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The Most Important Issue in the PT Profession

May 10, 2008 • Health Care News • Larry Benz

And I really mean it.

There is a raging debate within the PT profession. Over past several weeks, I have seen it as part of many discussions and it was recently manifested on a PT listserve of the administrative section of APTA. I know that listserves are “old technology” but it actually works well for PT’s who tend to be slow adapters and certainly if it isn’t broke, don’t fix it!

The debate is centered over a seemingly growing movement that unfortunately has far reaching consequences: Do all services rendered within a PT clinic have to be one on one and performed by a PT or a PTA (I personally would prefer to leave the PTA out of any discussion but since medicare in much of their policy implementation makes us reimbursement equals, I will include).  The debate unfolds something like this:

The Players:

Practical Practitioners:  PT’s mostly who are in private practice or typically on a day to day have some encounter with the repercussions of the economics of their practice. If not in private practice, they oversee a department or a clinic and its financial performance and thus are faced with reimbursement realities, compliance, and trends and the pressure to keep their department or facility above water.

Insulated Idealists:  PT’s in the industry who don’t practice at all (e.g. some academics), or who make their living not in PT practice but in lecturing to PT’s on reimbursement or coding, most members of the federation of state boards, or PT’s who are in a niche industry (e.g. they do 100% cash Pilates) that is grossly atypical and misrepresentative of the overall PT sector.  The bottom line on these idealists is that at the end of the day they never are faced with the real world difference between the service of PT and its financial viability.

The Debate:

According to the Insulated’s, 100% of all PT has to be done one on one by a PT or PTA without exception and to do anything to the contrary is fraud and should be punished by jail, fine, license revocation or preferably all three (truth be told a few canings ought to be in there as well).  They believe that Medicare superimposed rules are the best thing since the Wii  and that the CPT codes by definition further support their position and every attempt should be made to gather national payors to get their acts together and adopt medicare as the de facto standard and in addition open up every practice act in the US and amend those to be of the same standard and consistency in every state where their position is duly reflected.

Iinsulateds believe that nothing should every be left to the judgment of a PT but rather every possible clinical scenario  and intervention should be explicitly listed and reflect that it has to be done one on one PT or a PTA.  They frequently site the excessive use of techs and aids in PT departments.  For the PTA, they typically suggest that the PTA is duly licensed and essentially the equivalent in every way except for evaluation, manipulation, and debridement (some Insulateds would point out that an advanced PTA can perform the last two).  Even a hot pack that nobody pays for has to be applied by a PT or PTA.  In there world, nothing is left to chance and the list of rules for PT and practice acts would be about the same size as Tolstoy’s War and Peace.  Economics is never considered because their fundamental belief is that PT ought to be free anyway and that any PT who makes more then them is a greedy crook who only looks at money.

On the other side is the Practicals.  They believe that medicare superimposed rules are stupid and that although you have to follow them that every attempt should be made to get rid of them and more importantly stop the madness from methastasizing to other payors.   The Practicals believe that a PT’s education and practice act allow both delegation of care and supervision in accordance to their judgment as a PT. They believe appropriate checks and balances are in place to prevent the excesses and avoid the impulse to manage to the small percent of PT practices that abuse the rules. Practicals look at the CPT codes in the same manner that physician’s-unless explicitly stated, supervision of support personnel thru delegation and direction aptly meets the description of the code even in cases where the word “one on one” is used as long as the one on one by a support person is done under supervision as outlined in their state’s practice act.

Relative to Vision 2020 Practicals actually buy into it and see the attempt by Insulateds as de-evolutionary to the profession. Practical believe that the Idealist’s view of Vision 2020 is illusionary. They believe Insulateds don’t see how their position runs contrary to a direct access practitioner who is autonomous  Practicals take the position that a doctorate degree with advanced clinical training is best positioned to make judgments within the scope of practice of what their support personnel can do in much the same way that you see physicians manage their nurses and techs.

Practicals both laugh and are incensed by the Insulated’s activism toward amending practice act and attempts to make all care explicit.  A practical would ask “do you see physicians trying to eliminate their nurses and support personnel from their supervision?”.

Practicals are faced with the financials repercussions of not taking certain contracts or the difficulty of trying to align quality care in a declining reimbursement arena by applying appropriate resources in conjunction with the insurance that patients have.  Practicals site the great success of the military and VA system who have empirically shown their cost effectiveness in an environment where reimbursement is not an issue and where the PT is given significant autonomy and unfettered supervision over their techs and support (and at least the case in the military prescriptive authority and ability to refer for imaging).

Practicals would like to debate eliminating PTA’s from the profession and site the drastic educational differences and the inconsistent Medicare policy towards them.  Any attempt to align a PTA as equivalent to a PT is appalling to a Practical.  Practicals also site that evidence does not exist to support any of the condescending positions taken by the Idealists and that the free market thru both quality indicators and consumerism will determine the most efficacious delivery of PT.  Practicals believe that PT can be economically viable if the shackles of the regulatory environment were lifted and the idealists would halt their ways in attempting to further restrict the profession from becoming autonomous providers.  Practicals believe that without margin their is no mission and that without economic viability that our best and brightest will not seek out a PT career and that we will quickly head towards a 7 year degree getting $27 per visit for one on one care with more loan debts than a third world country.

I don’t think you have to guess which side that I am on.

The Question:

Which side are you on?  Who is winning?  What are the implications of Insulated’s position for the future of PT?

larry@physicaltherapist.com

Larry Benz

Dr. Larry Benz, DPT, OCS, MBA, MAPP, is the Executive Chairman of Confluent Health. He is nationally recognized for his expertise in private practice physical therapy and occupational medicine. Dr. Benz’s current areas of interest include conducting research and integrating empathy, compassion, and positive psychology interventions within physical therapy. He released a book on September...

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