"The Truth Behind APTA’S Campaign Against POPTS" courtesy of the AAOS

[ptisfun2]

Even for patients whose insurance does not require a script for PT, sometimes clinics will still want one to cover their own butt).

We really are our own worst enemies

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Members don't see this ad.

 

[DesertPT]

Why do physicians think they are in charge of the PT POC even when insurance requires a referral? How is it different than an HMO requiring referral to a specialist? Is it just the cliqueishness?

To me it has to do with history, organizational policy and procedure, and physicians having way too much power.

Your statements are to excessive and grandiose in their scope, in my opinion. Insurance companies and some PT clinics (even in full direct access states) want to see a script from a doc for PT primarily not because they believe the doctor should control the PT POC but because we live in an increasingly litigious nation where frivolous medical malpractice suits are rampant and very costly to the entire healthcare system. Thousands of people are out there willing to do or say anything to make a buck, and as a consequence, everyone has to cover their butts in all conceivable directions.

You talk like physicians being involved in any way in the work of PTs is all motivated by questionable agendas. Realistically speaking this is the exception and not the rule. The vast majority of healthcare professionals are going to work each day and doing their job the best they know how. And aren't interdisciplinary healthcare teams supposed to be the way of the future, providing the highest quality, most effective care possible to patients?

 

[DesertPT]

We really are our own worst enemies

It is unfortunate, but it is something born out of necessity and not desire.

 

[DesertPT]

And thank you everybody for your great posts and for keeping this discussion going strong, it has been an insightful conversation.

 

[Fiveoboy11]

You are right that it is the payors and laws for the most part. Even in states with unrestricted direct access a large number of payors (ie private insurance, medicare/medicaid, workman's comp insurance) will require a script from a doc before they will pay for PT. Even for patients whose insurance does not require a script for PT, sometimes clinics will still want one to cover their own butt. I'm all for direct access, and yes superfluous doctor visits definitely increase cost, but really its not that difficult to have one 15 min. appt. with an orthopedist for a H&P/exam and to get the script before you go to PT. You never really have to see the doc again in a lot of cases (though some such as workman's comp often requires a new script from the doc every 30 days or something along those lines).

So, are you a pre PT student or what?

As far as I'm concerned "script" should be banned from PT language. It implies PT is scripted, therefore done as ordered, making us techs. None of which are true. People who use language other than referral or consult have a lot to learn. And try substituting physician for "doc" and you'll have it.

 

[Fiveoboy11]

Your statements are to excessive and grandiose in their scope, in my opinion. Insurance companies and some PT clinics (even in full direct access states) want to see a script from a doc for PT primarily not because they believe the doctor should control the PT POC but because we live in an increasingly litigious nation where frivolous medical malpractice suits are rampant and very costly to the entire healthcare system. Thousands of people are out there willing to do or say anything to make a buck, and as a consequence, everyone has to cover their butts in all conceivable directions.

You talk like physicians being involved in any way in the work of PTs is all motivated by questionable agendas. Realistically speaking this is the exception and not the rule. The vast majority of healthcare professionals are going to work each day and doing their job the best they know how. And aren't interdisciplinary healthcare teams supposed to be the way of the future, providing the highest quality, most effective care possible to patients?

How many "clinics" have you been in? The evidence shows that a "doc" "script" does nothing to "cover our butts" or reduce "litigation" and I disagree that most PT's feel the need for non direct access atmosphere.

 

[ptisfun2]

How many "clinics" have you been in? The evidence shows that a "doc" "script" does nothing to "cover our butts" or reduce "litigation" and I disagree that most PT's feel the need for non direct access atmosphere.

I agree. As a PT, I firmly believe all individuals should have a malpractice insurance (independent of a clinic policy) policy; not to allow illegal or unethical behavior, but to provide support to me in case something happens. Anything given to the patient by a physician for PT does not divorce a PT from litigation. As a licensed professional, I am responsible for my conduct and practice, and a piece of paper from someone else will not change that.
And I am partial to 'consult' vs. 'prescription' or 'evaluate and treat referral.' It is how I discuss things with students, and shows the collaborative effort for patient management between all health care providers, including PTs.

