Concerning News from the AAPMR

[Disciple]

1. Legislation Introduced in Congress: Physical Therapy Direct Access

Senators Blanche Lincoln (D-AR) and Arlen Specter (R-PA) along with Representatives Earl Pomeroy (D-ND), Jim Ramstad (R-MN), Tammy Baldwin (D-WI), Ron Lewis (R-KY) and Tim Murphy (R-PA) recently introduced The Medicare Patient Access to Physical Therapists Act (HR 1552/S. 932). Under the bill, Medicare beneficiaries would not be required to obtain a physician referral before seeing a physical therapist.

Current federal law requires that a Medicare beneficiary first visit a physician or have his or her physical therapy plan of care certified by a physician before receiving outpatient services provided by a physical therapist.

Previously, AAPM&R organized a national coalition of physicians’ organizations that successfully opposed similar legislation because we believe the protections and assurances in the current law are essential and that their elimination will erode the quality of patient care and may increase the costs of such services to the Medicare program.

In addition, the Medicare Payment Advisory Commission’s (MedPAC) December 2004 Report to Congress, recommended against eliminating the current referral requirement, and specifically found:


The current system of requiring a physician referral ensures that physical therapy services are medically appropriate and necessary.

Access to physical therapy services for most beneficiaries is not impaired by the current requirement.

The referral requirement is consistent with Medicare coverage rules for other services, such as home health care, skilled nursing facility stays, and occupational therapy.

To the extent that referral requirements reduce the amount of unnecessary services, such a requirement results in a net savings to Medicare.

The referral requirement is consistent with private payer strategies .

AAPM&R is currently planning strategies to oppose the legislation and will update members on its Web site.

I guess all specialties have their own issues with mid-levels.

Don't know what the heck they're thinking if this is all in the name of saving money. Physiatrists and other physicians are the ones stopping patients from getting endless sessions of "passive" physical therapy i.e. massages and ultrasound.

This could be bad news for Physiatrists without good MSK/Spine/procedural training.

Don't really get this one, either, from the AAPMR's spring Resident News Letter:

If you’re open, there are a lot of jobs out there,” he said.

“If you’re open,” seems to be the password to opportunities as you search for jobs and fellowships. Awni stresses that the opportunities are there for those with an open mind and are not intent upon private practice outpatient-only work right away.

Physicians just starting out are well advised to seek an inpatient-care position, he said, because outpatient care generates too little contact in the professional community. “You have to find a way to get to know people to get those referrals,” Awni said. “If you’re carrying five, 10, or 15 inpatient beds, that’s your bread and butter, that pays the bills until the outpatient work picks up. Most people don’t realize that you need to do some inpatient care to set up your outpatient practice down the road.”

What are they talking about? If you need some cash until your practice picks up, just sign up with Concentra or an EMG service like One-Call. Yeah, maybe you need the inpt referral source if you're setting up a spasticity or MS clinic, but for the average MSK/Spine guy, this is not necessary.

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[delicatefade]

As a physical therapist, maybe I can offer a little insight into the motives behind the direct access push.

Let me start by saying that as a general rule, I do not support direct access for physical therapists. However, I can see the logic in some of the arguments the APTA is using to push these bills.

As you all know, all PT schools will soon be required to be at the doctoral level (DPT). As far as I know this is not a push into the realm of physicians (like NP's gaining independence from FP's or CRNA's gaining independence from anesthesiologists). Instead, it is an attempt to "level the playing field" between physical therapists and chiropractors, who have been at the doctoral level and have enjoyed direct access to care for years upon years. The APTA feels that the education of a PT matches or exceeds the education of a chiropractor, and to be honest, I see their point.

The PT profession has been working very hard at evidence based practice to provide evidence for PT modalities (therapeutic exercise, ultrasound, e-stim, etc) that have been used for years without much proof of their efficacy. A quick glance at some of the articles being published in the Physical Therapy journal and the Journal of Orthopedic and Sports Physical Therapy, just to name two, should show you the number of studies that are being done to look at the reliability, validity, and efficacy of assessments, measurements, and treatments. I haven't really looked at chiropractic literature so I cannot comment there.

Part of the APTA's argument is that PT's are not trying to be doctors. They simply want patients to have direct access to physical therapy care without having to go to their family practitioner first to get a generic diagnosis of "low back pain" or "shoulder bursitis" and a prescription for Motrin and Flexeril with a referral to PT. Now physicians are arguing that patients need to be seen by a doctor first to rule out non-musculoskeletal causes. The APTA argues that PT's are trained in enough differential diagnosis to understand when something is outside of the scope of a PT's practice and requires a physician referral.

The argument I've heard for direct access to PT lowering health care costs goes like this: patient goes to FP, gets dx of "low back pain" and sent to PT. Most insurance companies will cover a certain number of visits before the patient has to be "re-certified" for more therapy by a physician. Typically this means stopping therapy, having the patient make another appt with their physician who will poke at their back for a couple seconds and send them back to PT with a dx of "low back pain". For someone with known chronic musculoskeletal back pain this is a total waste of time and money.

