RFP - Get the Picture?

Here's an example of an RFP relationship that not only doesn't serve patients, but clearly serves the financial and control needs of the physician portion of the "partnership"  (and I use this term loosely).

Physiatry and Physical Therapy Facility in Jersey

One of the primary arguments of those who support RFP (referral for profit) initiatives is that a closeness breeds communication and understanding. Perhaps supports could tell me whether this quote could be any clearer regarding what is really going on in these facilities:

"Doctors, Liss noted, diagnose and are schooled in the efficacy of medications and therapies. In other words, according to Liss, doctors know "what can be accomplished by physical therapy."

"Thus, a patient who arrives at PM&R suffering from a spinal, skeletal or muscular ailment enters the center through the waiting room, walks a short distance to a doctor's office, gets diagnosed, and then crosses the hall to a therapist's office to begin devising a treatment plan."

You've got to love the tangible monetary benefits of being the middleman. When high quality evidence exists regarding the efficacy of physical therapy for a wide variety of ailments, when evidence clearly shows patients are very infrequently offered these options, when evidence shows the superior diagnostic and treatment skills of therapists, and when therapists still engage in these relationships ceding control and management to others, we know we still have serious problems with professionalism in our own backyard.

Any supporter of RFP want to step up and explain how this helps either the patients or our profession?

Comments

[Selena Horner]

I'm pretty sure that the physiatrist that recruited me for employment in a referral for profit situation did his residency at New York-Presbyterian Hospital. He talked very highly of the physical therapists within that system. A definite team approach occurred back in the 80's and it was quite collaborative in nature. From a clinical perspective he liked the model that was used in that system for patient care - the efficiency, the timeliness and the communication via team meetings. His goal was to have the same type of model occur in a RFP situation.

As I've said before, with the RFP situations, it all depends on the specifics of the day to day operations and the policies in place. From only a financial perspective, all RFP situations are horrible because they take the opportunity for revenue away from physical therapists not in a RFP situation.

[Jason Silvernail]

Care to address the "professionalism" aspect of RFP relationships and how that might differ based on the "day to day operations"?

[Ken Mailly, PT]

If PTs are to have any hope whatsoever of acheiving professional status (notice I say "if"), then we must take ownership of our professional services. Relationships between professionals are one thing, "ownership" of one profession by another, is an entirely different matter. The term POPTS is, on it's face, absurd.

Physical Therapy is either a professional service exclusively controlled & owned by the professional, or it is a commodity owned by anyone. There is no middleground in this battle.

Will ALL PTs ever fully accept this? Probably not, but they certainly can be forced to do so, which is becoming increasingly likely.

[Sean]

... In this corner, Selena, the champion for RFP not being inherently unethical. And in the other corner, everyone who sees PT as a career, not just a job.
We've had the RFP, unethical discussion many times. I've heard the same argument from every former RFP practicianer I've interviewed, "oh working so closely with the doctors is so great". Many of us work that closely with a number of docs. The only difference between us and RFP'apists is that we didn't sell out all our colleagues to get that relationship THE EASY WAY.
Ken, and the originator of this post hit the nail on the head.
Selena, your tired argument of where the money goes has been rehashed time and again. The bottom line is that RFP is a conflict of interest.

[Selena Horner]

Sean, I have actually met a few therapists who are employed in RFP situations. They are therapists that are not recent graduates and through discussions do have what appear to be good skills.

I definitely did not allow the surgeons who employed me to tell me professionally what I needed to do with any patient. I did not practice unethically - my documentation met all state, federal and third party standards; I did not fall into the HUMmer category; I utilized standardized outcome measures to substantiate my clinical decisions; I refused to allow aids or techs to provide any aspect of treatment to patients that were under my license. In other words, I practiced the same way that I did when I was employed by a physical therapist in a private practice... when I was employed with a physical therapist who had contracts to provide rehabilitation services to a home health agency... when I was employed in a hospital outpatient setting... and when I was employed by a foreign trained physical therapist owner.

When I was employed in a RFP situation, did my professional choice hurt local physical therapy clinics financially? Yes. When I was in a RFP situation, did the patients that I was responsible receive care provided by inappropriately trained staff, achieve poorer than average outcomes, utilize services at a higher rate or receive a high amount of passive modalities? No. Did I personally have an "easy" relationship with the physician owners? No. That relationship was one of the most conflicting/heated and direct relationships I've had to experience.

When I was employed in an outpatient hospital setting in which the location was in the same building as the hospital managed family practice, how is that situation any different? The profits went into the same organization... the referrals were tracked internally... recommendations for physical therapy sites were ONLY for the hospital owned outpatient clinics.... expectations for the amount of referrals from the family practice physicians were to be met (although it was a hush, hush kind of thing). I had lunch with the physicians... I waited outside of the physician's treatment rooms to communicate with a physician... and sure, I'd snag the physicians occasionally to come to my part of the building to assess a patient AND I'd get paged to come to their area to consult with them on a patient they had. I'd work acute patients into my schedule same day referral and they'd work patients into their schedule same day consult if I was definitely concerned about something. In this situation, did my professional choice to be employed in a hospital outpatient satellite facility hurt local physical therapy clinics financially? Yes. When I was employed in a outpatient hospital satellite situation, did the patients in which I was legally responsible for care receive care provided by inappropriately trained staff, achieve poorer than average outcomes, utilize services at a higher rate or receive a high amount of passive modalities? No. Did I personally have an "easy" relationship with the family practice physicians? Yes.

Apparently, I've sold out to all of you twice in my career. By the choices I've made based on the type of employer of the setting in which I was employed, I am to be considered unethical, unprofessional AND I'm just doing a job. Hmmm...

[Sean]

"expectations for the amount of referrals from the family practice physicians were to be met (although it was a hush, hush kind of thing)."
So once again an administrator is deciding who needs to be seen and how often. This is where the PT needs to speak up. This is why PT's need to be the directors, VP's, owners. It's not about who gets the $ in the end, it's about practicing ethically. Only we PT's are qualified to make sure this is accomplished. Selena, you just gave 2 perfect examples as to why.
Allowing the situations you describe to go on, based on your stated level of understanding, is selling us out. It's not just about putting a financial squeeze on ethical providers, it's that you did so by practicing unethically, in the exclusive best interest of
the profiteer.

[Selena Horner]

Sean, how is it that you are able to reach the decision that I practiced in the exclusive best interest of the profiteer?

