You Cannot Complain if You're Not Involved: Perspectives of an Advocacy Veteran
"You Cannot Complain if You're Not Involved": Perspectives of an Advocacy Veteran
Eva Norman, PT, DPT, has been a force in federal and state-level advocacy for physical therapy for nearly two decades, and a mentor to aspiring advocates for nearly as long. Currently, she is chair of the PT-PAC, the profession's political action committee, but her involvement also includes service as a Federal Affairs Liaison from the Minnesota Chapter of APTA and as an APTA "Key Contact" — a member who serves as the primary contact with their state’s U.S. senators or representatives. She owns Live Your Life Physical Therapy, a cash-based wellness and prevention-focused clinic that offers physical therapy, occupational therapy, speech therapy, and a range of other services. Norman is a certified exercise expert for aging adults.
#PTTransforms caught up with Norman to find out how she got started in advocacy, her thoughts on its importance, and how APTA members and stakeholders can get involved.
What led to your interest in advocacy? Was it a single "a-ha" moment or a gradual realization?
When I was 13 years old, I was involved in a traumatic accident and was told I would never walk again. Thanks to an extraordinary physical therapist, I have little to no deficits. My physical therapist gave me reason to live and provided such a better quality of life for me. And I'm a better person today because of that experience.
After that yearlong course of rehab, my mom promised God that if I lived, we would give back. She had me volunteering all over — clinics, hospitals, group homes, everything. It was my way of thanking the profession. I am very grateful, and I've always tried to give back, so that's been a part of me for most of my life — just not always through advocacy.
As a new graduate I moved to Minnesota. One of my first supervisors, Anne Coffman, sat down with me at the beginning of the year in 2003 and said, "Let's set your annual goals." She told me that she wanted me to have a goal of being more active in APTA, specifically in Minnesota. I asked her for suggestions, and I told her that I've always wanted to give back and make a difference in the profession. She told me that the best way to do that was by getting involved in government affairs.
I was like, "Huh?" I looked at her and said, "Anne, you realize I'm apolitical. I don't vote. I don't even know who my members of Congress are. That's not my world. You're barking up the wrong tree." Anne said, "But your passion for your profession is so strong, and you have so much energy, you'd be so good. Just go to a meeting and listen."
So I did. I attended my first chapter government affairs meeting, and it just so happened that the president of the chapter at that time, Paulette Olson, was also the chair of the government affairs committee. She was talking about repealing the therapy cap. The committee was sitting around this table, and I was in the back of the room, just there to listen. But something got to me—in the middle of the discussion I raised my hand, just rudely interrupted, and said "I have a question."
I asked, "Why are we still lobbying that issue? I thought we repealed that, didn't we? We sent all these letters to Congress. We took care of that, right? What happened?"
Paulette looked at me pretty sternly and said, "You cannot complain if you're not involved." And then she went on with her meeting. I literally fell into my seat, I was so embarrassed.
After the meeting, Kathleen Picard, who today is a dear friend and mentor, applauded me for questioning the status quo. She encouraged me to keep attending meetings and keep talking. I'll never forget the impact of her words since they solidified my commitment to keep advocating for my patients.
I knew that day that I wanted to make sure my patients never had to ration care due to the therapy cap, and I wanted to help advance the profession through passage of critical legislation. By the end of the month, I was being asked to go to my first Federal Advocacy Forum in Washington, D.C., to lobby.
What’s the one thing you wish more members understood about professional advocacy?
Advocacy can be simple. A lot of people think, "Oh it's so much work, I don't have time for that." But as I tell my students, you can get involved in so many levels. It could be as simple as educating your patients and your colleagues about the issues impacting the profession and encouraging colleagues to get involved through our grassroots network, the PTeam.
Through the free APTA Action App, you can join the PTeam in less than 30 seconds and get alerts about legislation that has been introduced or needs action. Through the alerts, you can take action in seconds by sending a message to all your members of Congress to educate them on the issue and seek cosponsorship. The APTA website also makes it easy for patients to have a voice, through the patient action center. Through these quick steps, you and your patients may be able to convince a member of Congress to support an issue, which ultimately can lead to moving critical legislation forward.
And for those who want to get more involved but are intimated, don’t feel as though you have to speak, just show up at a district meeting, town hall, or fund raiser, and let other colleagues do the talking. Numbers matter to members of Congress. It lets them know that an issue is important and that there are others who care. Understand that these legislators are regular people, and you’re the constituents and experts on these issues. You’re the most important person in the room to them.