 

[Fiveoboy11]

I agree. As a PT, I firmly believe all individuals should have a malpractice insurance (independent of a clinic policy) policy; not to allow illegal or unethical behavior, but to provide support to me in case something happens. Anything given to the patient by a physician for PT does not divorce a PT from litigation. As a licensed professional, I am responsible for my conduct and practice, and a piece of paper from someone else will not change that.
And I am partial to 'consult' vs. 'prescription' or 'evaluate and treat referral.' It is how I discuss things with students, and shows the collaborative effort for patient management between all health care providers, including PTs.

Yea,

Nice rationale, I got an "order" so "I'm covered." Not so much. You're responsible no matter what. To me referral is the most appropriate as we are a separate discipline. Meaning potential for co management but the PT decides the POC. Consult is next but (to me) it implies evaluate and make recs, then two parties decide the whole POC, not just "the PT" (true collaboration). Script means the referring provider decides POC as does order (with no eval, and no input from the PT), but the PT can call if they have a problem with "the plan."

 

[Azimuthal]

Are physicians really the gatekeeper or is it the payors and state laws that limit/dictate autonomy?

If it was just the payers and state laws, why are physician groups fighting tooth and nail to prevent patients from choosing to see a PT as a primary. Attached was an ad sponsored by the NYSSOS in the May 22, 2006 edition of The Legislative Gazette. Fortunately, it back fired and direct access was granted to PT's.

 

[DesertPT]

So, are you a pre PT student or what?

As far as I'm concerned "script" should be banned from PT language. It implies PT is scripted, therefore done as ordered, making us techs. None of which are true. People who use language other than referral or consult have a lot to learn. And try substituting physician for "doc" and you'll have it.

How many "clinics" have you been in? The evidence shows that a "doc" "script" does nothing to "cover our butts" or reduce "litigation" and I disagree that most PT's feel the need for non direct access atmosphere.

Thank you for putting an ignorant young whipper-snapper back in his place.

Although I must say the "clinics" in quotation marks thing was a little rude. I have been in 6 clinics or hospitals as a patient or as a volunteer, if you must know. All have been real PT clinics with real PTs.

 

[DesertPT]

I agree. As a PT, I firmly believe all individuals should have a malpractice insurance (independent of a clinic policy) policy; not to allow illegal or unethical behavior, but to provide support to me in case something happens. Anything given to the patient by a physician for PT does not divorce a PT from litigation. As a licensed professional, I am responsible for my conduct and practice, and a piece of paper from someone else will not change that.
And I am partial to 'consult' vs. 'prescription' or 'evaluate and treat referral.' It is how I discuss things with students, and shows the collaborative effort for patient management between all health care providers, including PTs.

Yea,

Nice rationale, I got an "order" so "I'm covered." Not so much. You're responsible no matter what. To me referral is the most appropriate as we are a separate discipline. Meaning potential for co management but the PT decides the POC. Consult is next but (to me) it implies evaluate and make recs, then two parties decide the whole POC, not just "the PT" (true collaboration). Script means the referring provider decides POC as does order (with no eval, and no input from the PT), but the PT can call if they have a problem with "the plan."

I'm sorry, I seem to have really offended some by using words such as "script" that perhaps implied the wrong thing, that is just what my insurance company and the physical therapists I have been treated by have called it. Also, I didn't mean to imply that PTs have the rational that they should follow orders to keep themselves safe. I imagine the clinics I have been to wanted a prescription/referral/script or whatever you want to call them to make sure their insurance claims don't get denied.

Why do some of these posts seem to imply the idea that it is an inherently bad thing for a person to visit a doctor before they visit a physical therapist? I'm for direct access as much as anyone else, but I don't see the advantage of having disdain for the medical profession.