Any physical therapist employed by anyone IS going to generate revenue for whoever owns the entity in which one is employed. In fact, I currently own my own clinic and every day I make clinical decisions that could be considered a conflict of interest because in every treatment session I profit. In your approach to arguing the topic, apparently, even now I am practicing both unethically and unprofessionally and in the exclusive, best interest of the profiteer (me).

[John Ware]

I'd like to expand on Selena's point about blaming the "profiteer." The current health care market-I hate to break to all of you-is, with a few notable exceptions, viewed and valued more as a commodity than a professional service. The continual emphasis on cost-cutting in order to make a decent profit is becoming increasingly difficult. In the case of Medicare, cost-cutting efforts are not working and it is going broke. Remember the lofty goals of managed care? Turns out, again, it's just another cost-cutting, zero sum-based approach to providing health care services.

The fact is, Sean, we're all selling ourselves short because we're involved in a system that largely does not reward outcomes based on results. As long as that is the predominant way in which health care consumers are forced to choose treatment for whatever ails them, all these arguments about RFP, regardless of who the "P" is, boil down to who is best able to slice the fat off the beef. I wish we were more concerned about breeding a bigger, leaner cow.
John

[Jason Silvernail]

John-
It's not about hating profit. It's not about "fixing" Medicare. It's about ownership of professional services.
Just that simple.

[sean]

John,
I am concerned with breeding a bigger, leaner, cow, and I have learned from Seth Grodin that it is properly termed a "Purple Cow".
I have always practiced in this manner, and now I am attempting to bring this message to all consumers, payors, and referral sources (not just doctors).
I have referred people to other practices because I know they are more qualified. I have discharged patients when they are not candidates for PT, even though it effected my bottom line. In an RFP situation, if you do this, you are slitting your own throat.
Selena stated how she worked in a place where referrals were tracked to make sure all patients were sent to her facility... this is a conflict of interest and should have been reported to the state (selling us out by not doing so). She admits that this practice of collusion hurt her competitors.
John your point is a good one, but does not address Selena's questionable behavior. I am not an expert on legal matters, but based on my knowledge of the collusion case, in MLB, in the 80's, she knowingly engaged in an illegal practice of collusion.
i recently turned down an FCE which could have earned my company a nice chunk of $. However, I spoke with the physician and told him that while I can provide an evidence-based, reliable test, it could not produce the hard numbers for which he was searching. He and I agreed he should send it to one of my competitors.
In addition, in my state (TX)the quality of services is highly valued in the W/C system. Many of the local, self-insured companies acknowledge our services are superior and preferred to those of RFP settings. All it took was giving the nurse case mgrs access to first person observation of the services being performed. In addition, they are thrilled with the fact that the we and the physicians include them in our treatment planning/discussions.
the private insurers haven't figured this out yet. Few of them do site surveys or visit while their patients are present. Instead, many of them choose to sign national contracts, below cost, with companies already in legal trouble (guess who).
Last year I refused to sign one of these ageements, again this year I refused a 30% increase over the original rates for the same reason. Guess what happened? I got the rates I wanted and needed to treat their patients with the highest quality of care. I don't think that therapists in general are selling themselves short, they're just afraid to negotiate better rates and unwilling to wait out the negotiation process. This is a lesson I learned from my amazing wife.
There are many things we CAN do to make the pendulum swing in the opposite direction. we just need to develope the negotiating power and balls (can't think of a better, more powerful word, feel free to edit if you can) to do so.

P.S. thanks to Christy at Preferred Therapy Providers too!

[Selena Horner]

Sean, you are actually being quite harsh toward me. Have you ever reported anything to the state? Have you ever reported issues in any facility within the facility itself - in particular the compliance officers? Whenever there is a conflict of interest and that conflict is reported, there has to be proof. In all honesty, there is no proof that referrals are tracked for a specfic anticipated referral rate. There are vague expectations.... there are discussions with the family practice physicians about the referral numbers and with the PT staff about the numbers. The PT director (physical therapist) tracks the referral stats and so does the PT marketing department. It would be nice to hear the view from other therapists employed in a hospital outpatient setting in which the hospital has satellite locations AND family practice physicians all within their hospital system. I'm sure that what I saw/experienced is not unusual.

One has to pick battles - generally one works within their own organization first to attempt change and then as a last resort reports to the state. There is no easy proof that what I stated occurred - nothing is in writing for all to see and it isn't shared with the PT staff. In other words, there is no written proof that would stand up to any scrutiny with any type of investigation by agency or even with the law. In fact, I'm sure that all the my supervisors in the system I had been employed would disagree with my statements, deny my statements and probably go to lengths to discredit my statements. The single piece of evidence that could be viewed as proof would be the piece of paper that the family practice physicians would hand to a patient in need of physical therapy services. That piece of paper only had clinics owned and operated by the hospital. From the perspective of the hospital, that was okay because ALL physicians in the area were provided with referral pads that looked just like the one their own family practice physicians used. Granted, what they were forgetting is the simple fact that patients were not told they could go anywhere and patients were expected to stay in the system. If the patient was employed in the system and had the hospital's own health insurance plan, I can guarantee the patient stayed in the system because $2,500 deductibles ensured employees with that plan stayed in the system for rehab services.

Sean, if I were to have reported the situation to the state, the state would not open a case to investigate for lack of proof. There is and was no proof.

Again, though, Sean... you are pointing the finger at me and using me as a scapegoat of sorts and really not addressing the issue of referral for profit. How exactly have you come to the conclusion that I practiced in the best interest of whomever was to profit? And, now that I own my own company... how does that alter your opinion when now I supposedly practice in my own best interest? I mean, now I don't have physicians making money based on referrals... I don't have family physicians within the hospital system keeping patients in the system... but I do have complete control to over treat and overutilize and increase my profit margin. Definitely more lucrative for me personally and financially.... hmmm.

[sean]

Selena,
Yes I have reported 2 unlicensed facilities to the state for advertising PT without a facility license (required in TX).
Your comment that your experience is "not unusual" supports my point and doesn't make it any less wrong/illegal.
I come to the conclusion that you practiced in the best interest of the profiteer because you said so in your posts.
Great, you own your own company. I'm sure all private-practice PT's are breathing easier now that they know that a sell-out is within their ranks. Just because you have your own company doesn't mean you're not employing the same tricks and illegal methods you learned in your previous practice employment. Only you truly know if you're not paying kick-backs and practicing unethically - the same goes for me and everyone in the profession.
Based on your self-stated participation in, and defense of all unethical, anti-competetive, and collusional practices, what are we in the forum supposed to believe?

