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Published 10/1/2009
Peter Pollack

Taking direct action on direct access

Concern for patient safety triggers one surgeon’s protest

The U.S. Congress is currently considering a measure that could have a serious effect on how orthopaedic patients interact with physical therapists. Concern over patient safety moved Peter L. Meehan, MD, to write Sen. Lindsey Graham (R-S.C.) urging him to reconsider his cosponsorship of the Medicare Patient Access to Physical Therapists Act of 2009 (SB950/HR1829).

The bill is designed to “amend title XVIII of the Social Security Act to authorize physical therapists to evaluate and treat Medicare beneficiaries without a requirement for a physician referral, and for other purposes.” In other words, Medicare patients would no longer need a prescription to contract the services of a physical therapist.

Dr. Meehan argues that physicians act as an important filter, screening patients from unnecessary physical therapy while offering diagnostic expertise that most physical therapists lack.

A compromise for access
“The concern I have with this,” says Dr. Meehan, “is that by education, physical therapists are not taught, nor are they licensed to diagnose, medical conditions. They have no educational component in interpreting laboratory studies. They’re a treatment group and do a very good job with that, but they’re not a diagnostic group.”

Dr. Meehan has been down this road before in his home state of Georgia. More than a decade ago, he and Hamilton E. Holmes, MD, found themselves testifying before a Georgia Senate committee on a similar issue. That bill was defeated, but in 2006 the issue arose again when Glenn Richardson, speaker of the state House of Representatives, attempted to return to his physical therapist after his prescription had expired.

“He’d been to a therapist and stopped going and his prescription lapsed,” explains Dr. Meehan. “And when he went back for more therapy he was told, ‘I can’t see you; you have to go see your doctor.’ He viewed that as an imposition, and I understand that. I’m very sympathetic to that.”

In the end, the Georgia legislature passed a compromise bill allowing patients who have been referred by a physician to return to qualified physical therapists for ongoing treatment for up to 60 days for the same condition.

Diagnosis before treatment
According to Dr. Meehan, a physical therapist’s lack of diagnostic training leads to several issues, most notably that lack of a proper diagnosis may not only delay the correct treatment, it could potentially put the patient in danger.

For example, when asked what he would do in the case of a 45-year-old male ex-smoker who was just starting an exercise program and complained of pain in his left shoulder, a physical therapist outlined an exercise program to deal with the issue.

“The problem is that pain in the left shoulder is also a symptom of a heart attack,” says Dr. Meehan. “It could be cervical disk disease. A lung tumor could cause the same sort of symptoms. Of course, it could be bursitis, but this is an example of an area in which you can’t jump to the conclusion that the problem is musculoskeletal.”

Additionally, in many situations physical therapy (PT) may simply be unnecessary, and providing such therapy adds an additional strain to an already expensive healthcare system. In Georgia, portions of the Medicaid system case load were privatized in the hands of three companies. According to Dr. Meehan, in the first year of operation, those companies realized millions of dollars in savings by closely monitoring the PT overuse in the Medicaid population. Putting the decision for treatment in the hands of physical therapists, he argues, will have a converse effect.

“We all understand primacy of diagnosis before treatment,” wrote Dr. Meehan in his letter to Sen. Graham. “We also know that many problems that we evaluate in our offices need no treatment because the natural history of the condition is resolution. One could treat this same problem with PT with the same result as the natural history of the disease process. If therapists are given direct access with the ability to treat and third-party bill (without medical diagnosis), the costs to the healthcare system will escalate as I assume they [physical therapists] will determine what a patient needs.”

More confusion on the way?
Complicating the issue is a bid by the American Physical Therapy Association (APTA) to develop and implement training programs that will, by 2020, produce doctoral-level physical therapists. According to the APTA vision statement, “physical therapists will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice.”

Dr. Meehan contends such a move will likely add confusion to a healthcare system that already includes chiropractors vying with orthopaedists to treat patients for musculoskeletal conditions. A lack of sophistication in understanding what orthopaedists do and how they are trained may lead patients to seek treatment from yet another group of practitioners who may not be the best choice for the condition at hand.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Additional Informations:

Medicare Patient Access to Physical Therapists Act of 2009

AAOS resources: Direct Access to Physical Therapy (member login required)

Sample Direct Access Advertisement (In PDF format, member login required)

Graph: Decision-Making Ability of Physical Therapists (In PDF format, member login required)

PT Self-Referral State Laws (In PDF format, member login required)

PT Self-Referral Map (In PDF format, member login required)

Direct Access MedPAC Report (In PDF format, member login required)

COA defeats PT direct access legislation