Tuesday, February 14, 2006

More on Referral-for-Profit Situations

DISCLAIMER: The opinions expressed in this blog belong to me, Joe Black, and no one else. I do not speak for any group, practice, or organization. I am a Physical Therapist and an Athletic Trainer, first and foremost. I also serve several roles in our professional associations, most notably as President of the Tennessee Chapter of the American Physical Therapy Association, also known as the Tennessee Physical Therapy Association. As such, I write this blog with great concern and caution. It can be difficult to separate my roles. I would insist that I have a right and, in some respects, an obligation to voice my opinion. In doing so, I am doing so as an individual.

I’ve never put as much effort and thought into any blog I’ve witten, but if you don’t want my opinion and/or cannot see it as separate from other hats I might wear, please stop reading now. Otherwise…

They’re now known as “Referral-for-profit” situations. POPTS is no longer the descriptive phrase of choice.

For most Physical Therapists, anti-POPTS sentiment has always been easy to sustain. Most PT professionals have a horror story about this or that doc that refused to let a patient see them for all the wrong reasons. Those that don’t work in referral-for-profit situations seem to have more than their share of those.

We forget, sometimes, that folks working in those clinics are Physical Therapists and Physical Therapist Assistants just like us.

They are not often, however, active members of APTA.

But if you want to be brutally honest about it, neither are most of the Physical Therapy professionals in the country.

Only about 43% of Physical Therapy professionals (PT’s and PTA’s) are members of APTA. In Tennessee, that figure is about 27%.

And less than that are what could generously be described as active members.

The referral-for-profit issue seems to get bigger by the day. Legislation, lawsuits, and appeals in South Carolina. Rhetoric and arguments. I have written here in the past about the conflicts.

The net result is that Physical Therapy professionals in RFP situations question the value of their membership in an organization that opposes their practice setting.

Put most bluntly, the whole issue begs a couple of questions:
1. Should PT professionals working in referral-for-profit situations belong to APTA and
2. How does an association that opposes their work situation, recruit and retain referral-for-profit therapists?

For me, the answer to the first question is yes.

There are many more issues in our profession than dealing with referral-for-profit situations.

Reimbursement, respect, our practice acts, Direct Access, autonomous practice, all the many things that are encompassed in the Vision 2020 statement.

Huge agenda items on our plate that make dealing with referral-for-profit situations somewhat secondary.

So yes, PT professionals working in referral-for-profit situations should most definitely be members of APTA, the only professional association that we have and the one that is fighting to protect your rights as a Physical Therapist or a Physical Therapist Assistant.

Fighting to make sure you get paid for what you do at a rate at which you can make a reasonable living. Fighting to both enact legislation to protect you and defeat legislation that would hurt you.

It is that simple.

As a commercial we’re hearing around here says, “the biggest no-brainer on the face of the earth.”

But the second question is much tougher. So, what are we to do?

I would suggest that the problem is really far less about the Physical Therapy professionals in referral-for-profit situations and far more about the physicians that employ them.

Let’s face it, if the playing field were level, this probably wouldn’t be an issue.

If physicians would offer their patients the option of obtaining Physical Therapy services at any appropriate provider, without attempting to influence those patients to visit a facility in which they have a financial involvement, we would not have the conflicts that we now face!

It would still be an issue but would cease to be an ethical dilemma and would certainly not be as contentious an issue as we now face.

Do not take this to imply that Direct Access is not an essential component of the future of this profession: It most certainly is.

And please do not ignore the stumbling block that referral-for-profit creates to achieving autonomous practice.

But without abuse of the referral system, and surely insisting on a single provider with whom that referral source has a financial interest can and should be classified as abuse, this issue would not be addressed with such passion and vigor.

Unfortunately, depending on physicians to self-regulate this one basic issue is highly unlikely.

So that brings us to our stumbling block: We cannot expect physicians to level the playing field, so what options do we have?

That is why there are attempts all across the country to legislate against a situation in which any physician profits from referral to any Physical Therapist.

It is perhaps the only mechanism we have to level that playing field.

I would ask the question of Physical Therapy professionals in referral-for-profit situations (not rhetorically): What would you have us do as a profession?

Any Physical Therapist should prefer that patients choose their services because of what they have to offer the patient, not how much the referring physician needs to supplement their income.