[Selena Horner]

Okay, Sean. You reported something that is black and white, easily proven with minimal financial burden to prove OR investigate. That's good and you should be applauded for taking a stance to reduce illegal activity. I know how much energy and courage it takes to stand up for what is right.

I'm actually not sure that it is wrong for hospitals with outpatient physical therapy satellites to provide referral pads to all the physicians in the area, including their own family practice physicians. The pads have the hospital system name in huge letters on top and the rest of the page appears like most referral pads independent physical therapists would provide to physicians. The back of the page has all the hospital satellite locations and phone numbers. The part that can't be proven is whether the family practice physician within the system that provided the physical therapy referral for physical therapy services actually states that services can be obtained anywhere but here is a list of the BLANK hospital system locations. So, now explain to me exactly how I should have reported that this kind of thing occurs WITH substantial evidence without a reasonable amount of doubt? 1) I didn't refer patients 2) I wasn't in the room with the physicians to know what was communicated to patients. Now, I can assume and I'm sure I assume correctly. Our legal system is not built on assumptions though. I hope you can appreciate that fact.

Second, it isn't illegal to track referrals. Most successful business owners are going to track referrals to know what physicians are referring, at what rates and to notice change in referral patterns which can then potentially open up communication. Now, my role as a physical therapist was to treat the patient - staff physical therapists were not involved in actually tackling the situation when referral rates were low. That role was handled by the marketing department. I know discussions occurred and I know staff therapists were questioned as to why rates might be low.... I can assume the type of discussions that occurred with the family practice physicians, but again, assuming isn't proof.

Again, you choose to ignore my questions to you. Instead you'd prefer to attack me personally and assume that I full heartedly support unethical situations.

How exactly did I practice in the best interest of the profiteer?

You also proved my exact point. Quote: "Just because you have your own company doesn't mean you're not employing the same tricks and illegal methods you learned in your previous practice employment." Remove the word 'you' and substitute 'physical therapist owners.'

The only way to truly know if a company is unethical, anti-competitive and collisional is only by analyzing records, billings, staff statistics, schedules, corporation papers and day to day operations. Before any investigation would even occur, there would need to be definitive proof that illegal procedures were occurring at a great enough frequency/rate such that the cost of investigating and proving was outweighed by the fines and penalties. AND there would also have to be proof that those involved were intentionally practicing fraudulently. Some things are not so easy to prove without having a definite position within the company to be privy to administrative meetings, emails and business statistics.

[John Ware]

This argument between Sean and Selena is a prime example of the point I was making about the current state of our health care system. Sean keeps coming back to anti-competitiveness, collusion and unethical referral-for-profit situations. However, how can such a situation exist when there is a fundamental lack of competition based on outcomes throughout health care- not just P.T.? I applaud Sean's committment to quality from his little corner of Texas, but I think his committment is exceptional, unfortunately.

I think that Selena's point that any situation, regardless of who profits, has the potential for unethical abuse is undeniably true and accurate, particularly in an uncompetitive atmosphere such as our health care system. I have worked in PT-owned situations where the use of evidence to guide treatment was subordinated to merely submitting a charge that would return a payment. I do not think this is unusual (the recent Medicare exceptions process is a prime example of another hoop-jumping maneuver for those who are motivated enough to squeeze a few more dollars out of the Federal government. Many will "game" this PROCESS just to get more visits whether needed or not.)

However, I also agree with Jason, that this issue does come down to an issue of professional ownership. I, too, become gutterally annoyed at POPTS in particular. I don't worry as much about the hospital outpt departments because they generally suck, and the good docs know it. I've moderated my view a bit because I now see the bigger picture, which is the anti-competitive nature of health care in general. Until our health care system moves in a direction that is based on results, not on merely compliance with rules and vague and convoluted process standards, I'm afraid we're going to have to continue to put up with the quasi-competition from the hospitals and ortho practices.
John

[sean]

selena,
I have answered all of your questions and supported my statements based on your own comments. You can propose any hypothetical situations you want, however your stated practices are the best support to my arguments.
I am not sure what a "collisional" practice is... but if it has questionalble ethics, I am going to infer that you've practiced it. Like I said, I'm not a lawyer, but based on what you have stated you and your co-workers engaged in practices which were unethical and not within the boundries of our practice acts. I'm glad you wrote that last paragraph because it, once again, reinforces my point that you have not practiced in a way that any ethical PT would want to be portrayed. Your legal speak is the party line of all ethically-challenged practicianers.
John, I am ignorant as to where you practice. My little(?) corner of Texas is Houston. However based on the 3 locations in which I have practiced since 1996, the docs are incentivised to send patients to the hospital systems' clinics with low rent, favorable reimbursement, access to to operating rooms, and inner-system referrals.
Let us take for example how a certain physician group, supported by a large hospital system forced out a national PT provider who could not make money practicing ethically in the evironment provided for them.
They enraged the doctors with their aids treating the patients. Enter another company which took over these same clinics. This company, which had an exemplary history of prviding outstanding patient care was forced to employ at least 3 people who only did maketing and channeling of patients to the physician group. After 2 years of this 1-way financial arrangement, the PT clinics were bleeding money, and sold out to a large hospital system.
John's statements about the potiential for unethical behavior is true for any business. the difference is that we are held to a higher standard in the medical profession. Just because "everyone does it" as John and Selena imply and admit, respectively, does not mean it is correct or commonplace.
Based on our healthcare system's size and inability to react to improvements in a timely manner, I propose that EBP is ahead of its time in PT. The answer to the problem is an ingenius marketing plan which targets the payors, physicians, and public. Unfrotunately with all the $ we spend on PACS, fighting off the pretenders and RFP profiteers, we have little left for such proactive measures.

[Selena Horner]

Sean, I believe you wear blinders. I'm definitely not ethically-challenged. My stated practices do not in any way, shape or form indicate that I practice unethically. You are hung up on my choice of employer. It is only based on my choice of employer that you have come to the conclusion that I am unethical. And your perspective is only based on what you have experienced, seen or heard in Houston. It is very shallow and presumptuous of you to just jump to conclusions without asking detailed questions. Referral for profit situations are legal, referral for profit situations do have the propensity to generate profit in some situations that technically services really aren't warranted (but because of the conflict of interest services are provided), all of that is true. It is completely wrong to assume that profits are being generated unethically. One cannot assume this until one analyzes the details.

