opinion needed; hospital-based or acute PT.

  • Tertiary Care: Complex disorders requiring multi-specialty collaboration; specialized PT (e.g., burn centers, spinal cord injury).

Global Health Systems Comparisons

• United Kingdom:

  • $100\%$ population insured via general revenues.

  • Spending: $7.5\%$ of GDP.

  • No deductibles; almost no copayments.

  • Challenges: Long waiting times; very little provider choice.

• Canada (National Health Insurance):

  • Single-payer system; $100\%$ population insured.

  • Spending: $9\%$ of GDP.

  • Physicians in private practice; fee-for-service.

  • Challenges: Long waiting lists; referrals required for specialists/PT.

• France:

  • $99\%$ population covered via payroll/income taxes.

  • Spending: $11\%$ of GDP.

  • Copayments: $10\%$ to $40\%$.

  • Third most expensive system; minimal waiting lists.

• Germany:

  • $99.6\%$ population covered via Sickness Funds (payroll tax ~$15\%$ of income).

  • Wait lists and rationing are virtually unknown.

  • Challenges: Low provider compensation; little negotiating power.

• Japan:

  • Universal mandatory employment-based insurance.

  • Funding: Payroll tax $8.2\%$ to $8.5\%$.

  • Copayments: $10\%$ to $30\%$ (capped at ~$677\text{/month}$).

  • No referral requirements for PT.

• United States:

  • Private Insurance Model with no central governing agency.

  • $187.4\text{ million}$ Americans have private insurance.

  • Technology-driven; focuses on acute care.

  • Challenges: High cost; unequal access; average outcomes.

Implications for Future PT Practice

• Lifestyle Conditions for PT Engagement:

  • Ischemic heart disease, hypertension, and stroke.

  • Smoking-related conditions and obesity.

  • Diabetes and cancer.

• 21st Century PT Clinical Competencies:

  • Smoking assessment and cessation.

  • Nutritional assessment/counseling.

  • Physical activity recommendations.

  • Stress and sleep hygiene assessment.

• Social Determinants of Health (SDOH):

  • Economic stability, age, gender, and social status.

  • Access to health services and quality education.

  • Healthy environments and social support.

• Emerging Opportunities:

  • Primary Care Physical Therapy.

  • Direct Access and Telehealth.

  • Population Health and Value-Based Care.

  • Technology-Enabled Practice Models.