Roughly one year ago, we had 2 blog posts regarding RC 15-10 that the Private Practice Section was moving forward to the 2010 House of Delegates. For a variety of reasons, the RC was withdrawn. The good news that it is back as RC-03-11.
I have taken the liberty to edit that post and have pasted it below with the addition of a few additional arguments that have materialized-most notably the lack of trust that PT’s have for each other.
Our national association espouses PT’s to be autonomous practitioners in its vision 2020 statement. At the same time, it maintains positions that restrict PT’s ability to practice within their scope of practice. These positions are then represented to third parties-including medicare and other payors in a variety of ways including insurance conferences. Left unchecked, medicare’s restrictive and oppressive rules might just metastasize as standard. Fortunately, the Private Practice Section is attempting to reconcile it by virtue of a motion to the House of Delegates: RC 03-11 Physical Therapist Accountability for the Delivery of Care. Unlike last year’s RC 15-10, the Section met with representatives of many other sections in order to craft a more comprehensive RC and support statement including multiple RC’s that if relative (depends on whether RC 03-11 passes), essentially affirm the position that “physical therapy is exclusively provided by a physical therapist”.
For reasons that historically are unknown to anybody out in the trenches actually seeing patients, APTA has the following positions:
- APTA’s position Direction and Supervision of the Physical Therapist Assistant (HOD 06-05-18-26) states:
The physical therapist assistant is the only individual permitted to assist a physical therapist in selected interventions under the direction and supervision of a physical therapist.
- In addition, the House of Delegates has also addressed payment for physical therapy services through the position Reimbursement for Physical Therapy Services (HOD 06-01-12-15) that states:
The patient/client management element of interventions should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant performing selected interventions under the direction and supervision of a physical therapist in accordance with the American Physical Therapy Association policies, positions, guidelines, standards and Code of Ethics.
The problem of course is that these positions fly in the face of the overwhelming majority of states and the model practice act which states the following:
- The Federation of States Boards of Physical Therapy (FSBPT) in its Model Practice Act defines two individuals involved as care extenders in the practice of physical therapy, the physical therapist assistant and the physical therapy aide. The Model Practice Act defines these two care extenders as follows:
“Physical therapist assistant” means a person who is [certified/licensed] pursuant to this act and who assists the physical therapist in selected components of the physical therapy treatment intervention. “Physical therapy aide” means a person trained under the direction of a physical therapist who performs designated and supervised routine tasks related to physical therapy services.”
Thanks to leadership within PPS, the RC efforts seeks to remove these baseless positions. While thankfully there are currently only a few private payors restrict practicing PT’s to anything other than primarily their licensure-as it should be-this seems to be lost on an organization that is clearly disconnected from the day to day practicing PT on this most important issue. Unfortunately, the largest payor-Medicare has adopted their completely unjustified position-much to every practice’s dismay which has done nothing but run up cost to practices and placed the focus on external compliance rather than patient care. Isn’t it a little ironic that in times to try and meet growing demand with less resources that we are restricting practice rather than trying to expand our scope like most other medical professionals?
For the “ insulated idealist PT’s” out there that disagree, the primary defense goes along these lines:
-you only want to use techs for financial gain-this RC is only about “MONEY”
-how can you represent anything a tech does as “physical therapy”?
-if we have that position than all MD’s will do is hire techs
-patients are already confused about who their PT is, utilizing techs will add to this confusion
-such a position would increase the amount of fraud in physical therapy
-payors will pay less knowing that you are using techs
-we will have to change all sorts of documents at the national level if we change this position
-how can we trust PT’s to actually make the right judgements regarding use of extenders?
let’s rebut these one at a time.
-you only want to use techs for financial gain-this RC is about “MONEY”
The primary reason that PT’s ought to be able to delegate and direct support personnel has nothing to do with financial gain but everything to do with their training, judgment, and scope of practice. A PT autonomous provider has the necessary education and this is supported by the majority of practice acts and the model practice act. It is almost hard to believe that a national organization would not be in support of the model practice act but that is an entirely a blog post of a different time. I have personally looked at 3 different non physician medical professions and the positions of their national organization. There isn’t one that attempts to superimpose, restrict, or eradicate their professionals scope of practice. Perhaps the best evidence that this position isn’t for financial gain is the liberal use of support staff by the US Military where reimbursement is not a concern and physical therapist’s have expanded scope of practice. Of note, is the high percentage of board certified PT’s and the significant scholarly contribution to the body of physical therapy knowledge by PT’s in the military. Few if any practices actually in practice take APTA’s position seriously other than for medicare patients where they are obliged. Why have a position that the overwhelming number of PT’s in reality don’t abide by because their practice acts don’t restrict them in that way? Lastly, why is it that in the debate of Direct Access for Medicare these folks don’t claim that the issue is “MONEY”. Isn’t direct access potentially a lot more financially oriented?