My last paragraph is pretty much the way it really is. That is the system in which we work. I know my last paragraph is absolutely correct. A few years ago, I spoke with a couple of attorneys who are definitely reputable (a line had been crossed and illegal activities were occurring), had my name passed to the FBI and then was called to a meeting with 4 FBI agents. 8 months later the conclusion was that the situation was commonplace. Not much anyone can do when even the judicial system is broken.

[Jason Silvernail]

The judicial system notwithstanding, ownership of professional practice is really quite simple.
If you work for your referral source, you're practicing unethically.
It really is that simple.

[Selena Horner]

It depends, Jason. It is dependent upon the details. To assume a person is unethical based on choice of employment is very wrong.

[John Ware]

Jason,
Can we say that physical therapy is a true profession? Here in Indiana, as in many other states, a PT cannot open a practice and call it a "professional corporation" (PC) as that designation is reserved for doctors and lawyers (I've worked in 5 states, and only in Missouri were PTs allowed to sue "PC". Perception is reality, is it not?

Do even most of our colleagues view themselves as professionals? Last I saw, only about 1/2 of licenced PTs are even members of APTA. These "professionals" often site the $400-500/year dues as too large a financial committment.

You work in very unique system that does not require a physician's referral for services, so I'm not sure you have a firm grasp on the situations of many civilian PTs practicing today. I know that the opportunities in PT-owned practices cannot only be hard to find, but often PT-owned practices cannot afford to pay the salaries and/or benefits paid by the POPTS and hospitals. Also, many situation are such that the female spouse is a PT, and the husband works as well, and the woman's salary is a secondary source of part-time income and/or insurance benefits for the family. In those common situations, the PT does not have much of a choice who they're going to work for.

My wife, a PT, is going to work for a home health agency this fall when my kids start back to school. It's a hospital-owned agency, as are almost all the home health agencies in our town. Is she unethical to go to work for this group that is affiliated with the hospital? Should my wife just not work in home health care in Fort Wayne since it is inherently unethical?

John

[Jason Silvernail]

Hi John. My work situation is not relevant to the debate - my being in the military is a choice much the same way as other employment choices there are pluses and minuses.

If you derive your income from the person who refers to you and they benefit financially from those referrals, then that's Referral for Profit, and I think that's unethical. Our professional association agrees with me.

If someone works for a hospital based system where the referring providers do not see more money based on their referral patterns, then I think you'd be hard -pressed to call that RFP. It certainly may be a bad business practice in other ways - specifically anti-competitive ways. Anyone have any ideas about how to delineate the difference? I'm not sure myself. I personally would not consider that an RFP/unethical situation - but maybe I'm just fooling myself here on this issue as it may be the same issue in a different form, and I'm not being sophisticated enough in my interpretation.

Certainly I think there ought to be an ongoing discussion of the kinds of professional relationships allowed in any profession, and we aren't doing nearly enough of that as a group in PT, I think.

Sure the PT has a choice of who they work for, John. If their personal financial situation is such that they have to compromise their ethics to put food on the table, then I think that's a different conversation, and I doubt many people would give them a hard time about that choice. But still, many of us (and I don't exclude myself on this - I'm not riding a high horse) make decisions that are questionable when it comes to RFP relationships, and I think we ought to call it what it is and hold them accountable, even if that involves just professional pressure such as we are seeing here on this blog. Situations such as are the topic of this thread are, I think we can agree, obvious.

Regarding PT as a profession - not all of us consider it so, but that opinion and our professional membership rates are not all that different from those of other professions (law, medicine, accounting, etc) the last time I looked. Am I off-base here?

Ultimately, we need to move our profession forward and address these referral and professional relationship issues. We may have to start by addressing the clear-cut cases first, and I'd be fine with that sort of gradual approach.

But some relationships (such as the one Sean and Selena are talking about) are quite obviously RFP situations, and answers of "it depends" and "you're being quite harsh" don't change that basic fact.

[Selena Horner]

Jason, it cannot be assumed that every referral for profit situation is unethical; it does depend on a variety of details. If a patient really and truly needed physical therapy services and the patient was advised to receive physical therapy services and the patient happened to choose a clinic that was referral for profit (even after full disclosure) and the patient did receive appropriate services, all factors considered - explain to me again how that is unethical? The person was going to have services anyway, the services were appropriate. If the physician has 100% physical therapy on the brain and envisions dollars in his/her head and refers every patient regardless of the patient's situation, that is definitely unethical. Every referral for profit has a propensity to be unethical by human nature alone, but that doesn't mean that every referral for profit is unethical.

The hang up is that the referring person's company made the profit. Again, it comes down to money with this argument - it always does. The physician gained the profit and took away potential customers from the independent practice practitioners. But the weird thing is that one wants to assume it was done unethically - that the opportunity to make a profit off the decision clouded the physician's decision-making process. (There is that possibility, yes, but one can't assume that happens.) Prior to the the physician setting up an in-house clinic, the patients would have had to have gone somewhere. Hopefully the independent therapists had been providing care to appropriate patients that really did require services. If the physician maintained the same frequency of referral rates but a larger bulk of patients chose (after full disclosure) to receive services in-house, the situation still isn't an unethical situation - an unfortunate situation for independent therapists, but not necessarily unethical.

Sure, it's an unfair advantage that physicians have been allowed. Life isn't fair. Who said life would be fair?

I do know, sitting at this end, it is very unreasonable how Sean and you want to decide to personally attack me and attempt to drag me and my reputation through the mud based on where I have chosen to be employed. Neither of you know any specific details about how I made clinical decisions and both of you choose to assume the worst of my character. It's almost like you both have a prejudice or something based on the choice of employment. The prejudice blinders never solve problems. You want to call it "professional pressure." Think again, Jason.

Right now, the very truth of the matter is that no matter where I choose to be employed in the public sector, some company or some person is going to profit from the services I provide. Getting the patient in the door is the first step in the opportunity to generate profit, yes.... but inherently, it is the claims generated on each patient that truly increases the likelihood of profit. The specifics of how those claims were generated for each date of service and the clinical decisions made in choosing the CPT codes billed is where one can determine if something unethical occurred.

The real solution to the problem of referral for profit is to change laws and make referral for profit situations illegal. And, yes... I do believe that most outpatient hospital physical therapy departments/satellites could be viewed as referral for profit - if a physician within the system only suggests a hospital based site the money for that recommendation stays within the system. It is all about money, you know? Once referral for profit situations are illegal, the independent physical therapists acquire the business again. I believe that is the whole crux of the matter.