[Editor's note: find out more about APTA's grassroots opportunities, including the PTeam, at the APTA Advocacy Grassroots Network webpage.]
What kinds of changes have you noticed in advocacy, especially advocacy for the profession, over the years?
When I got involved with my chapter as the Federal Affairs Liaison 13 years ago, there were only a handful of us from Minnesota attending the Federal Advocacy Forum. My fellow liaisons encouraged me to seek funding to bring others to Washington, D.C. I convinced our board of directors to provide funding to take one constituent from each congressional district. Therapists from all over the state got involved. Our grassroots grew rapidly overnight. That led to the chapter successfully creating a scholarship program for students and stipends for therapists to attend the forum. As part of the preparation for attending the forum I hold quarterly key contact meetings to educate our grassroots. I also give lectures to the various PT and PTA programs throughout the state. Every year we take more and more therapists and students to the forum. This kind of evolution is happening all over the country, which is allowing us to have a stronger voice on Capitol Hill. This improvement is making a difference as shown by the legislative wins we see year after year.
What’s your advice to a member who’s thinking about becoming more involved?
Talk with your chapter or section federal affairs liaison. That person has experience, knowledge, and resources that can help you become an effective advocate. Also, ask them if they can recommend a mentor. Having someone you can talk to who has participated in advocacy at a local or national level can help you build confidence and craft your message.
Have you had any moments in which you thought to yourself, "THIS is why I’m involved in advocacy"? What were they?
This goes all the way back to 2003, when I first got involved in advocacy. At that time my congressman was Jim Ramstad, and I kept thinking about one of the things that Justin Moore our CEO now, but back then he was director of government affairs — said, that it's all about relationships. I took that to heart, so I contacted Ramstad's campaign team and asked to get involved with his campaign but said that I wanted facetime. They said that would not be a problem, and I had the opportunity to talk with him at several events. By 2004 I actually got a meeting with him — and I even got a hug! He was happy to see me, and during our conversation, he told me that he would be on board with our legislative priorities, even willing to cosponsor if needed. I walked out of that meeting practically in tears, thinking what a difference it had made for my profession and my patients to develop a relationship.
So, years go by, and I continue to help with his campaign and set up meetings with the congressman in his home district. That led to him inviting me to fund raisers and introducing me to other members of Congress. Eventually, the relationship was so strong that we were able to get Ramstad to become the lead Republican sponsor on APTA's Medicare direct access bill — an important issue for us but controversial for Republicans. However, he did not hesitate when asked and stated, "You've educated me on this issue for years, and we're wasting too many health dollars." It was the moment when I realized the power of what can happen through advocacy and by building relationships.
How do you respond to critics of APTA's advocacy efforts?
The association is doing so much on our behalf. If you are not satisfied with what is being done, contact the public policy division of APTA to seek answers to your concerns. They will answer your call or respond to your email. I encourage you to research the advocacy section of the APTA website and read position papers, white papers, educational materials, and resources to help you better understand the issues, and what the association is doing to protect and promote the profession. As Paulette Olson said to me years ago, "You cannot complain if you're not involved." I encourage you to get involved, learn about the issues, and ask questions.
Is advocacy only about notching up legislative and regulatory victories? In other words, what does it really mean to be an advocate for your profession? And why is it important for APTA members to be involved?
It's about learning about the issues important to our profession and patients. It’s about educating our legislators, patients, coworkers, students, and other therapists about these issues. It's about giving a voice to our patients by sharing their stories with members of Congress. It’s about attending events that can build relationships with our members of Congress. It’s through these ongoing conversations and relationship building that leads to legislative victories. Imagine if every member took time to educate and build a relationship with their legislators. Our voices would be heard loud and clear on Capitol Hill. We would have far more legislative wins in a shorter period of time, helping to improve the lives of that many more of the millions of Americans seeking health care. Learn, educate, advocate — physical therapy and our patients are counting on every one of us.
What's the value of PT-PAC in particular to the profession?
The dollars that go to PT-PAC help us develop relationships with influential members of Congress, those on important health committees that can move our legislation forward. PT-PAC also helps us elect friends of physical therapy to Congress each election.
