Concierge service delivery is a business model that has been adopted by physicians, chiropractors, and physical therapists. In this model, the provider accepts cash payment for services and does not bill insurance companies. This is appealing because it eliminates the restrictions imposed on clinical decision-making that are driven by insurance-based requirements (Pulford et al., 2019). Services are paid for by the client, provided in the environment of choice, and for the duration and purpose designed collaboratively by the client and the physical therapist. The mobile portion of this service delivery model involves the therapist providing therapy or wellness services in the client's home, place of work, or other desired location, allowing true customization and convenience. These services could also include fitness prescription or performance enhancement programs. Although prevention and wellness services delivered by therapists are supported by the American Physical Therapy Association (APTA, 1995), they are underutilized in contemporary practice.

The concierge model is currently offered in the physical therapy community. With decades of declining reimbursement rates, physical therapists know that simply working harder and faster is not the answer (Kapasi, 2017). A Facebook group, "Uncaged Clinician," has 8.3 thousand members who largely run independent concierge mobile services (Bayliff, 2018) and "PT Entrepreneurs," another Facebook group (Matta, 2018), supports clinicians in starting and growing their cash-based therapy business.

The APTA vision is to transform society by optimizing movement to improve the human experience. Among the guiding principles to achieve the vision are value and innovation (Vision Statement for The Physical Therapy Profession, 2019). To accomplish this, the healthcare industry needs to continuously develop innovative ways to provide services within a system that is facing challenges such as increasing demand for services, poor coordination of care, distrust of the public toward healthcare providers, and declining reimbursement rates (Kapasi, 2017). The concierge mobile model supports the APTA vision.

Some advantages to the concierge mobile model include flexibility in location of service, options beyond the scope of insurance-based models, and reduced documentation requirements. There is freedom to provide services in places such as the office of a public servant who can't leave his post, the shop of a busy electrician, the home of a client, the athletic track, and the community park trail. Concierge mobile physical therapists develop customized services that are available to advance clients to functional outcomes that exceed what would traditionally be covered by insurance and allows the duration of treatment to be established by the client and the therapist. Another attractive feature is that the documentation is focused on tracking progress in language that is meaningful to the client and complies with licensing and liability requirements while reducing insurance-driven documentation demands. Castins' webPT (2019) blog lends credence to the advantage of the concierge mobile physical therapy model eliminating ambiguity about what is and isn't covered, allowing flexibility in scheduling, reducing clients' travel time, and decreasing time spent seeking physician referrals.

There are some downsides to the concierge mobile model. Cash pay is not feasible for all clients, and the therapist must be knowledgeable in state and federal guidelines and assume a greater liability than in traditional models. Although cash pay could be a barrier for some, increasing copays, deductibles, and restrictive plans yield expenses that are frequently on par with a concierge fee structure. A recent study published in JAMA found that Americans spent 33.9 billion out of pocket when combining musculoskeletal disorders and falls (Dieleman et al., 2020). Therefore, it is important for healthcare providers to consider new paradigms of efficient, effective, and value-based care delivery to best meet the needs of clients. The concierge mobile physical therapy model supports this goal.

In my own practice, some clients do not feel they are achieving their maximum potential when receiving insurance-based therapy. Many wish to push beyond injury recovery and establish goals that reach past their baseline functional status. One client seeking help to achieve a high-level mountain climbing goal despite his orthopedic injury history, benefited from a flexible training program designed to optimize his movement, and enhance his human experience. Another client who exhausted her insurance benefits both with home care and outpatient physical therapy following a cerebral vascular accident, was not satisfied with her on-going limitations. She enjoys the continual push during her concierge mobile physical therapy sessions to make slow sustained progress, achieving goals such as safely walking at the public park and functional use of the affected hand for her baking hobby that enhances her quality of life. These are examples of the contrast between insurance-based function and client-driven optimization of movement to enhance their human experience.

Another reason clients may seek concierge physical therapy services is to supplement insurance-based services. One client who is receiving home care physical therapy twice a week after a long hospital stay with medical complications, supplements these sessions with concierge sessions. Another client who was diagnosed with a brain aneurysm does not fit the homebound criteria, however, the assistance required to get access to outpatient therapies has many barriers. Therefore, the concierge mobile physical therapy service model best met the client's needs.

Healthcare reform is driving providers and patients to value-based payments and away from procedure-oriented, fee-for-service reimbursement. Payment models such as cash-based clinics, pay for performance, out-of-network services, accountable care organizations, and concierge practices may potentially result in enhanced outcomes related to patient care (Charles et al., 2018). The concierge mobile physical therapy and wellness model provides an expanded choice for both providers and clients in their healthcare and wellness delivery options. There are many advantages suggesting this model is here to stay, providing a means to optimize movement to enhance the human experience.

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