In the meantime, instead of attacking those in referral for profit situations and attacking them for their choices, it would be much wiser to put together information that highlights questionable clinical decisions. What are some red flags that indicate a situation that might be more than just unethical, but actually illegal? What can the therapist do in that situation? What evidence will be needed to prove the illegal activity? How much evidence is enough evidence? What type of questions should a physical therapist ask prior to choosing a referral for profit situation? What are some potential responses from those questions and what do those responses really mean? What organizations will accept reports of potential illegal activity? How does the therapist protect him/herself in the event the therapist decides to report the situation? What are the ramifications of reporting any incident? The therapists employed in those situations may very well be the ones you want assisting anyone with a goal of having referral for profit situations illegal because those therapists will be the ones that might be privy to the information needed to put a stop to referral for profit situations. Choosing to attack them definitely isn't the way to change the situation though. In hindsight, I sometimes wish that a few years back I had someone within my own profession to really talk to who could have given me a bit of extra insight - without judging - so that the situation I observed had a different ending.

[Eric Robertson]

I am almost fearful to stick my toes into this boiling pot of water, but I would like to point out one thing. Selena wrote, "it cannot be assumed that every referral for profit situation is unethical." I disagree. When it comes to healthcare, we must hold ourselves to a higher standard. If simply a POTENTIAL for gain exists, the situation is unethical. Therefore, it does not depend on the details, it should be avoided. Those working in those situations can rapidly find themselves in hot water, as was the case for people in my state of SC when this situation gained legal legs.

Selena, I appreciate your tenacity in this argument and there are some good points you raise, especially in your last comment.

Jason, I admire your committment to your obviously strong opinions and devotion to the concept of professional autonomy.

Let me raise this question (which I plan to deal with more through a pending blog post): Why are POPTS such as the one in the original post good for consumers? Ethics aside, let's discuss the customer service aspect of the issue.

[sean]

Eric,
Your fears are about to be realized. Selena is going to respond to you stating that she is in private practice and could decide to see a patient for more visits than necessary. She will say that would be an unethical way to profit. She would be correct. However she will refuse to admit that the RFP setting is any different than where she works now with respect to potential for over-utilization. And as always we will try to convince her with posts that she is wrong. The argument will go in circles and we'll never get anywhere.
We love you SC. The whole country needs to make it illegal for PT's to work for docs. It will certainly cut down on the prevalence of PT apologists for RFP.
The best way to combat this is through our educational programs teaching the unethical nature of that setting and not allowing clinical affiliations to be completed in such settings.
I have a question which at this time you may not know the answer Eric: For SC schools' out of state clinicals, do they allow them to be done in RFP?

[Jason Silvernail]

Eric-

Come on in, the water's fine.
:)

Selena-
I haven't attacked anyone. I've simply made statements about professional autonomy and practice arrangements that are in accordance with the position of our professional association.
If you have decided that that position conflicts with your stated opinions about the ethical flexibility of RFP arrangements - so be it. If the shoe fits, etc.

I think, however, that Eric is right, and we probably should focus on the effect of this sort of thing on the consumer.
We have data from CMS showing RFP situations are billing for care which does not meet the standard for physical therapy, for example. Anyone care to recap some of that data and show why this is an issue that is actionable - meaning it's detrimental impact on consumers?

[Selena Horner]

Ah... the data. The data CMS data doesn't tell us anything, Jason. You see, it gets complicated. Physician owned practices have 2 options when submitting claims. Option #1 - "incident to" billing. In this situation the claim is tagged definitely to a physician. Option #2 - physical therapists employed in a physician owned clinic billing out using the PT's PIN or NPI with reassignment of benefits to the employer. In this situation the claim is tagged definitely to a physical therapist. The error is, in the data that you are speaking, physical therapists employed by physicians have their data dumped into the same category as independent physical therapists. In other words the queries performed on the claim data CMS holds were not clean enough queries to actually answer any type of questions regarding utilization or types of treatments billed. You will get clean data on "incident to" billing, clean data on hospital/facility billings but the independent physical therapist category is not what it truly appears. There needs to be another category - physical therapists employed in a referral for profit situation with claims generated with a PT PIN or NPI. I would think that once that type of query occurs with one more category added, then the accurate information can be analyzed.

[Eric Robertson]

I contacted a faculty member at the Medical University of SC and asked them your question about clinical education. Here is their response: "Even before the ruling in SC, the PT program at MUSC attempted to have clinical experiences solely at facilities that were in line with the APTA code of ethics and other adopted position statements. This would include PT owned facilities that were judged not to be in compliance with these policies and positions. To my knowledge, it has been this way for a long time, not just a recent happening. Basically, every attempt is made to be compliant with the APTA code of ethics and other position statements that have been endorsed over the past."

That's some good stuff!

[John Ware]

Sean,
I think you're naive to think that over-utilization isn't widespread in PT-owned situations as well as POPTS. Re-imbursement pressures are monumental and growing (due to increased cost-cutting efforts of 3rd party payers). Look at this month's (August) PT Journal for the survey on use of US by OCS's (no less) in outpatient settings. Most of the respondents reported using US for a variety of conditions for which scant, if any, evidence to support its use exists. Why do even the supposed "experts" in our field continue to use a modality for which there is little evidence to support its use for most conditions we see in the clinic? Now I suppose it's possible that the respondents who over-utilize US work only in RFP situations, but I doubt it, as that has not been my experience. I have never worked for a POPTS or a hospital. I have always worked for either myself or a PT. I have worked in 6 states. The use of US and other poorly supported modalities and interventions is widespread in PT-ownership situations, in my experience. The reason: because we can- and we'll get paid for it even if it doesn't get results. Some "entrepreneurial" PTs figured this out a long time ago, and unfortunately, it's become habit for many. In this non-competitive environment tradition/habit trumps results/outcomes. It's that simple.

So why doesn't everybody leave Selena alone. You're barking up the wrong tree.
John

P.S. Eric, I wonder how MUSC would have responded to this question: "Do you attempt to place your students in clinics that utilize best evidence, track outcomes and can demonstrate results of treatment?"

[Jason Silvernail]

John-
How does your point about US utilization address the ethical breach of RFP? Previously you have been a staunch supporter of the anti-RFP position, but you appear to have sprung to Selena's defense by attempting to say the problem isn't ownership of service, but of over-utilization. Worse yet, by saying we are 'barking up the wrong tree', you appear to imply that the problem is really evidence and not professional ownership. Huh? What's changed in the interim?

Eric-
great stuff.