-how can you represent anything a tech does as “physical therapy”? This isn’t SKILLED physical therapy!
You don’t. You only represent what a PT performs, directs, and delegates under supervision as a PT. A PTA by definition (including CMS) cannot make clinical judgments nor changes in plan of care yet we have no issue representing their work under supervision of a PT as “physical therapy”. A PT can easily make judgments about what tasks a PT tech can do as well. “Skilled” physical therapy is a redundant and unnecessary term that was placed in the PT world by CMS who wanted to ensure that differential from “maintenance” and even that is being legally challenged. The skill of the PT is in their collective use of clinical decision making, examination, and hands on techniques. All physical therapy is “skilled” and like all aspects of medicine certain tasks require higher level of skills than others (heart bypass takes more skill than doing a blood pressure).
-if we have that position than all MD’s will do is hire techs
The significant difference here is that nobody is advocating that the PT is not the sole source and responsibility of providing physical therapy. Physicians who do not hire PT’s to provide physical therapy are clearly in violation of this principle.
-patients are already confused about who their PT is, utilizing techs will add to this confusion
When providers use multiple support personnel it is incumbent on them to clearly differentiate. Do patients get confused between who is the doctor and who is the nurse? Proper risk management is indicated so that confusion doesn’t occur under any scenario.
-such a position would increase the amount of fraud in physical therapy
Thankfully, few private payors have adopted the stifling national positions so rampant increase in fraud is unfounded. In fact, if one looks clearly at the recent and well publicized fraud cases, there is clearly a malicious intent to tamper the rules. We have to avoid dumbing down the rules in PT under the flawed assumption that all PT’s are crooks and incapable of decision making. Fraud in physical therapy is almost always committed by those with a criminal, malicious intent-not the 99.99% of PT’s who see patients everyday.
-payors will pay less under knowing that you are using techs
Perhaps somebody hasn’t realized that despite our national organizations attempt to restrict PT’s from practicing within their license that payors have already decreased reimbursement significantly. The variables that determine what providers accept as payment are completely independent from what our national organization’s positions. In fact, the representation of those positions has unfortunately worked on medicare causing the most disruptive of processes including scheduling exceptions to avoid overlaps and resources, additional monitoring costs, and a focus on hourly billing that results in a wage cap on physical therapist’s earnings. Recent studies indicate that the most disengaged professions are those that work on a billable hour rate in an algorithmic fashion. Is that what we want with such superimposed rule restrictions? There are many PT’s who believe that nobody can treat a patient except a PT or a PTA. Support of RC 03-11 will not prohibit them from practicing that way. Side note: the states with that are the most regulated and most restricted from a practice act standpoint have the lowest reimbursement in the U.S.-sorry New York.
-we will have to change all sorts of documents at the national level if we change this position
That’s just a shame isn’t it-progress does have a cost. Let’s not do anything cause it will cause further edits and clarifications in support of a PT autonomous practitioner working within their scope of license.
-how can we trust PT’s to actually make the right judgements regarding use of extenders?
This argument seems to be catching the most steam and one that I find the most amusing. Out of one side of the mouth is an argument about how PT’s can effectively and efficiently differentially diagnose a direct access patient but they cannot be trusted to make decisions on supervision! Inpatient PT’s can delegate on a vent dependent patient but outpatient PT’s can’t use an extender!
I urge you to talk to your component’s delegation and voice your support for RC 03-11 Physical Therapist Accountability for the Delivery of Care. It’s high time we have consistency in a PT’s license and outdated and unfounded positions from our national organization.
Just because I disagree with APTA on this significant issue doesn’t imply that I am anything but an ardent supporter and volunteer of our profession’s national organization. It’s time to bring transparency and active debate to such a critical issue in our profession rather than leave it in the hands of those that quite honestly may not represent the PT’s in the trenches.
I look forward to the thoughts and debates on this.