With these dollars, we are able to attend fund raisers where we have facetime and can have important conversations that are critical to the future of the profession, as well as the health and well-being of our patients. These dollars ensure our seat at the table to communicate our patients’ needs. A lot of our members don't even know about the level of our involvement until they ask the question, but we're there, and it's because of the support and generosity of so many members. That support is what led to us being so influential during the repeal of the hard therapy cap — we were being called upon as experts throughout the process. When amendments were proposed, even at the 11th hour, we were called upon for comment. That was a direct result of the relationships we were able to build through member support of PT-PAC. We cannot advance the profession without PAC dollars. Members, donate now, donate often. You will make a difference!
How has your involvement in advocacy affected your own work (and professional philosophy) as a PT?
Giving my patients a voice is most important to me. With proper consent, I now seek out patient stories throughout the year from various congressional districts within the service area of my business, and I video their message to share with members of Congress. I introduce my clients to the patient action center. I send emails through the legislative action center every Friday during my workday. I educate my staff on the issues, and mentor and encourage them to get involved in advocacy on a local and national basis. I educate whoever is willing to listen on the importance of physical therapy advocacy.
APTA advocacy resources:
APTA Advocacy in Action: 2019 Wins, and What's on Our Radar for 2020
By Justin Elliott
With the start of 2020 we begin the second and final year of the 116th U.S. CongresS. Last year was filled with challenges and
opportunities on Capitol Hill and with federal agencies, and they're sure to continue into this year. APTA's taking the advocacy lead
on a number of bills impacting the physical therapy profession and the patients we serve that may be addressed in the 116th Congress,
Physical Therapist Workforce and Patient Access Act (H.R. 2802/S. 970): Adds PTs as eligible providers to the National Health
Services Corps Loan Repayment Program, which can provide up to $50,000 in student loan forgiveness in return to for a two-year
commitment to work at an approved site located in a rural or underserved area.
Prevent Interruptions in Physical Therapy Act (H.R. 5453): Expands locum tenens — the ability for a physical therapist to bring
in another licensed PT to treat Medicare patients and bill Medicare through the practice provider number during temporary absences
— under Medicare for outpatient PTs in all geographical areas (currently, PTs may use locus tenens only in designated areas that
typically lack adequate health services).
Primary Health Services Enhancement Act (H.R. 5693): Designates PTs as primary health providers in federal community health
Allied Health Workforce Diversity Act (H.R. 3637/S. 2747): Creates a scholarship program for individuals from underrepresented
populations for the fields of physical therapy, occupational therapy, audiology, and speech-language pathology. The U.S. House of
Representatives has already passed its version of the bill, so our focus now turns toward the Senate.
While those issues continue to be discussed, we also worked on legislation that was resolved last year. Among our wins: the
finalization of the fiscal year 2020 appropriations bill for the U.S. Department of Health and Human Services, which included a $3
million increase in funding for the National Institute on Disability, Independent Living, and Rehabilitation Research. APTA was part
of a coalition that advocated for this increase in rehabilitation research funding. Congress also passed, and the president signed,
the Protecting Access to Wheelchairs Act, another piece of legislation that we backed.
Our successes in 2019 were fueled by tremendous work by our member advocates, who sent over 67,000 emails to members of Congress
and hosted 60 in-district practice visits with memberS. In addition, PT-PAC, our political action committee, raised $812,963 in 2019,
a 9% increase over 2018. It's hard to overestimate the role PT-PAC plays raising our profile on Capitol Hill, just as it's hard to
overestimate the value of donations to the PAC. Federal law prohibits APTA from using member dues for political contributions, so
your support of PT-PAC is much appreciated.
So what's in store in 2020? My colleague Laura Keivel, APTA's grassroots and political affairs specialist, and I recently recorded
a webinar that covers many of the issues and bills that are on APTA's advocacy radar. It's free to download and provides lots of
detail. In the meantime, here's a quick summary of some of our biggest issues.
Clearly, the biggest issue facing the profession in the near-term is fighting CMS-proposed changes to the 2021 Medicare physician
feel schedule that would result in an estimated 8% payment reduction for PTS. This year, we're ramping up efforts to fight that ill-
conceived plan. APTA is grateful to RepS. Buddy Carter (R-GA) and Lisa Blunt Rochester (D-DE), who are leading a House letter of
inquiry about the proposed cuts that will be sent to CMS. We're also working with the other impacted health care provider groups to
aggressively advocate to CMS on this issue, as well as to pursue legislative options to prevent the CMS proposal from being
implemented in its current form. If you haven't seen it yet, check out APTA's #FightTheCut resource page and consider adding your
voice using some of the advocacy vehicles provided.