[sean]

John,
While the over-utilization of US is addressed better in the "time warp" thread, these "entrepreneurial PT's" are actually saving patients and insurance companies money. When ultrasound pays <50% as much as 97110, these gals/guys are actually reducing their profits.
Your thought that I am "naive" is worth discussing. While the private practice settings I have worked in have been very ethical, obviously you have encountered a very different environment. Which begs the question, why not turn them in? I mean, since I am so naive, and you are aware of this going on in so many practices, why aren't you known as the Grim Reaper of unethical PT practices?
If you are not going to take action as required in the code of ethics, aren't you equally as unethical.

Eric,
So does that mean that they interpret Principal 9 in a fashion that allows or disallows RFP clinicals. If all our state _PTA chapters interpreted it as many of us do, RFP would become extinct.

[John Ware]

Jason,
I'm glad you asked. I'm reading an excellent book by Porter and Teisburg (Harvard and Darden business school profs)"Redefining Health Care." Don't get me wrong- I hate POPTS. But now I know WHY I hate POPTS. It's not for the reason I thought, which was the whole RFP thing, which sounds good in theory and you can make all the arguments about ethics and collusion- basically all the arguments Sean has made. The reason I hate POPTS is because the damn docs have the dough to run a leaner business (shave the fat)than I can. They have the money to hire MBAs to run their office and pay CPAs and attorneys to audit their books and policies/procedures. And what's worse is the fact that POPTS are a constant nagging reminder to me that results-quality-is of such little value in our health care system. If results did matter, POPTS wouldn't survive because I'm convinced that the best PTs do not work for doctors.

But they do survive, and they thrive. Do they over-utilize (i.e. gage in unethical conduct)? Sure they do. But, as the US example indicates, so do the OCS's among us when it comes to using a machine that shouldn't exist in any PT clinic unless you have a niche practice in fracture healing. Now, if you want to make the argument, "Well, they do it a lot more," then we can go round and round on that, too.

Sure, RFP is unfair, it's wrong, it's full of conflict of interest. The doctors themselves don't give a rats rear about all that. They hire the attorneys and accountants to ensure that their legal, and they sleep fine at night. Do the PTs who work for them care? I think they care about making a living doing what they were educated to do, and getting well-compensated for it. Some of them care a little more, like Selena, who took a stand when she saw them cross a line. I wonder how many PTs who work in PT-owned practices have stood up to their bosses when they thought they were straying out of ethical bounds. I wonder how many PTs in PT-owned practices use US for "soft tissue healing" and then blithely submit their charges at the end of the day.

Let's fight the right battle.
John

[Jason Silvernail]

What battle would that be, John?

I thought getting our members to adhere to our code of ethics regarding RFP situations was a battle worth fighting.
Perhaps you feel I'm wrong on this point?

[Christian]

This is an interesting discussion. My question is, what is the primary issue? Is it ethics, prividing high quality care to patients, or having fare competition for patients? No matter how you look at it, physician owned practices/PT's are always in a position to have questionable ethical delimas concerning patient care. If a person is concerned about providing care with the highest of ethical standards, then this RFP situation is not appropriate. However, that does not imply that all other PT employment/practice situations are any more ethical. I have been employeed by a private practice in which I was told I needed to average 16 visits per patient. As a PT, I had never encountered this practice and believed it only existed in Chiropractic practices. (Prior to this position, I worked for a very large nonprofit co. in an outpatient clinic where I was required to average 4 "procedures" per patient visit.) When I questioned the 16 visit standard I was informed that this was a "national average" for PT care, that is was "good for business", that "we work hard for our patients and with declining reimbursments we need to keep them", and "there is always something more we can do for them". In retrospect, it does not suprise me to find this attitude in a Post-modern culture where reletivism meens that whatever is good for me(business) must be right. Needless to say I left this employer as quickly as possible.
There are some serious ethical issues that we as PT's need to address. No PT should allow themselves to be subjuct to outside influences that dictate how a patient is cared for. Ethical issues could present themselves in a variety of ways. RFP is just one.

[Jason Silvernail]

No one is making an argument that RFP is the sum total of ethical dilemmas faced in any given day.

Some of us are saying that it's an important issue in many ways and it's a part of our code of ethics that we should be serious about.

Before talking to Selena and John, I thought that was a majority viewpoint. Perhaps I miscalculated.

[Selena Horner]

There are 2 avenues where unethical activity can occur in a RFP situation.

1 would strictly be with the physician - who the physician refers and the clinical rationale or lack there of for the referral.

The other is with the physical therapist - determining if the patient is really a candidate for services, determining the interventions, and determining how the interventions will be delivered.

A physical therapist cannot control the decisions of the physician, but the physical therapist can control his/her own decisions. IF there are some "rules" in place, like Christian mentions above, no matter the employer, it would be very difficult to practice ethically. The ethical dilemmas can and do occur in any situation without regard to employment situation. A RFP situation really isn't any different than other employment situation. What Christian states is common in this area also - various expectations imposed on therapists with a whole goal of generating more revenue.

[Jason Silvernail]

Selena states: "A RFP situation really isn't any different than other employment situation."

Needless to say, this summarizes the post and comments quite well, and explains the issues in a nutshell.

Our professional association does not agree with that position, and neither do I. At the end of the day, we are left with this issue - important enough to take sides on, I think.

[Selena Horner]

Thanks for taking that statement out of context, Jason.

[Carina Lowry]

This has been a very interesting argument. I have to say a few things. First yes, POPTS are inherently unethical and a conflict of interest. They do not promote autonomy. They do not promote "wealth within the profession" to quote Peter McMenamin who has written extensively on this subject. Our professional association has taken a stance on this issue and some states have tried to enact some legislation but very few have succeeded. Why do you think this is? Well one reason could be that the lobbies of the AMA are very well funded and legislators listen to doctors no matter how their argument lacks logic or research to back up their statements. The second reason is because not everyone is on board with the professional association and does not view the professional association as representing their interests. I have been in situations where we have acutally had PT's lobby AGAINST the state professional association stance.

Yet the basic argument here is who profits when pt care is dictated. It does not have to be just from the referral sources prompting the pt to go to a certain facility. I have worked in situations like the ones previously described where a certain number of units were required for a specific billing period (ie 4 units per 30 minutes) or where the pt was double booked over another and I was told there was no way to charge for a group code. If I did not charge appropriately, the slip was put back on my desk circled so that I could "remember what else I did with the pt." But wait, this didn't happen at a POPTS...it was in a private practice. Further you don't really know who you work for until you actually work for them. I have discussed billing situations in interviews only to find it vastly different when I went to work for the private practice. I truly believe that ANY time you have billing tied to a bonus structure, there is inherent conflict of interest and a pressure to bill more. It would be interesting to see how many PT's out there have been in similar situations. I venture to guess that this is rampant in private practice.
I also think it would be an interesting study to see how the gross billing differs between a bonus based incentive clinic versus a hospital based clinic and how this compares to pt outcomes, but I imagine this study has already been done.

