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Physician-owned physical therapy services threatened, prohibited in some states
AAOS, state orthopedic societies argue that taking PT from physicians will remove control of care.
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Office-based physical therapy services and their potential benefits to patients remain under scrutiny.
South Carolina recently became the second state to see its Supreme Court reinterpret an existing physical therapy statute and prohibit physician-owned physical therapy services.
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While this reinterpretation may not initially have national implications, it is just one of the first steps by the American Physical Therapy Association (APTA) to become independent from physicians, according to David A. Lovett, JD, director of the American Academy of Orthopaedic Surgeons (AAOS) Washington Office.
“There is a game book that they’ve been pushing over the years and this – the South Carolina case – is just one more step in the direction of where the physical therapists want to go,” Lovett told Orthopedics Today.
APTA’s “game book” also includes the Medicare Patient Access to Physical Therapists Act of 2005, as well as pushes for reinterpretation of physical therapy statutes in other states. All of these moves are part of a larger picture that APTA hopes to achieve by 2020.
In 2000, APTA developed the Vision Statement for Physical Therapy 2020, also known as Vision 2020. By 2020, APTA says, consumers and health care providers will recognize physical therapists as doctors of physical therapy, who will directly diagnose, treat and prevent musculoskeletal disabilities.
“They pushed to change the licensing requirements of those who do physical therapy,” Lovett said. “At a national level … physical therapists who are employed by physicians have their own Medicare billing numbers, but APTA has wanted to push to make that impossible, so there is a national strategy and there’s a state strategy.”
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South Carolina ruling
In a majority ruling, the South Carolina Supreme Court found that prohibiting physician-owned physical therapy services does not infringe on the practice of medicine or violate the equal protection rights of physical therapists who want to work for physicians.
They noted that allowing such services in physicians’ offices questions who is the primary beneficiary of physical therapy fees. The Court also noted the potential for financial conflicts of interest and the limitations for consumer choice in choosing a therapist – a major argument of APTA.
But the AAOS, South Carolina Orthopedic Association (SCOA) and South Carolina Association of Medical Professionals (SCAMP) disagree. The latter two groups filed the original appeal to the reinterpretation.
In an amicus curiae brief, the AAOS explained that prohibiting physical therapy services in physician offices could lower patient quality of care because orthopedic surgeons could no longer directly participate in the rehabilitation of their patients.
“There’s no evidence at all that demonstrates that physical therapists as employees in an orthopedic surgeon’s office offer quality of care that is any less or that there’s any overutilization of that care,” Lovett said. “In fact, for patient convenience, there is a strong argument to be made. The position of our academy … is that physical therapy in office as an ancillary service is completely acceptable and appropriate.”
On Oct. 10, SCOA, SCAMP, individual orthopedists and orthopedic groups in South Carolina filed a joint petition for rehearing of the South Carolina case, Grant Nyhammer, assistant general consel for AAOS, told Orthopedics Today.
Implications for South Carolina
South Carolina orthopedists are troubled that the quality of care their patients receive from physical therapy will no longer be under their supervision.
“We’re very concerned that physicians won’t be able to … direct therapy for their patients in whichever matter they think is the best done for that patient and that situation,” M. David Mitchell, MD, immediate past-president of the SCOA, told Orthopedics Today.
Mitchell and the SCOA members are also concerned about recruitment. “It’s going to be very hard for our state to attract orthopedists when there are 47 other states that do not have restrictions on physical therapy in the office,” he said.
Not only has the ruling disrupted many of the physical therapists currently employed by physicians, but also it has unfortunately placed the state’s physical therapists at odds with orthopedists in the state, Mitchell said.
“We’re going to have to put our patients’ care first and … put our adversarial relationship to the side,” Mitchell said.
APTA has continued to argue that physicians may overuse physical therapy if under their employment. But now, the SCOA is concerned that overuse could occur without the physician’s input.
“We are really worried about the overuse of physical therapy when we have no control over it,” he said. “We want our patients to receive good quality care and not have a therapist think that he or she has to produce so much income from one patient.”
South Carolina’s next steps
Mitchell said the SCOA’s next steps involve pushing for legislative action. Last year, they attempted to convince South Carolina’s legislators to pass a law as part of the Physician Practice Act that would allow orthopedic surgeons to employ physical therapists in their offices and in a referral setting.
However, the legislatures left the decision to the Supreme Court, and planned to return to the issue legislatively if the Supreme Court did not rule in the orthopedists’ favor, Mitchell said.
“And that is what the SCOA would like to have addressed legislatively this year. … It will have to be that now [so] the legislators can’t avoid making the decision,” he said.
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South Carolina is not the first state to face this situation, Nyhammer said. In 2002, the Delaware attorney general issued an opinion to interpret an existing statute and effectively prohibit physical therapists from being employed by a physician and receiving referrals from a physician.
According to the AAOS Bulletin, Missouri’s self-referral law prohibits physicians from sending patients to a physical therapy office in which they have ownership, effectively banning physicians from employing physical therapists.
“There are a handful of other states that have physical therapy acts similar to Delaware and South Carolina where it’s possible that an opinion by the attorney general could change the practices in those states,” Nyhammer said.
The AAOS identified fewer than 10 states where a change in practice is possible, but could not share the names of those states with Orthopedics Today, Nyhammer said.
Steps by the AAOS
While APTA holds the office-based physical therapy issue above any others, the AAOS still has to address national issues such as medical liability reform and the payment formula – both of which consume staff and resources, Lovett said.
“For us as an academy or the orthopedic community, how do we deal with an issue that’s No. 1 for a non-physician provider group, but we have other areas of concern?” Lovett said.
APTA devotes most of its staff and resources to this issue and others related to the Vision 2020, Lovett said. Deciding on the academy’s appropriate response to the issue is a challenge, while so many other priorities exist at the national level.
The AAOS recently reorganized its structure to meet these challenges and other state and federal matters head on, Lovett said. His office in Washington now handles all federal and state matters under a new name – the Office of Government Relations.
“We thought that issues like medical liability reform and this nonphysician provider scope issues like the physical therapy one [have] links between the national, federal and state efforts,” Lovett said.
For more information:
- http://www.judicial.state.sc.us/opinions/
- David A. Lovett, JD, is the director of the AAOS Washington office, 317 Massachusetts Ave NE, 1st Floor, Washington DC 20002. He can be contacted at 202-546-4430, fax: 202-546-5051, or lovett@aaos.org.
- M. David Mitchell, MD, is the immediate past-president of the South Carolina Orthopedic Association and an orthopedic surgeon at Orthopaedic Associates PA, 1330 Boiling Springs Rd., Suite 1600, Spartanburg, SC 29307. He can be contacted at 864-582-6396, fax: 864-543-2939, or at mdmmd@bellsouth.net.
- Grant Nyhammer is assistant general counsel for the American Academy of Orthopaedic Surgeons, 6300 North River Road, Rosemont, IL 60018-4262. He can be contacted at 847-823-7186, fax: 847-823-8125, or nyhammer@aaos.org.