And if you don’t think that is how too many physicians see your services, then you haven’t had a frank discussion with one yet or you haven’t seen one of the many advertised services that offer the opportunity to physicians to establish this “ancillary source of income.”

Physical Therapy professionals should refuse to be an integral part of a system in which the physician demands that the patient go to “their” clinic. If there is any clinician out there that insists that this could never happen at their clinic, give me two weeks to talk to the other clinics in the area and I believe I will find evidence to the contrary.

I would ask that any PT professional ask themselves those same two questions in light of the information provided and then tell me how you would answer them.

But in the meantime, all Physical Therapy professionals need to be active members of our professional association (APTA), working toward those objectives that are common and important to all of us.


Friday, December 30, 2005

Another question from the field

This came in from a soldier in Iraq. I admit that I'm a bit stumped. If you've got any ideas, either e-mail them to me or post them as a comment.

"I ran a 6 miler when I first felt it. I hadn’t run in months and then I just jumped right into it, all through college I was a long distance runner so I thought it would be alright. I started feeling a tightness towards the end of the run but it went away. A week later I did a 10 miler and I felt it almost as soon as I started running, but after a couple of miles it went away and I did not feel it anymore. A week later I did an hour long hill workout on my bike (keeping in mind I had been biking pretty religiously over the past couple of months). I didn’t feel anything during the workout but about an hour after the workout it hit me gradually and I have been feeling it ever since. I have been stretching (with a bent leg, to focus on the soleus) and doing bent leg calf raises at the advice of my physical therapist back in the states. I have tried to ramp up my running slowly 3 times now and I have not been able to break 2 miles without enough discomfort for me to think I should stop. I always feel the most pain when there is physical pressure on the tendon i.e. a boot that covers my ankle or the back of a tennis shoe. I can not create pain or soreness by poking around with my fingers neither can any physical therapist that I have seen. I do not have any pain or discomfort doing calf raises. I do not have weak calf muscles and my hurt Achilles is definitely more flexible now than my good one. I have tried ultrasound therapy (1 month) deep tissue massage (2 weeks) and active release (1 month). While all of them helped my ankle feel good immediately after the procedure it was less than an hour before I was right back where I started. I have not noticed any significant improvement or it getting worse in the 8 months that I have had it. There doesn’t seem to be anything I can do to really get it moving one way or the other. I should also say that I was stupid and after I hurt it, I did quite a good bit of strenuous hiking and then tried to climb Mt. Rainer all within 2 weeks of when I hurt it (it should be noted that none of these activities really made it feel any worse). After I initially hurt it in May I did not ice it or do anything else significant to try and help it except rest it when I wasn’t hiking. It was probably a little over a month before I saw a physical therapist for the first time. I probably deserve this for how stupid I was in addressing this initially, but now I am at the point where I am seriously thinking that a prosthesis might help me live the active life that I once did before this happened. Currently where I work I have to climb quite a lot of stairs. I do my best to climb and descend the stairs flat footed as opposed to pushing off with my toes like you normally would. I have also cut out the back of my combat boots at the advice of another physical therapist to help relieve some of the pressure, it definitely helps a lot as far as pain goes. It should also be noted that my Achilles passes the Thompson test (squeezing the calf muscle and watching for the foot flexing) no problem. Anything you can do to help me would be greatly appreciated. "

And in response to my request for further information (where specifically does it hurt), I got the following:

"I could never pinpoint a focal area of the pain, it kind of jumps around. I can tell you that I’m pretty sure it’s not the muscle. The pain is definitely centralized up and down my left Achilles tendon. If I had to give you an area that hurt the most I would have to say it is the middle to upper Achilles. Upper being where the Tendon inserts into the muscle and middle being maybe two inches above where the tendon inserts in the calcaneus. But definitely more in the body of the tendon than anywhere else, I think. I know that doesn’t really help too much, but I’m definitely going to stick with in the body of the tendon. Thanks for any insight you can provide."


Happy New Year!


Thursday, December 22, 2005

A Clinical Question

A friend and colleague sent me the following question today. It seems quite appropriate to put it on this blog and see how others see the situation. Just go to the "comments" section and post your reply.