 

[fozzy40]

In POPTS physicians are always the gatekeeper regardless of law and insurance. State law in AZ (where I work) has unrestricted direct access, and there are insurances who allow direct access. Do you think I have not seen physician referrals ordering a specific frequency and duration and interventions with those insurances? Do your practice patterns with regard to PT vary by insurance? If you transplanted to AZ would your organizational policy and procedure magically morph with the law with regard to PT? Many insurances do require physician referral to cover services but how does that necessitate a physician directing "the PT"? I.e. Why do physicians think they are in charge of the PT POC even when insurance requires a referral? How is it different than an HMO requiring referral to a specialist? Is it just the cliqueishness?

To me it has to do with history, organizational policy and procedure, and physicians having way too much power.

So again, is it really physicians are the problem or the payors? I do not know too many physicians that are dying to have this vice grip on PT or any profession that you seem think we crave. You seem to blame everything on physicians and that somehow we have created this master plan to corner the field. Don't hate the player, hate the game.

 

[fozzy40]

If it was just the payers and state laws, why are physician groups fighting tooth and nail to prevent patients from choosing to see a PT as a primary. Attached was an ad sponsored by the NYSSOS in the May 22, 2006 edition of The Legislative Gazette. Fortunately, it back fired and direct access was granted to PT's.

View attachment 185165

That's news to me. I work at the national level for the AAPM&R and it has never once been brought up. Perhaps this is more of a state and national level orthopedic charge. Most docs I have spoke to have not had strong feelings about it. Point taken but I honestly do not think that the AMA or AOA has strong feelings about it.

 

[ptisfun2]

I'm sorry, I seem to have really offended some by using words such as "script" that perhaps implied the wrong thing, that is just what my insurance company and the physical therapists I have been treated by have called it. Also, I didn't mean to imply that PTs have the rational that they should follow orders to keep themselves safe. I imagine the clinics I have been to wanted a prescription/referral/script or whatever you want to call them to make sure their insurance claims don't get denied.

Why do some of these posts seem to imply the idea that it is an inherently bad thing for a person to visit a doctor before they visit a physical therapist? I'm for direct access as much as anyone else, but I don't see the advantage of having disdain for the medical profession.

I meant no disrespect, and I am sorry if you interpreted it in that way. All PTs need to operate within their own license, and make choices that each PT feels comfortable with. I also have absolutely no disdain for any health care professional, and again, so sorry if you thought I did. I have been a PT for over 20 years and have always treated patient management as a collaborative effort with all health care providers (and the patient) involved in the care. I think isolating our profession is dangerous by not working with others.
Finally, I stand by my assertion that a PT is responsible for his or her own professional decision making, and protection comes not from another health care provider, but our own knowledge, etc. And protection comes from that...with malpractice insurance as a failsafe. I find it surprising that so many colleagues rely on a clinic policy rather than buying their own. This is a discussion we have with students.
Approximately 80% of the patients I treat are direct access, but seeing a physician first, second, or third may also be important/required/suggested. If insurance will reimburse for direct access, I do not give it another thought about seeing a physician. Unless my clinical decision making realizes that it will be helpful or necessary.
But I reiterate I meant nor mean no disrespect to you.

 

[DesertPT]

If it was just the payers and state laws, why are physician groups fighting tooth and nail to prevent patients from choosing to see a PT as a primary. Attached was an ad sponsored by the NYSSOS in the May 22, 2006 edition of The Legislative Gazette. Fortunately, it back fired and direct access was granted to PT's.

View attachment 185165

To say that physical therapists are not qualified to make diagnoses of any kind, full stop, is some truly repugnant propaganda.

Those who wrote that poster should be ashamed of themselves. That a professional society of surgeons would publish a document espousing what it knows full well to be a bald-faced lie is absolutely reprehensible.