But that's not all, by a long shot. We're also working with legislators and their staff on multiple bills related to home health
and postacute care; advancing physical activity, prevention, and health promotion; providing better access to care for children, the
elderly, our veterans, and persons with disabilities; and advancing rehabilitation research. Like I said, it's going to be a busy
year. Some other bills we are working on include:
Improving Seniors' Timely Access to Care Act (H.R. 3107): Seeks to reduce prior authorization burdens in Medicare Advantage
planS. This bill continues to gain momentum and currently has 161 House cosponsors.
The Individuals with Disabilities Education Act (IDEA) Full Funding Act (H.R. 1878/S. 866): Increases spending over the next
decade to bring the federal share of funding for special education up to 40%, the amount committed when the law was first enacted in
CONNECT for Health Act (H.R. 4932/S. 2741): Expands the use of telehealth under Medicare.
Medicare Patient Empowerment Act of 2019 (S. 2812): Allows PTs to privately contract under Medicare (also known as an "opt out").
Protecting Student Athletes from Concussions Act (H.R. 5611/S. 2600): Establishes specified minimum requirements for the
prevention and treatment of concussions in school sport.
Lymphedema Treatment Act (H.R. 1948/S. 518): Expands Medicare coverage for compression garments for beneficiaries with
lymphedema. The legislation has passed the House, and the APTA-supported bill will now be considered by the Senate, where it already
has 70 cosponsorS.
With 2020 being an election year, our work to let our voice be heard is now more important than ever. While the elections will
undoubtedly strain partisan divisions and increase political noise, we will continue our bipartisan focus on advocating for the
physical therapy profession and getting results for the patients we serve. And there's still time for you to engage: Join us at the 2020 APTA Federal Advocacy Forum this March 29-31 in the District of Columbia, where we will bring our message to Capitol Hill.
As APTA member Theresa Marko, PT, DPT, MS, wrote in a recent APTA blog post, "Advocacy for our profession isn't a spectator sport." We need you on the team now more than ever. Check out our federal advocacy page for more information.
Justin Elliott is APTA's vice president for government affairs.
Want to know more about APTA's efforts on Capitol Hill? Check out this webinar that provides an in-depth update on APTA's Public
Policy Priorities as they relate to the 116th CongresS. The webinar covers many of the issues and bills that APTA is leading or
supporting up on Capitol Hill. It's free to download and provides lots of detail. Note: The webinar was recorded via
Advocacy for Our Profession Isn't a Spectator Sport
By Theresa Marko, PT, DPT, MS
I have been a practicing physical therapist for 20 years. When I think about how long that is, it blows my mind.
For many years I was probably a lot like many PTs you know: not involved with APTA or advocacy, happy to be treating my patients and making an impact changing people's lives every day. It was gratifying to know that I was helping my patients to be more fulfilled because they now could walk down the street, or go to the grocery store, or sit on the floor to play with their grandkids. I was satisfied with my role in my profession.
Along the way, however, things changed. And the change wasn't even intentional.
At some point, I wanted to be sure that my education and knowledge base were equivalent to the DPT education currently taught, so I made the decision to get my DPT postprofessionally from Des Moines University. While I knew at the beginning that I was going to learn things, I had no idea that this education would change the course of my life and my core beliefs.
During a class I learned about advocacy and its impact on our profession. It was as if a fog lifted. All of a sudden I clearly saw that the system I had been working in all these years was impacted by the laws legislators make and, maybe more important, that these very legislators had no idea what my profession does or how much of a positive impact we have on the world.
It became clear to me: These legislators were not making laws that were in the best interest of my patients, my profession, or me personally. At that very moment, the light switch flipped, and I knew I must take up the banner to let legislators know. The spark of advocacy lit a flame in me, and I was compelled to come into the advocacy arena.
I knew that while sometimes it is true that one person can articulate her or his dreams and have a great impact, it's a relatively rare occurrence. But I also knew, deep down, that change can be made through many people—that together, we can create a much louder collective voice with a resounding boom. And I wanted to make as big an impact as possible. I knew that aligning myself with my professional association and other like-minded individuals would be the best path for what I hoped to accomplish.