Of course, most of these arguments go out the window if the patient is seeing a physiatrist first, but as you know, most people with musculoskeletal complaints go to their family doc.

I'll end with this: I see a great deal of misunderstanding about what PT's actually do with patients. Time and time again on my FP rotation this year, we would refer patients to PT and the doc would tell them that the PT was going to do some sort of "passive" exercise program and probably some ultrasound or e-stim. This is not what a typical PT does. PT's really are experts at functional mobility, kinesiology, therapeutic exercise and biomechanics. MOST PT's will do a thorough examination to find out WHY the patient has a particular complaint and will design a therapy program that addresses the CAUSES of a patient's dysfunction. Yes, this will often include passive exercises and modalities such as ultrasound, particularly in the acute stage of inflammation, but I really don't think most PT's are simply doing session after session of ultrasound, e-stim, and/or massage.

As you can see, this push for direct access isn't quite so black and white. PT's are not pushing for the same level of autonomy as NP's and CRNA's. I think they simply want to be recognized as experts in non-medical neuromusculoskeletal care, and perhaps there are some situations that really do not require the input of a primary care physician. I don't think many PT's would argue against the value of having a physiatrist involved in a patient's care.

 

[delicatefade]

By the way, if this really is a threat, it is more of a threat to primary care physicians who generally provide poorer quality care to patients with musculoskeletal complaints than physiatrists or physical therapists.

I think that if you are a physiatrist with training in pain management, spine, and or MSK, if you are willing to network most physical therapists in your area would be HAPPY to involve you in the care of their patients should direct access become a reality. I really mean this when I say that most PT's I know really appreciate the value of a good physiatrist or pain management physician.

 

[Hemisphere]

agreed not sure direct access to PT would necessarily be bad for physiatrists! Most FP's/Internists refer to PT for "low back pain" as discussed above. During my TY I did not see one referral to a physiatrist for the patients I treated with chroinic pain, they all went to PT. then they come back to the internist get sent for another course or get put on vicodin or oxycodone or something perhaps for "DJD" or "osteophytes" or something. Then there might be a referral to a surgeon... Then finally the pt might see a physiatrist with a referral from the surgeon waaay down the road.

Now consider this, the patient goes to PT first and does not get better with a short course of physical therapy. Then the PT refers the patient to the local physiatrist rather than back to the FP. This could actually increase business and improve efficiency, as long as we are able to maintain good relations. Physiatry would then be the first doctor to see these patients and could be the 1st to design the plan for msk pain - conservative vs. internventional vs. this is medical and the patient actually does need to see a pcp. that is afterall an area of expertise of our field. Thoughts?

It seems that independent PT's would then be subject to malpractice lawsuits if they did not refer early on enough and something became a serious medical problem.

 

[SSdoc33]

Correct me if I'm wrong, but therapists are trained in how to treat specific medical conditions with modalities, exercise, etc. They are NOT trained in how to diagnose these medical conditions. Therein lies the difference in the two fields. This is no slight against physical therapists, but it would be inappropriate for a patient to directly see a physical therapist without first undergoing a medical evaluation. Shoulder pain, back pain, ankle sprains are one thing, I agree that a therapist may have way more knowledge than your run of the fill FP, but when you look at the gamut of diagnoses that is referred to PT, a physical therapist is not qualified. Thoughts?

 

[HolisticMed]

Just would like to make some further distinctions between chiropractic and physical therapy. All chiropractic schools are 4 years in length and the first two years are virtually identical to allopathic/osteopathic schools. It also requires hundreds more hours in physical diagnosis(msk and other) than is required by physical therapy schools. In addition, chiropractors are rigorously trained to interpret radiographs... as well as ct's and mri's. Debate what you will about chiropractic theory and practice, but these educational requirements are mandated for all chiro schools(yes even the more philosophical ones)

All of the 4 year physical therapy degrees currently equate to Phd programs... the elevation from a masters to a doctorate in physical therapy does not have any clinical significance in the current legislation(meaning it does not grant any further capabilities).

 

[mehul_25]

All of the 4 year physical therapy degrees currently equate to Phd programs... the elevation from a masters to a doctorate in physical therapy does not have any clinical significance in the current legislation(meaning it does not grant any further capabilities).

I think anyone with a PhD would vehemently argue that a DPT is not equivalent to a PhD...

 

[lobelsteve]

DC's reading imaging is a joke. THey ignore all the rules and just make crap up and use their own language, lines, and angles to justify their means.

 

[HolisticMed]

"I think anyone with a PhD would vehemently argue that a DPT is not equivalent to a PhD..."

What I meant by it being equivalent to a Phd was in the fact that it is an academic doctorate, not a clinical doctorate like a DVM, DC, DPM, DS etc...
The acheivement of a doctorate of physical therapy does not increase a physical therapists scope of practice in any way.

"DC's reading imaging is a joke. THey ignore all the rules and just make crap up and use their own language, lines, and angles to justify their means."

