Sniff and Scurry Navigate the Red Queen's Race: Occupational Therapy Private Practice in 2024

I've struggled to find models that help me understand the challenges facing my private practice. I have never really been strongly interested in pop-thought conceptual non-fiction books because they tend to be overly simplistic and repetitive. 'Who Moved My Cheese' is a classic example, even if it did resonate with a lot of people in its time.

Anyway, I have been thinking about change and adaptation because I have been trying to pump figurative bullets into our private practice for a couple years now and it just won't die. A global pandemic didn't kill our private practice - we were propped up by a generous governmental solution to keep our employees.  Then there was an increasing demand for therapy since the pandemic created a whole new generation of developmental and mental health problems for the pediatric population. Selling the office building didn't kill the private practice either - demand for in home and community services took the place of the outpatient model. Passing leadership to my wife and personally stepping away didn't work - she runs it too competently, and I guess that says something about how relatively unimportant I was once the thing was up and running! Ending our participation in private insurance didn't work - cash payment and municipal contracts now exceed any reimbursements we got through traditional methods. 

We must look like Sniff and Scurry with adaptability these last few years but I assure you I am actually a secret double agent doing my best to sabotage everything.  And I am failing in my covert mission.

My real best case scenario would be to pass the practice along to someone who wants to run the darn thing. Selling a private practice, or even giving it away, is not as easy as it might seem.

This morning I was told (again) about the problems of the new Early Intervention billing system - something I stopped ranting about several years ago once I realized that the purpose of the system was not to help children but rather to give an appearance of helping children - thereby meeting the cultural need of feeling good but not really investing at the level that would make a difference. Don't get me wrong - there are many many good people with good intentions providing excellent services at the street level in that system - but it is run by a government that has little interest in the well-being of children.  Since children don't represent a powerful voting block, and the young parents of those children don't have the platform or space to organize and influence, the government does just enough to give the appearance of trying.  And they complain about it endlessly - since it is no one's priority - so the Federal government kicks early intervention policy to the States for implementation, the State does what it can with little money, and tries to pass it off to the municipalities who listen to people who don't want high property taxes.

Anyway, now there is a new billing portal for early intervention - again.  There are problems with implementation - again.  There are already delays and problems with payment - again.

Predictably, providers are talking about leaving the system, so the State will achieve the objective of back-door cost containment by driving providers out of early intervention.  The bureaucrats will shrug their shoulders and give the therapists a 5% increase every 20 years, and get away with it. If you see any OT, PT, or speech therapist crying after the dock workers just got a 62% increase over the life of their 6 year contract - now you know why. I try to explain to the EI providers - it is all about power, and you don't have any! No one likes that message, but it is true.

So why is it impossible to kill off therapy practices?  It is rather simple, actually.  The needs just don't go away.  That is the only rational part of the equation, even if it is a devastatingly sad reality.

I think the correct model that explains the whole phenomenon is what can be called the concept of 'Red Queen Hypothesis.'  I should write one of those books about this, but I already said they are boring, so I am just putting these ideas into a blog post.

In evolutionary terms, the Red Queen Hypothesis (adapted by the Lewis Carroll character that runs in one place and gets nowhere) states that a species must constantly adapt in response to the environment or they will become extinct.  So in this case, therapists and the early intervention system are engaged in an evolutionary arms race where each side is trying to adapt strategies in response to the other. Specifically, therapists must navigate complex reimbursement boondoggles to try to provide services and get paid, while the state just keeps creating more detailed and complex policies, requirements, and mechanisms for delay and denial of care.

These are two competing evolutionary objectives.

In the Red Queen model, therapists must strategically adapt and engage in gamesmanship with coding strategies, learning new payment systems, appeals, re-submissions, etc. Competent and caring therapists do this as naturally as breathing - it is not just something you can turn off.  This often results in total burnout, and can drive people out of the system - except for those who are somehow adaptive and caring enough - the Sniffs and Scurrys who are so competent that they can't manage to be killed off by the game.

End result - naturally caring and adaptive therapists struggle to advance their interests in patient care, children don't receive even a fraction of what should be prioritized for them, and bureaucrats focus on areas that will support their power base.

So this phenomenon won't kill off our practice either. Caring and associated adaptability are genetically coded into Sniff and Scurry.  Perhaps the real question is how long we can sustain the delicate balance without losing sight of our own well-being in the process. It is a problem.