Physical Therapists and the Great Divide

For those of you in the United States, if you have a thumb on the pulse of physical therapy, you are noticing more and more opposing views on a variety of topics.  Because of transparency, it is easily observed through forums, blogs and list serves that our profession is divided on a variety of issues:  use of ultrasound, the theory of the biomechanical model for some manual therapy approaches, manipulation, evidence-based practice, the educational model, dress code...  (do we ever agree on anything?)

We have a divide in our profession on these most important issues.  Like it or not, the most important issues are key to our survival as a profession.  The majority of physical therapists practice in an outpatient physical therapy setting.  Regulations that affect our ability to practice efficiently, our ability to generate a profit, our ability to determine staffing and use of staff, and our ability to create and design our own business models will negate any benefit we may reap as a "doctoring profession," the vision of 2020, or being neuromusculoskeletal experts because of the risk of becoming extinct. The divide on the behalf of one group is based on perceptions and emotions. Generally, it never does much good entering into an emotionally charged discussion, which is why I have held my thoughts back.  Reality is, we need to talk; we need to learn to compromise; we need to learn to negotiate and we need to reduce this divide to increase our likelihood of survival.

The majority of the state practice acts are direct access. There is a frivolous suit out there initiated by the NATA against the APTA. Fair practice is being argued. What about CMS? Doesn’t CMS affect our “fair practice?” Doesn’t imposing physician referral oppose a state practice act of direct access and reduce our ability to practice? Safety is always cited as the rationale for physician referral, but what does data suggest? Do states that have direct access have a substantially higher amount of malpractice suits involving Medicare beneficiaries? Doesn’t CMS also affect our “fair practice” by dictating and micromanaging clinical decisions related to supervision and delegation?

A big beef of mine is the one-on-one CPT code definitions for the outpatient setting. Assumptions have been made; beliefs have been formed; one-on-one treatments are superior and anything different is suboptimal. Hasn’t anyone actually wondered if assumptions are true? I have. We have more and more research indicating that subgrouping patients and treatment based interventions will increase the likelihood of effective treatment. Could the same be true for one-on-one versus group situations? (Group will be defined as 2 or more concurrently scheduled patients with their own individualized plan of care in an outpatient setting.) No one has argued the benefits for group situations other than the financial component. In the past, I have treated 4 concurrently scheduled patients in which I had full control of the mix of those patients attending for services. There is definite benefit with the right mix of patients. The patients amongst themselves motivate each other, support each other, some compete with each other and applaud each other. I even have some data that I have analyzed to answer my own question as to whether there is a difference in outcomes between the services I provide in group situations or one-on-one situations. For me and my practice, if someone had a lumber or lower extremity complaint, there was no difference in the functional outcomes between the two groups. Patients with a cervical or upper extremity complaint had on average pretty much a whole minimal clinically important difference between scores with better function obtained for the group situation. I have no idea what happened differently between groups but that’s pretty substantial. For me, dictating one-on-one treatment sessions reduces the effectiveness of outcomes for those patients. What about costs associated with care? Overall comparison of group situation versus one-one-one situation indicated on average 2 less visits. So, am I being cost effective with one-on-one treatment sessions? The definition of those codes reduces our clinical and professional ability to assess various treatment models and options to increase our effectiveness and efficiency.

There have been round and round discussions about “skilled” and PT extenders. In my opinion the “skill” in what we do is the design of the package we create within the written plan of care – the progression of interventions to meet defined goals for each individual patient. There is definitely a time and place for PT extenders and I’d assume the variables that impact the clinical decision for utilizing PT extenders are frequency of visits, patient co-morbidities, stability of patient presentation, severity of patient presentation, patient previous response to treatment… The emotionally laden discussions never really discuss the variables to consider when delegating, but instead fall back onto “skilled.”

Some arguments for PT and PTA only treatments cite safety as a rationale. I requested the Physical Therapy Claims Study from CNA/HPSO. What’s actually happening out there with liability claims? From January 1, 1993 through March 31, 2006 there were 1,464 closed and open claims (number might be off because there could be more open claims that haven’t been filed yet). When looking at closed claims, if there were 140 to 160 claims for 51,000-56,000 policies about .28% of the policies had a liability claim. I get the impression that quite a few therapists believe that PT extenders are used at too high of a frequency and inappropriately. With just that small amount of data, it doesn’t seem from a risk management perspective that PT extenders increase liability claims, IF the therapists that believe they are used at too high of a frequency are accurate in their beliefs. 77% of claims occurred in a physical therapy office or clinic (non-hospital). Claims that occurred from services provided in a nursing home were the highest, averaging $76,000 compared to about $38,000 for physical therapy clinics. The highest occurring primary injury was fractures at 27%. The second highest primary injury for claims at 18% was burns that had an indemnity payment of $25,000! (We argue and discuss PT extenders and “skilled” and maybe we should consider the risks and costs associated with heat modalities that haven’t even been shown to be effective!) The allegations: failure to supervise treatment/procedure at 15% of claims, injury during manipulation at 11% of claims, improper technique at 11% of claims, injury during heat therapy at 10% of claims and injury during resistance exercise or stretching at 7% of claims. The reason that I think the liability claims data is interesting is because CNA/HPSO of course wants to share the information with clients so physical therapists can be aware of what is happening to reduce risk which will actually increase profit for CAN/HPSO (less claims = less expenses and less indemnity payments). Within the recommendations for risk management, nothing was stated on eliminating PT extenders or suggesting that PT extenders were a variable in failure to supervise claims. The recommendations do not suggest that treatments provided only by PTs or PTAs reduce risk. The Study

We could be WAY ahead of the game if we had a definition of quality of care.  Outcome numbers to determine if the issues revolving around one-on-one care and use of aides are issues or non-issues would be helpful also.  Does anyone have this type of information?  FOTO has been around for quite some time, does anyone have any data to share that might help resolve differences of outcomes when dovetailing patients?  What about data to compare use of PT extenders or no PT extenders?  If there is a difference, is it statistically relevant?  Are we divided over a non-issue?

It would be interesting to see a discussion revolve around these issues that reduce our capacity both financially and professionally based on something other than opinion and emotions.  Can we present data to support thoughts? It’s almost as though professionally we have been brainwashed to believe something without any substantiating evidence. Show me why aides shouldn’t be utilized; show me why CPT codes state one-on-one and this is believed to be the best option for patient care; show me why a physician needs to refer; show me why a physician has to approve a plan of care.  Can we reduce our professional divide by eliminating the emotion and replacing emotion with some level of supporting evidence?

Do others think about these topics?

Selena Horner