I have a friend/colleague/fellow triathlete that has a 6mm X 10mm OCD on lateral aspect of talus secondary to lateral ankle sprain. She is scheduled for surgery, however the surgeon told her that she recommends no more running distances above 10 miles. She was signed up for an Ironman in Idaho and usually does 1-2 half Ironman races/year, as well as several Olympic and sprint distance races.

This friend is also a PT so knows enough about the injury to be worried, but is questioning if the recommendations are too conservative.

I have my opinions, but was wondering if anyone else out there could weigh in on this based on experience.

Merry Christmas (yes, I still say that).

Joe B

Thursday, October 27, 2005

News from Maryville

On October 12th, Pam White resigned as President of the Tennessee Physical Therapy Association. Since I was Vice-President, I then became President, just before the 2005 TPTA Fall Meeting.

That means that I have a whole new set of responsibilities and priorities. One of my very best friends called my wife that same week and asked "can you believe he's doing this?" My wife replied "of course."

I must admit that I once aspired to the TPTA presidency, but Pam was so much more qualified than I am, I was very satisfied serving as her vice-president. At 52, I had long since decided that I would finish this term as VP (it is up in 2007) and then fade into the fabric of TPTA, always serving but certainly in a minor capacity.

All that got swiftly changed.

I look forward to the challenges before me. I have embraced the office and have dedicated myself to succeeding.

I believe that we are called to service. My leadership mantra is as the "servant leader."

I am passionate about the art and science of Physical Therapy and am convinced that the practice of Physical Therapy is inextricably linked to the actions of our professional association.

There is no other answer beyond a simple "of course."


Wednesday, September 28, 2005

NATA Speaks Up

September 27, 2005

Dear NATA Member:

Last April, the NATA released a chart review study that is intended as a marketing tool to promote the athletic training profession to patients, physicians, insurance company personnel, and others. Subsequent to its release, there has been no discussion regarding the authenticity or facts found as a result of the study. There has, however, been discussion related to the methods. It is my hope that the focus will be on the results as it demonstrated that when doing rotator cuff rehab in one practice, athletic trainers were found to do better, in less time, and at less expense than other allied health care providers. As an athletic trainer, I celebrate these findings and am confident a more in-depth and broader based outcomes study will find similar results.

As I am sure you know, in the past year many within the NATA and I have worked to develop and improve the relationship with the American Physical Therapy Association and its Sports Section. Last February, I was welcomed and treated very well at the Sports Section Annual Meeting and had a productive meeting with President Ben Massey of the APTA. As a result, President Massey addressed our members at a General Session in Indianapolis. In August, representatives from the NATA and APTA met in Dallas. The meeting was cordial and, in my opinion, productive. We agreed to future collaborations and I looked forward to continued discussions.

With this as background, President Massey recently called to express his concerns related to this NATA marketing tool. He respectfully asked that it be withdrawn and I declined to act on this request. Due to his and the APTA's strong opposition to this chart review, President Massey informed me that any and all future collaborations would be cancelled. Although I regret that the APTA has chosen not to continue with future collaborations, I do not believe that the study is erroneous or its findings untrue. I also believe that it is the NATA's duty to market our profession and its practitioners in whatever legal, moral, and legitimate way it can. I believe this chart review meets these standards.

It is my opinion that other associations have sought and will continue to seek ways to prevent athletic trainers from becoming eligible for CMS approval as well as other national and state initiatives. It is our responsibility to counter these inaccurate portrayals of our practitioners with information that is legal, moral and legitimate and this is what we have done. We will continue to portray accurately athletic trainers and the unique set of skills we bring to health care regardless of what our opposition may wish.

In spite of recent events, I remain committed to making friends where possible and supporting common causes to benefit the public to whatever degree we can. We will continue to represent our members and profession in as aggressive a way as is dictated by our opposition as well as our desire to reach our goals while maintaining the dignity of the profession and its practitioners. We have not, nor will we, represent our members in any way that is less than honest. It is our hope that our competitors will some day recognize and support our efforts to offer aid to a public that can benefit from our unique set of skills. Until that day, we will be required to choose athletic trainers first and we will do just that.


Chuck Kimmel, ATC
President NATA

Monday, September 26, 2005

APTA Speaks Up

The following can be found at http://www.apta.org/AM/Template.cfm?Section=Current_Issue&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=25128

I print it here in the interests of objectivity:

APTA Dismisses NATA "Study" Promotion

Once again, the National Athletic Trainers' Association (NATA) has vainly attempted to find some justification for its expansive view of athletic trainer services in its efforts to secure athletic trainer parity with physical therapists.