While chiropractors certainly do have their specialty specific methods of interpreting radiographs, they are first trained in traditional allopathic/osteopathic radiological interpretation. While xray analysis is sometimes warranted for chiropractic care, its most important role is so that the chiropractor can rule out organic pathology such as cancer, fracture, etc... Which is vitally important seeing as how patients have had direct access to chiropractic (not needing an md/do referral) for several decades.

 

[delicatefade]

I agree that a therapist may have way more knowledge than your run of the fill FP, but when you look at the gamut of diagnoses that is referred to PT, a physical therapist is not qualified. Thoughts?

Can you re-word this??? I was following you until you got to this sentence, which makes no sense to me.

 

[blast7]

Correct me if I'm wrong, but therapists are trained in how to treat specific medical conditions with modalities, exercise, etc. They are NOT trained in how to diagnose these medical conditions. Therein lies the difference in the two fields. This is no slight against physical therapists, but it would be inappropriate for a patient to directly see a physical therapist without first undergoing a medical evaluation. Shoulder pain, back pain, ankle sprains are one thing, I agree that a therapist may have way more knowledge than your run of the fill FP, but when you look at the gamut of diagnoses that is referred to PT, a physical therapist is not qualified. Thoughts?

I'm not sure what you mean here. All Physical Therapists are required to perform their own evaluation regardless of any diagnosis given from the MD. If there are yellow flags, red flags or any indication that the findings from the therapist do not correlate with mechanical findings then any PT with common sense will refer them to their PCP.

 

[SSdoc33]

delicatefade and blast7, what im trying to say (although obviously not very eloquently) is that i dont believe that PTs are qualified to diagnose medical problems. PTs are trained to treat, thus the "therapy" component of physical therapy. allowing a PT to diagnose a medical problem opens up pandoras box of missed diagnoses, delays in appropriate treatment, and inefficient health care delivery.

red flags or even yellow flags can be very subtle and often missed. this is true of a physician or a therapist. i have to believe that a physician would catch more of them than a therapist who hasnt been trained in medical diagnoses.

 

[dc2md]

DC's reading imaging is a joke. THey ignore all the rules and just make crap up and use their own language, lines, and angles to justify their means.

come on steve. there's a BIG difference b/t a general chiro reading a spinal xray and a chiro with a diplomate in radiology reading one. the radiology diplomates i know are very well trained in reading xray, CT and MRI films..probably better than some radiologists I've been working with at the hospital i was just at.
but yeah, i agree, all those damn angle and lines are ridiculous.

chris

 

[lobelsteve]

come on steve. there's a BIG difference b/t a general chiro reading a spinal xray and a chiro with a diplomate in radiology reading one. the radiology diplomates i know are very well trained in reading xray, CT and MRI films..probably better than some radiologists I've been working with at the hospital i was just at.
but yeah, i agree, all those damn angle and lines are ridiculous.

chris

I was in a DC office yesterday. Supre nice guy, strongly believes in the DC model, Gonstead certified. He loves taking 14"x36" films and can cure bowel disease by making spinal adjustments.

I may be obtuse, but could somebody show me literature (peer reviewed) that these Xrays have any value. I have no problem saying that folks make **** up to suit their own ends. This is out of alignment so I need to manipulate here, add E-stim here, repeat Xrays after adjustment, etc. I feel the same way about the myofascists and the need to trigger point everything weekly. THey are rapidly going the way of the dodo due to declining reimbursement. I'll cross-post your comments on the radiology forum and see what response they give you. The specialty of radiology exists because of the need for somebody to be able to read the films better than the other doctor. Kind of like me and my needles. To say that a DC with training in Unicorns and Fairy dust compares to an MD radiologist is more than a stretch. I've heard the false science and I do not believe. If people want to go to DC care, I applaud them and gladly work with the DC. Getting adjusted feels good and there is very low risk of any bad outcomes. But the whole concept that because the cord is inside the spinal canal, pushing the bones around is going to cure X,Y,Z diseases does not make empiric scientific sense.

 

[dc2md]

apparently u've only been exposed to the quackery side of chiropractic. chiro was founded by those quacks but has evolved into so much more. but like politics and religion, there are two extremes in the chiro world. one side (lets call them the conservatives) believes they can cure everything by manipulating the spine and therefore relieving theoretical pressure on spinal nerves that innervate (either afferent or efferent) particular organ systems. the other extreme of chiropractic believes spinal manipulations are but a tool of relieving pain (gate control kind of thought at least)...but still just an adjunct to regular MSK rehabilitation.
i think we both agree the former is ridiculous. millions of people swear by it and to that i say "good for them". placebo relief of pain is still relief of pain. everything we do in medicine has a good deal of placebo effect added into the legitimate effects of our pills or procedures.

but let's get something else clear steve. the quack you recently saw was def. NOT a chiro with a diplomate in radiology. judging the quality of radiology experience and expertise by watching a "regular" chiropractor would be like judging medical radiologists by how well an internist can read films...not too damn good judging from my experience. and no, full spine xrays are certainly not good for viewing true spinal pathology...i'm guessing not even those quacks would say that.

on another note though, my chief told me i'd probably get to do an interventional spine elective this year (as an intern). how cool is that? i'm so damn excited!!!
later man,
chris