So I started going to conferences and getting to know my colleagues who were already taking up this banner. I joined the PTeam to get advocacy newsletter alerts, became a Key Contact for APTA, went to the APTA Federal Advocacy Forum, went to my state chapter Lobby Day, and attended local district meetings. I started to meet all the people who had been there so many years before me. They had been fighting for me, on my behalf, and on your behalf—we just didn't know it.
Since then, I have gone to board meetings, been on conference planning committee meetings, and become part of several committees of APTA and its components, where we meet to strategize on how to improve things for the entire profession and our patients.
Whether you know it or not, there are so many of us in this volunteer army, fighting for you, fighting to keep reasonable payment, fighting to get more practice rights (imaging and telehealth, anyone?), fighting administrative burden (prior authorization, yuck!), and so much more. The list is long, and the progress is slow, but, still, we all realize that we are #BetterTogether and our #CollectiveVoice is louder when we stand as one.
As I have become part of the army that advocates for change in our system I have witnessed firsthand the dedication, passion, and effort that goes into this fight. The time alone is substantial: days missed out of financial opportunity from the clinic, time away from loved ones, children and pets missed, jet lag, and exhaustion from trying to do it all.
I didn't know these people were doing all this for me. For you. And now I am one of them. And I can't help thinking that if only more of us understood what's truly happening, the commitment and effort it takes, some of us wouldn't be so quick to dismiss what we've accomplished and what we continue to fight for. Thus, I have taken it as my life's mission to spread the word of what we are doing and what we are trying to do.
Here's the deal: Whether anyone likes it or not we all have to operate in "the system" — our American government, its democracy, bureaucracy, and politics. I've learned that making change is painfully slow, takes much patience and perseverance, is built on relationships, has so many moving parts and opposing forces, and often feels like an uphill battle. But I love advocating for my profession and do it with joy. Because what's the alternative? Stand alone? Get swallowed up by another profession that has a bigger association and larger lobby?
This is my profession, damn it. This is my life's work and I will not see us diminished. What about you?
So, yes, I choose the side of the association. I choose the side of the volunteer army that continues to try to launch all these sparks of change, hoping that they will catch. I feel what we as PTs offer to the world is so special that we must safeguard it and hold it close, as it is dear. We make an impact on people's lives in a way that most don't. That's pretty awesome.
Instead of being a clinician inside the system who must succumb to the powers that be, I choose to be someone who is trying to influence the system to operate the way I believe it should. In our profession, there is no "they." There's only us. And it must be us who step up together with our collective voice to create change.
Theresa Marko, PT, DPT, MS, is a board-certified clinical specialist in orthopaedic physical therapy. She is a member of the APTA Public Policy and Advocacy Committee as well as the APTA Private Practice Section Government Affairs Committee. In addition, she serves on the Practice Affairs Committee of the American Academy of Orthopaedic Manual Physical Therapists and on the Finance Committee of the APTA Academy of Orthopaedic Physical Therapy. She was recently named federal affairs liaison for the New York chapter of APTA.
Want to learn more about how you can advocate for the profession and its patients? Visit the APTA Advocacy webpage for involvement opportunities and ways to take action. Better yet, learn about APTA advocacy firsthand (and then take what you've learned to Capitol Hill): join us for the APTA Federal Advocacy Forum, coming to Washington, DC, March 29-31.
5 Reasons Why I Love Working in a Military Health System
By Ashish Kakar, PT, DPT
I'm a physical therapist (PT) at Walter Reed National Military Medical Center (WRNMMC), and I love my job.
I didn't start my career in the military health system (MHS). I worked in a civilian outpatient physical therapy clinic like a lot of physical therapists do, and then began working at WRNMMC 2 years ago. I have to say that it has been an eye-opening experience for me. What I want to do in this post is to break down the 5 reasons why I love working in the MHS. They revolve around 2 things: our patients, and the autonomy PTs have in taking care of them.
The patient population: As a PT working at WRNMMC, I see a diverse group of patients. We see active duty service members, beneficiaries of service members, and retirees. The variety of patients, in turn, allows me to see a wide variety of diagnoses from poly traumas to neck and low back pain. This keeps me excited to come to work every day, because I know I'm likely to see something different. Most important, it's incredibly rewarding to know that I can help return active duty service members to full health and duty.