This time the "evidence" is found in a retrospective "study" (that would probably be better categorized as an "infomercial") conducted by an orthopaedic surgeon, a physician assistant, and two athletic trainers. The "study" purports to show that athletic trainer services are cheaper than the services of physical therapists; that the utilization of athletic training is lower than that of physical therapy; and that comparable outcomes are achieved by the provision of both services. (For a copy of the report on the "study," see www.scottgudemanmd.com/programs/atc.cfm

Because of the lack of any citation, it appears that the report of the "study" was not published in any peer review journal. Likewise, there is no mention of an Institutional Review Board (IRB) approval.

Among the "study's" many failings are the following:

Small "Study" Size: The "study" looked at only 36 patients-16 of whom were workers compensation patients with half of those reportedly treated under a physician extender model (involving an athletic trainer) and the other half under a physical therapy model. Twenty non-workers compensation patients were likewise treated under the same models. In all instances, the treatment followed rotator cuff surgery.

Lack of Random Assignment: Although the patients' charts were reportedly picked at random, there is no indication that the assignment to treatment models was also randomized. Likewise, there were no criteria listed for the assignment of patients to the physical therapy model or to the physician/athletic trainer model.

Lack of Patient Comparability: There is no reported evidence that patients in the different treatment models were matched for age, sex, previous functional level, etc. Nor is there mention of even the most basic demographic information.

No Actual Physical Therapy Costs: None of the cited physical therapy charges were actual charges. An estimated "average" treatment charge of $130 was provided by physical therapists from 5 facilities with no mention of whether or not the patients in the "study" were treated in those facilities. There is also no indication of whether these were "billed charges" or "paid charges" or whether they were comparable with the calculation of the "costs" for athletic training.

Orthopaedic Bias: As the report on the "study" itself notes, "because patient satisfaction was based on subjectivity measured by the orthopedic surgeon who operate on the patient, some level of bias cannot be excluded."

Outcomes Impacted By Orthopaedic Bias: The report refers to "comparable subjective outcomes." These subjective outcomes were subject to the same bias as noted above because the measure of outcomes was based on "patient satisfaction," as determined, not by the patient, but by the surgeon.

Questionable "Findings:" It is difficult to confidently determine the meaning of most of the data. Without appropriate statistical testing, what is the real meaning of three tenths of a point difference in satisfaction ratings-which did not even come from the patients themselves? Workers compensation patients received fewer visits from the athletic trainers than did the non-workers comp patients. Yet the average costs for the workers comp patients were higher, thereby implying that these patients received less care at higher costs. However, the reverse is true for the physical therapy patients, who appear to have received more care at slightly lower costs. So, which group of workers comp patients received the care with the better value?

NATA's promotion of this extremely questionable "study" is but another example of its willingness to grasp at any straw in support of its ongoing opposition to the recent Medicare decision that excludes athletic trainers from reimbursement under Medicare's "incident to" provision. APTA will continue to monitor information disseminated by NATA relative to physical therapists and the practice of physical therapy, and respond as appropriate.

Wednesday, September 14, 2005


You've got to check this one out.

Look at www.nata.org/committees/indocc/ComparaAnalysis.pdf.

See what I mean?


To see the "research" that this summary sheet was based on, look at www.scottgudemanmd.com/programs/atc.cfm.

You might notice that I put "research" in parentheses. Reliable resources well versed in research techniques have raised huge questions about the research process with regards to this "study."

I have always been very proud to be an Athletic Trainer and proud of the organization that represents that profession. But this one really bothers me.

Why this? Why now?

The past 7 months have been filled with cooperation and discourse between APTA and NATA. I'd be willing to bet the farm that those days ended with the publication of this document.

Bewildered. Betrayed. Distressed. Increasingly angry.

Those are the words to describe what I am feeling right now.

What do you think? Share your comments with me so I can then, in turn, share them with anyone else. If you want to remain anonymous, I will respect that.

And please send this blog to every Physical Therapist and Athletic Trainer you know. This could be bad and reasonable heads everywhere need to get involved.