My other question is this: should we be billing blind--the same regardless of if it's Medicare or private insurance? What is the ethical dilemma in this?

I think we shouldn't throw stones at Selena until we address the unethical practices in our own profession. I have found it's just easier to move on than report this type of behaviour. Maybe this is the wrong approach but then again how difficult is it to prove culture?

Carina

[Jason Silvernail]

Hi Carina.
While I understand most of what you've written here, one line really confuses me. I'll take it in two parts.

"I think we shouldn't throw stones at Selena..."
I'm not throwing stones at anyone in particular, just the concept of RFP. Selena's just the only one on the blog here who thinks this is a defendable practice scenario and who bothers to try to defend it. At least she's sticking to her guns, for what that's worth. Though the tacit support in this matter she is apparently getting from you and John Ware does make me wonder.

"....until we address unethical practices in our own profession."
This is exactly what the RFP issue is - addressing these practices in our own profession.

Selena-
I don't believe that statement I quoted above is at all out of context, I feel that your line of argumentation is essentially that RFP situations aren't inherently more unethical than any other employment arrangement. My professional association and I disagree with that idea. If I've mischaracterized your position, please feel free to correct me.

[Sean]

John,
I asked you if/why you have/haven't turned in all these unethical practices. I'm asking again but this time including Christian and Carina.
Christian and Carina stated that your supervisors encouraged you to charge for more than what was done. Did you inform them of the error they were making? Did you inform the state? If not, aren't you just as unethical as they are?

[Selena Horner]

Sean, I don't believe you understand what anyone is up against to "turn" anything in. First of all, unethical doesn't always = illegal. Second of all, most physical therapists aren't going to have concrete proof.

If it isn't illegal, no one cares.

I have found that the corporate compliance department can be helpful when it comes to issues that appear illegal and unethical. Just because corporate compliance becomes involved does not mean that anything changes. Corporate compliance can write up their interpretation and their recommendations but by no means does that mean that any departmental changes occur. From my experiences, it is a joke... you would think that corporate compliance would re-visit the issues a month or two or even 6 months and then 12 months down the road to ensure change occurred (because the change suggested will definitely reduce the likelihood of fines and penalties from CMS). Now, from experience, a word of caution.... you will forever be treated differently after you choose to communicate to corporate compliance. Your action will NOT be viewed as anything to be congratulated, praised or considered outstanding. Even if you first bring up the issues within your department with someone who has the control to change things and nothing happens and then you contact corporate compliance, things turn sour very quickly. Maybe I should have done all my reporting anonymously.... I don't know, but be prepared for back stabbing and poorer performance evaluations. It isn't the corporate compliance department that causes the grief - it is instead your supervisors and administration - often fellow PTs. They will want you out... out, out, out because you are discussing changes that will cut into profits.

When you file a complaint with the state, just a verbal report isn't going to float. When the state investigates, the state needs something concrete. An investigation won't even occur without any concrete evidence. When an investigator comes to your house, the investigator wants written proof/evidence and wants your story or explanation of the documents. You have to remember, often times physical therapists really aren't going to have anything concrete in writing to supply. Often times, supervisors/administrators won't reply in writing to emails questioning practices. Instead they pick up the phone and call OR hold a private meeting with you. If ethical or illegal issues are brought up, do you think they are on any meeting agendas? No... If you do bring them up in a meeting, there won't even be any meeting minutes that the topic was addressed. For some reason, those types of issues are conveniently forgotten by the responsible party for maintaining meeting minutes. Carina receiving a little piece of paper asking her if she "remembers what else she did with the patient" isn't proof of anything. If anything, something like that reflects that she may have memory deficits. If you don't have anything concrete and in writing (and what John, Christian, Carina and I have experienced won't be in writing in any policy and procedure manual), it just becomes your word against their word. That doesn't work because people lie and in reality, if your supervisors/administrators are threatened, they (often fellow PTs) begin making a case against you that can be used to create the picture that you aren't credible or reliable.

Jason, no matter where a physical therapist is employed where profits can be generated, the physical therapist will always have ethical issues that arise. A RFP situation with physical therapists on staff doesn't have a different flavor or theme of ethical issues - they are the same doggone issues that a PT will experience with ANY employer.

I wholeheartedly agree with Carina, John and Christian.... we have huge ethical issues out there that no one ever wants to address. Oh, the RFP is EASY... that's just a profit generating situation that the big, bad physician is taking advantage of... but what about us as a profession in all the other employment situations? The crap Carina, John and Christian bring up is commonplace. As Carina says... you go in and interview and ask questions and what you are told is definitely not what is. And, then after being hired, you yourself start mentally debating with yourself - how long to wait to bring up the crap... what avenue to take... what will the ramifications be... what are the politics...... when something is unethical, how unethical does it have to be before you just can't tolerate it any more?

Think of HealthSouth... it took a patient to bring that crap down.

Taking over ownership of our professional services obviously puts a stop to RFP and keeps the financial return with the physical therapist but it definitely doesn't ensure a lack of existence of ethical situations. We're humans; some people are greedy; some people like to work in the gray and push, push, push the boundary... we have a lot of physical therapists employed in supervisory/administrative/ownership situations and from what I have experienced, there is no guarantee that everything will be ethical.

I don't know what the answer is, but I do know that there is a lot more bad than just RFP and the bad is right there with us and the decisions we make - regardless of employment situation.

[Jason Silvernail]

It's interesting how often the "there are other ethical situations other than RFP" argument seems to come up here. As it happens, not only do I agree, that actually seems to be a distraction from the main point.

This particular post is just about RFP, though I've heard nothing from any supporter of that arrangement that I find convincing. I take it that amounts to concession?

[John Ware]

Jason,
Is this debate about learning and growing or merely winning?

What I'm trying to convey here is that RFP is a bit of a red herring when it comes to ethical problems in physical therapy practice. They've become the whipping boys for those of us trying to eke out a living in a health care system that rewards how MUCH you do to someone more than how WELL you do it. That's a zero-sum system that is not concerned with results. It is very hard to practice and simultaneously run a business ethically when how WELL you do something doesn't matter. It's demoralizing.

