While I am not a regular reader of Advance Magazine for Physical Therapy & Rehab Medicine (and I doubt this blog is in their RSS reader), it was with great interest that I read “Another POPTS View. A healthcare attorney challenges the APTA’s campaign against physician-owned PT services”. The article was strangely reminiscent of a published study which clearly demonstrates that cigarette smoking is an underused tool in high performance training.
The study on runners does an excellent job of documenting numerous research which demonstrates that cigarette smoking has an impact on three factors related to endurance performance: serum hemoglobin, lung volume, and weight loss. There is nothing inherently incorrect about the citations. However, as Kenneth Myers from the University of Calgary points out, “”if research results are selectively chosen, a review has the potential to create a convincing argument for a faulty hypothesis. Improper correlation or extrapolation of data can result in dangerously flawed conclusions.” This couldn’t be any more relative towards Cary Edgar’s POPTS viewpoint (he is founder of Ancillary Care Solutions which works with physician groups on in-house physical therapy).
While the smoking study only made improper correlations, the Advance article provides major inaccuracies. The most obvious one is the major point of their contention – the 2005 Medpac report which reports on physical therapy spending per patient in a variety of ways to include practice setting. The data reported in the 2005 report is for the year 2000, not 2005 as he cites but let’s not let the facts get in the way of improper correlation. Even if the data weren’t eleven years old (no shortage of POPTS proliferation during this time), the “spending per patient of $653 in private PT practices, and only $405 in physician groups” is like saying the increased lung capacity of a COPD patient provides an advantage in an ultra marathon. To be fair, it is probably difficult for an attorney to realize that there are major differences between patients seen in an orthopedic POPTS clinic vs. a freestanding private practice relative to acuity or routines including the “one visit only home program or DME only visits cause the patient lives far away” syndrome that is commonplace. Of course, there are tons of anecdotes of patients self-discharging because of the cattle call or inconvenience of the POPTS clinic resulting in a lower per episode cost but let’s not even go there. Furthermore, medicare’s data in private PT practices includes many POPTS who have obtained medicare numbers and re-assignment of their PT’s. The bottom line is that medicare’s own data doesn’t unfortunately fully discern between POPTS and non-POPTS.
As to the claim that APTA is misrepresenting conflict of interest. Are you kidding? The major issue of inherent conflict of interest via self-referral is not cost per episode but in excess referring of patients that don’t need the service. There are a plethora of studies that show the problems of referring to entities that a physician owns including this recent one from a few days ago which show there is a different threshold for referral where there are financial incentives. By the way, if you are going to reference Medpac reports, why wouldn’t you provide the one from June 2010 as highlighted in this blog which includes the following quotes:
“Moreover, there is evidence that some diagnostic imaging and physical therapy services ordered by physicians are not clinically appropriate”
“There is evidence that physician investment in ancillary services leads to higher volumes through greater overall capacity and financial incentives for physicians to order additional services. In addition, there are concerns that physician ownership could skew clinical decisions”
APTA’s white paper on POPTS was written in 2005 prior to 2010 Medpac and the significant number of published imaging studies which continue to demonstrate self-referral problems. APTA shouldn’t be attacked for this paper, they should be applauded as the evidence since then is more than just a little compelling. Perhaps my favorite part of the viewpoint is the contention that ” APTA’s promotion of autonomous private therapy practices has almost undoubtedly resulted in lower payment rates for physical therapy services”. While I completely agree that payment rates for services have been unfortunately lowered, this is mostly due to PT’s who sign the contracts and their inability to have any leverage in contract negotiations-something we can’t put on the shoulders of APTA.
As to common ground, there is one area that I completely agree with the author:
“While the APTA and its state chapters have devoted a tremendous amount of time, energy and money in their decades’ long campaign against POPTS and therapists that work for POPTS, they have apparently not conducted or sponsored any studies seeking to validate their allegations that physician-owned PT results in overutilization and unnecessary cost. Instead, as discussed above, the APTA has chosen to cite outdated and misleading studies that support its position and ignore findings that do not support its position.”
