David Teuscher, MD

AAOS Now

Published 7/1/2007
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Susan Koshy, JD

State Societies share advocacy strategies at NOLC

Scope of practice issues, physician-owned therapy services remain “hot topics”

When state orthopaedic society representatives converged on Washington, D.C., as part of the 2007 National Orthopaedic Leadership Conference (NOLC), they not only visited their elected officials on Capitol Hill, they also spent time with each other, sharing strategies and information on effecting change at the state level. At the AAOS State Societies Strategy Meeting, state orthopaedic society leaders, officers, and executive directors from more than 40 state societies focused on legislative and organizational issues.

State advocacy was center-stage, in response to efforts by podiatrists to expand their scope of practice and attempts by physical therapists to prohibit physician ownership of physical therapy services. Orthopaedic surgeons, attorneys, practice administrators, and state lobbyists participated in panel discussions and provided advice and education on effective strategies.

Podiatry scope of practice
John S. Early, MD,
chair of the Health Policy Committee for the American Orthopaedic Foot and Ankle Society (AOFAS) presented a national overview of efforts by podiatrists to expand their scope of practice. He discussed the structure of the organizations overseeing the practice of podiatry, as well as the curriculum, postgraduate training, and residency requirements for podiatrists.

According to Dr. Early, neither the public nor legislators are very knowledgeable about the limits of podiatric training. As a result, some podiatrists are effectively advocating for an expanded scope of practice to the ankle and beyond. Only four states—California, Montana, Tennessee, and Connecticut (pending)—follow the American Board of Podiatric Surgery (ABPS) guidelines of requiring training to match scope of practice.

“Although podiatrists provide a valuable service within the medical community,” said Dr. Early, “nationally recognized standards—widely accepted by the medical community—are important for safe, effective patient care and essential to maintain public trust. Privileges for ankle surgery should coincide with demonstrated training, using the ABPS status as the minimum standard.”

State experiences
In Texas, said David Teuscher, MD, past president of the Texas Orthopaedic Association (TOA), podiatrists have attempted to change the definition of the foot to include the ankle and leg. The resulting lawsuits—including a restraint of trade suit against both the state medical society and the TOA—were both costly and wearing.

“A state specialty society can carry a scope of practice fight only so far,” said Dr. Teuscher. “Scope of practice issues affect all physicians and all physicians must join together to address these issues.” To ensure patient safety and oppose unsafe scope of practice expansion, the Texas PatientsFIRST coalition was formed by 17 medical and specialty societies and the 10 largest county medical societies in the state. The coalition is working to educate legislators and the public; as a result, physicians have increased their effectiveness at writing and passing legislation.

Steven Ross, MD, former president of the California Orthopaedic Association and AOFAS president elect, discussed his state’s experience in this area. Dr. Ross stressed that formal education and training are the cornerstones of appropriate, quality care. “Educational standards are essential to ensure public safety and need to be monitored and accredited by a national organization recognized by the Federal government,” said Dr. Ross.

Finally, Alan S. Routman, MD, president of the Florida Orthopaedic Society (FOS), discussed a new strategy to introduce “Take Back” legislation in Florida. Under current statutes, podiatrists in Florida can perform surgery below the knee and can provide nonsurgical treatment up to the hip. Last year (2006), the FOS proactively proposed legislation to restrict all podiatry treatments to the foot and ankle. Although the bill had limited success, it did prompt the Florida Podiatric Medical Association to begin negotiations with the FOS. Rather than abandon foot and ankle treatment to podiatrists, advised Dr. Routman, “articulate a clear delineation of hospital privileges for members to use locally and be active on your hospital’s committees and carefully screen podiatrists’ applications and privileges.”

David Teuscher, MD
Alan S. Routman, MD

Physician-Owned Physical Therapy Services
“In my state,” said Bernard Kirol, MD, the president-elect of the South Carolina Orthopaedic Association (SCOA), “a physical therapist can employ an orthopaedic surgeon but an orthopaedic surgeon cannot employ a physical therapist to assist with patient care.” Dr. Kirol described how an opinion issued by the state’s Attorney General was used by the physical therapy board to revoke the licenses of physical therapists employed by physicians. (See “Orthopaedists beware: You could be losing control of your practice,” AAOS Bulletin, December 2006.)

Dr. Kirol stressed the importance of establishing relationships with legislators before a crisis occurs. “It’s not all about money,” he said. “We are more likely to take advice from someone we know and trust; politicians are no different.” He also encouraged meeting participants to contribute to political campaigns and to be advocates for patients with these decision makers.

SCOA has not given up on the issue of physician-owned physical therapy services (POPTS), but has hired a lobbyist and is laying the political groundwork to introduce new legislation. “We are repositioning SCOA to be a strong political advocacy group for patients and orthopaedic surgeons in South Carolina,” he concluded.

POPTS in other states
Attorney Lenora Pate spoke about the Alabama experience with POPTS. A recent rule adopted by the Alabama Board of Physical Therapy would prohibit financial arrangements between physicians and physical therapists and make it “unbecoming” conduct for physical therapists to accept referrals from a physician who employs them. When the rule was brought before a legislative oversight committee, however, it was overturned by a unanimous vote. In 2007, the Alabama legislature passed a resolution upholding this vote.

In addition, in 2007, the Orthopaedic Provider Network and the Medical Association of the State of Alabama introduced legislation—recently signed into law—that would prevent the Alabama Board of Physical Therapy from passing any rule that would deny physical therapists licenses or suspend them from practice for being employed by physicians.

John M. Vines, chief executive officer of the Campbell Clinic, discussed POPTS in Tennessee. Although the situation there was similar to that in South Carolina, the outcome was very different. A cooperative effort and a proactive stance by the Tennessee Orthopaedic Society and the state medical society resulted in legislation that protected POPTS.

“Get your own lobbyist, as well as a strong champion for your issue,” he advised. “Sometimes you have to play offense, but first know your state laws and be able to articulate the distinctions among state laws.”

According to Alan Skipper, the executive director of the North Carolina Orthopaedic Association, developing coalitions with key organizations and building relationships with legislators was key in defeating a bill that would have prohibited POPTS in that state. Virginia Orthopaedic Society lobbyist Cal Whitehead reported on a compromise over direct access to physical therapists that resulted in a 5-year agreement by all parties not to

introduce legislation that would change (expand or restrict) physical therapy scope of practice or affect POPTS.

Copies of the presentations made at the NOLC State Societies Strategy Meeting are available on the AAOS Web site, at www.aaos.org/Govern/State

Susan Koshy, JD, is manager of state society and legislative affairs in the AAOS department of government affairs. She can be reached at koshy@aaos.org