 

[DesertPT]

I meant no disrespect, and I am sorry if you interpreted it in that way. All PTs need to operate within their own license, and make choices that each PT feels comfortable with. I also have absolutely no disdain for any health care professional, and again, so sorry if you thought I did. I have been a PT for over 20 years and have always treated patient management as a collaborative effort with all health care providers (and the patient) involved in the care. I think isolating our profession is dangerous by not working with others.
Finally, I stand by my assertion that a PT is responsible for his or her own professional decision making, and protection comes not from another health care provider, but our own knowledge, etc. And protection comes from that...with malpractice insurance as a failsafe. I find it surprising that so many colleagues rely on a clinic policy rather than buying their own. This is a discussion we have with students.
Approximately 80% of the patients I treat are direct access, but seeing a physician first, second, or third may also be important/required/suggested. If insurance will reimburse for direct access, I do not give it another thought about seeing a physician. Unless my clinical decision making realizes that it will be helpful or necessary.
But I reiterate I meant nor mean no disrespect to you.

Thank you for a great post, I definitely agree with everything you've said here!

 

[jesspt]

That's news to me. I work at the national level for the AAPM&R and it has never once been brought up. Perhaps this is more of a state and national level orthopedic charge. Most docs I have spoke to have not had strong feelings about it. Point taken but I honestly do not think that the AMA or AOA has strong feelings about it.

Fozzy,

Your professional organization may not feel strongly about it, but an organizaiton here in Illinois certianly felt compelled to lobby hard againt direct access to physical therapists. Here is the Illinois State Medical Society's Memorandum regarding direct access - https://www.isms.org/uploadedFiles/...ction_Hub/Past_Issues/HB4478PositionPaper.pdf

In it, they mistate the Illinois Physical Therapy Association's argument, and make other erroneus statements.

 

[Fiveoboy11]

https://www.aapmr.org/email/state/CONSTITUENT-LETTER-HB-4603_JUNE-21-2011.docx

Above is a pre made script for PM&R physicians to vote no against direct access in MI a couple years ago (found on AAPM&R website).

http://m.amednews.com/apps/pbcs.dll/article?aid=/20090618/government/306189999&template=mobile_art

Article about PM&R physician opposed to Medicare PT direct access.

https://www.aapmr.org/advocacy/societies/Documents/2013-State-Legislation-Summary.pdf

Looks like the AAPM&R is really interested in the legislation of many different professions.

 

[fozzy40]

Thanks for the references. Really news to me which is sad! As I've said, I'm for direct access in general which is a different topic from this thread. However, I do agree on limiting the scope of certain practitioners because I really do think it's a public danger. Not just rhetoric but I've seen it first hand in my community.

 

[NewTestament]

However, I do agree on limiting the scope of certain practitioners because I really do think it's a public danger. Not just rhetoric but I've seen it first hand in my community.

What's the public danger? Do you think most physicians even know what physical therapists do? Do medical schools even talk about physical therapy to their students?

 

[Fiveoboy11]

I think it is likely that physicians are hands down the most dangerous healthcare profession. All others combined vs medicine do not come close. I.e. the danger of OTC tylenol far surpases the danger of PT, so consider prescription medication, and any intervention or surgery whether elective or not. Interesting how physicians do not supervise one another given the overlap in education and training and practice patterns. Perhaps PM&R physicians should supervise their own specialty given all the opioid mills and overutilization of interventions and too much imaging and POPTs. Same goes for orthopods and spine surgeons and probably every other medical specialty. Versus make believe supervision of something that they have no training in, has little to no danger, is efficacious and relatvely low cost.

You'd think that these other dangerous professions would be permanently disabling and killing patients left and right.

 

[fozzy40]

I had one patient this morning who's naturopath has convinced her that she has MS. Now they are off on a goose chase with unnecessary testing and procedures.
There was an incident in my area of a CRNA getting in over their head resulting in a death.
Multiple deaths in Oregon recently related to midwives delaying care for mother and babies.

I'm not saying that iatrogenic bad outcomes are specific to nonphysicians but in many of the cases it was due to them simply not having the training to recognize the signs.