Perhaps it's not the battle, but the battlefield that we need to define better. As PTs who are concerned with utilizing evidence to advance practice, we are well-positioned to change the debate away from these ancillary issues of RFP and start talking about the best, most efficient ways to get pts better.

Sean,
I don't recall you specifically asking me what I did in those questionable situations. Much of that occured earlier in my career. I made complaints to management, mostly about caseload requirements, and some concessions were made. Eventually, I left and went to work for someone else. At one point, I got involved in a group PT practice as an owner. The same arguments would come up about charge/visit, pt volume etc. We finally parted ways. Should I have turned them in. I'll defer to Selena's answer there. When you're in the thick of it, much of these ethical infractions are subtle and very difficult to actually prove. At that point, you just want out.

John

[Jason Silvernail]

Hi John.
It isn't about winning, but clarifying what issues there are so we can discuss how they impact our patients and our profession. If there's no agreement on where we stand on ethical issues, then it's truly difficult to move forward as a profession to address them. Especially such an obvious issue as RFP.

I started this post in the beginning with a situation that I thought was very clearly not in our patients or our profession's best interest - what I thought was a situation we could all agree on.
If even that setup way up top at the first post has driven this much back and forth on comments, I don't see how we have a shred of a chance to address any of the other issues that you and others have brought up that aren't directly relevant to RFP.

I don't want to win, but to see our profession have clarity on the RFP issue. It doesn't appear that that will happen here, however.

[Vince]

I sounds like there are three separate arguements here. 1) RFP 2)PT practice ethics 3) Personal ethics regarding reporting other PTs

I think RFP is unethical and I argree with Jason. Yes, there are PTs that practice unethically, but I think this is a different issue than RFP. I've work for some bad PT offices and I had similiar situations as mentioned by John and Selena regarding the difficulty of practicing ethically in those situations. I agree with Selena that nothing will happen in less there is evidence to support your claims.

But PT ownership is a separate conversation than PT ethics and I think they are getting confused here. I don't see lawyers or MD questioning thier right to own thier own profession because some MD or lawyers practice without ethics. This obviously isn't happening in thier profession and for the life of me I can't figure out why PTs defend RFP.

Unfortunately, there are some parts of the US where the only way you can make a decent salary, support a family, and put food on the table for your family is to work in some unethical situations. If a PT has an option of working for a PT and make 20% less while practicing unethically and making 20% more while practicing unethically working for an MD. 95% of PTs will work for the MD.

Business ethics is an oxymoron.

[Jason Silvernail]

"business ethics is an oxymoron."
Maybe, but we can do what othe r professions do and have strict rules about ethics, autonomy, and ownership.

There's no real reason we shouldn't.
All Selena's arguments to the contrary.

[Vince]

Jason,

Who could argue with that? Without ownership, we have no control over our profession. It really is that simple as you have previously stated.

[Carina Lowry]

Jason,

What other professions (doctors, lawyers, CPA's etc) have done is to make it illegal for anyone who is not of the profession to set up a professional corporation. I couldn't go set up an office as a CPA because I am a PT. Until we have name and business protection, anyone can set up a PT clinic and in some states can even practice therapy without any ramifications. We need legal protection first I would think?

Carina

[Jason Silvernail]

The rules I'm speaking about are professional ownership of services, though Carina is certainly right that there are other legal related issues.

I'm trying to focus on what WE can do as a profession about this.

[John Ware]

Vince,
If you're of the opinion that "business ethics" is an oxymoron, then you fall into the category of the demoralized, as I have alluded to in my last post. I have been there, believe me, it's no fun.

I have become a pragmatist with regard to this RFP argument. Here are the facts that I base my pragmatism on:

1) Many, if not most, PTs, do not behave as professionals, in the true sense of the word (see John Child's post on the Wong et al article about the use of US).
2) RFP is just one situation of several in which this lack of professionalism is evident.
3) RFP within our field is legal.
4) Ownership of one's profession, while certainly desirable, requires that the members of the supposed profession behave as professionals.
5) Behaving as a professional requires adherence to professional ethics AND the utilization of best evidence to guide clinical decision-making.
6) The current US health care system is not set up to reward those who produce results for pts; therefore,there is no incentive to change practice patterns based on outcomes evidence (other than the idealism of many PTs to truly help people).
7) Professionals in other fields are rewarded for their expertise by providing benefits to their clients that cannot be provided by someone who is not similarly educated and trained.

My conclusion: RFP is a product of a system that does not reward excellence resulting in blurred ethical lines, quasi-professional behavior of the players in the system (including physicians), and ultimately poor value for the sick or injured patient.

What we can and should do about RFP: First, quit whining about it. Second, start in your own practice setting utilizing best evidence AND collecting outcomes data for specific conditions that your are treating. If PTs start doing this in large numbers, 3rd party payers will take not, and then unethical RFP situations as described by Selena (as well as any unethical, over-utilization situations) will die by attrition as they will not be able to show that they get results.
John

[Selena Horner]

Jason, chances are the only way the RFP situation can really be changed is legally. The hard and true fact is that no one cares about ethics. RFP are strictly a business decision to increase revenue. It is not a fact that all RFP are unethical.

Our profession can't solve the problem. What percentage of physical therapists are members?

The whole RFP situation is so full of emotions. Excellent clinics have had to close their doors. Small private clinic owners have fear - fear of the same business outcome. Those therapists have spoken and are screaming for our profession to do something about it. They have no idea how to protect themselves and how to keep their doors open in this particular fight.

The marketing game has to change. Physicians can be either be helpful for our business OR they can slit our throats. We need to target the public. We target the public as John mentions... 1) the power to choose AND 2) our outcomes. But as Wainner, Flynn and Childs are always hammering - we have an identity problem and the public doesn't even know what the heck our role is in their health or lack there of.

Professionalism, autonomy and ownership do not eliminate any of the ethical issues that seem to always revolve around RFP. It definitely sounds good on paper, but to think the ethical problems just go away is ludicrous. Ownership only eliminates anyone other than a PT from profiting from PT services.

The way to reduce the ethical crap is to stand up and fight the fight collectively. It's definitely not an easy road, but if everyone started doing it, management and administration would wear themselves out at some point in time. It's a whole lot easier to win a battle with 9 therapists within an organization fighting the fight to be professional versus one lone squeaky wheel. We definitely aren't "professionals" when we allow administration to have hard "rules" to be followed with every patient that walks in the door. Why do we allow that?