 

[fozzy40]

What's the public danger? Do you think most physicians even know what physical therapists do? Do medical schools even talk about physical therapy to their students?

I'm not sure about all physicians but I know plenty personally from my experience in PT clinics. Most likely most Physicians do not no much what PTs do but they should. Has your PT departments offered to teach at the local med school? Personally, I think it's a great idea.

 

[Fiveoboy11]

I had one patient this morning who's naturopath has convinced her that she has MS. Now they are off on a goose chase with unnecessary testing and procedures.
There was an incident in my area of a CRNA getting in over their head resulting in a death.
Multiple deaths in Oregon recently related to midwives delaying care for mother and babies.

I'm not saying that iatrogenic bad outcomes are specific to nonphysicians but in many of the cases it was due to them simply not having the training to recognize the signs.

May be so. I would bet though that if you were blinded to the provider type in these scenarios it would expose the bias. If the exact same things happen with a physician at the wheel it's ok or more ok than if not.

Also, how often do you see mismanagement of patients among your colleagues? If not often then there's an issue of giving clique passes. If often then there's an issue of double standardization.

And how is it ok for people to get elective plastic surgeries? I had a patient who almost had to have her whole leg ampuated after elective cosmetic plastic surgery. How about overuse of medication, surgery, procedure, and testing by physicians? What do you think is more dangerous? What we know about physician practice patterns or what we can extrapolate from anecdotes about non physicians?

 

[Fiveoboy11]

I'm not sure about all physicians but I know plenty personally from my experience in PT clinics. Most likely most Physicians do not no much what PTs do but they should. Has your PT departments offered to teach at the local med school? Personally, I think it's a great idea.

I'd like to see mandatory observation by residents who are clinical and are likely to refer to PT's in order for residencies to be accredited. Medical school is too early. Plus they need to be in the clinic, not see a powerpoint.

 

[Schland]

There's a DO program at the school I went to. A group from the class 2 years ahead of me did a capstone where they pretty much interviewed the DO students with what they think PTs do and then later informed them of our education. They found that most of the students saw us a massage therapists except for those who have personally been to PT or had family who had PT. Later that year 2 DO students came to our class to lecture us on how they are pretty much the same thing as an MD (and no I don't want any more discussion on that on this particular form, I know there is enough of that) and then asked us about our education. They were surprised what they heard and said we should educate the DO students. -.- Yeah I'm sure they were from a different class but it was still annoying to hear.

I know with my school (and I'm sure most if not all others) had a HUGE focus on when to refer out patients who were not PT appropriate.

Unfortunately it seems most other health care providers (and the public) have no idea what PTs learn and what is fully in the scope of practice. Perhaps it is our fault for not advocating enough but I truly hope that will begin to change with time.

 

[fozzy40]

May be so. I would bet though that if you were blinded to the provider type in these scenarios it would expose the bias. If the exact same things happen with a physician at the wheel it's ok or more ok than if not.

Also, how often do you see mismanagement of patients among your colleagues? If not often then there's an issue of giving clique passes. If often then there's an issue of double standardization.

And how is it ok for people to get elective plastic surgeries? I had a patient who almost had to have her whole leg ampuated after elective cosmetic plastic surgery. How about overuse of medication, surgery, procedure, and testing by physicians? What do you think is more dangerous? What we know about physician practice patterns or what we can extrapolate from anecdotes about non physicians?

Less likely for those mistakes to happen if a physician because they have been trained to look for those warning signs. I'm not going to talk about elective plastic surgeries. Kind off topic.

With respect to the mismanagement, it so clear they had no idea what they were doing. You deliver your baby at home and the baby doesn't cry should lead you to think something is wrong...you don't assume it's a calm birth because it was at home and then watching the baby die over the next 48 hours. But yes Fiveoboy11...I'm sure it was physician bias spinning the story.

 

[fozzy40]

@Schland The "massage" comments unfortunately are a public perception problem not a physician specific problem, as you stated. I agree that there needs to be more education from both sides.