Working with my military counterparts: WRNMMC is my first clinical experience in the MHS, and the facility is considered the "flagship of military medicine." I work alongside my active duty PT counterparts and military and civilian physical therapist assistants and physical therapy technicians, many with deployment and overseas experience. The level of care and compassion that the WRNMMC PT staff show daily is what makes this service run as well as it does, and it is one of my favorite things about working at WRNMMC.
The ability to refer to other specialties: Patients that come into the rehab department come with multiple levels of complexity, and some need more resources than others. As a PT in the MHS, I can refer the patient to whatever type of care the patient may need. I can say that having the ability to refer patients to behavioral health, orthopedic surgery, physical medicine and rehabilitation, and other specialties improves the patient experience. It allows me, as the provider, to provide the best care for my patients and saves the patient time from having to wait and see their primary care physician for such things.
The ability to order imaging: As the primary care provider for musculoskeletal conditions, it is imperative that PTs can order imaging for their patients when warranted. This is not a tool that I use that often, but having the ability to order imaging improves patient care and gives me the ability to diagnose and treat accurately.
Innovation: The ability to be on the cutting edge of practice is what makes working in the MHS so great. Working with physical therapy leadership in the clinic, I have been able to develop the "Back on Track" class. This is a pain neuroscience education class for patients with low back pain who are at risk of developing chronic pain. I have even been able to offer this class along with regular physical therapy follow-up appointments over telehealth, an emerging technology offered by WRNMMC.
It is all these things and more that allow me to be the provider that my patients need to get better faster. It is these privileges that allow me to be the primary care provider for musculoskeletal conditions. It is my experience at WRNMMC that has allowed me to practice to the limit of my education and to experience the true impact that physical therapy can have on patients' lives and the health care field.
It is this experience that also has sparked my interest in working with the Federal Physical Therapy Section of APTA to help develop the primary care special interest group (SIG). The goal is to help promote PTs as the primary care providers for musculoskeletal conditions. If you would like to learn more, check out section's SIG webpage.
I appreciate having the opportunity to be able to write this blog for APTA, but I haven't yet shared my favorite thing about working at WRNMMC: our wonderful service dog, Staff Sergeant Truman. He brings a smile to every patient's face that he sees!
The author has no conflicts of interest to disclose. The views expressed in this blog are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, Veterans Affairs, Army, Navy, or US government.
Challenges and Opportunities in Telehealth: A Q&A With the Experts
Telehealth is in the news lately, as state and federal lawmakers debate the necessity and logistics of remote patient care and payment, including the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019. The bill, which APTA supports, would expand the use of telehealth services and ease restrictions on telehealth coverage under Medicare, as well as encourage the Center for Medicare and Medicaid Innovation to identify which services delivered via telehealth can result in cost-effective and positive patient outcomes.
#PTTransforms Blog spoke to APTA members Sarah Gallagher, PT, DPT, and Alan Lee, PT, DPT, PhD, about the possibilities, challenges, and current use of telehealth across health care professions. Gallagher is the owner of South Valley Physical Therapy, a Colorado private practice specializing in neurologic and vestibular physical therapy that began providing telehealth services to solve an access to specialty care problem. Lee is the telehealth lead for the APTA Frontiers in Rehabilitation Science and Technology (FiRST) Council and vice president of the Technology in Physical Therapy Special Interest Group of HPA The Catalyst, APTA's section on health policy and administration.
#PTTRANSFORMS: How is telehealth being used already, both inside and outside the physical therapy profession?
Gallagher: In my practice, we primarily treat vestibular conditions. Outside of assessments and adapted interventions, we can educate patients and family members, learn about how the person interacts with their native environment and make recommendations, make the person independent in their home exercise program, help them problem solve where and how to do the exercises they were taught in the clinic, progress activity recommendations, evaluate performance on home exercise equipment, and make recommendations for office environments and ergonomics.
Lee: Within physical therapy, telehealth is used synchronously with live audio and video sessions and asynchronously with remote biometric and imaging sessions, as well as remote monitoring. Telehealth inside and outside of physical therapy is used in large federal health systems such as the Department of Veterans Affairs, as well as large private health systems such as Kaiser Permanente. Some corporate telemedicine firms contract with health care plans to provide additional telemedicine services.
Physical therapy telehealth services are emerging in pediatrics, geriatrics, women's health, oncology, wound management, orthopedics, neurology, cardiac and pulmonary rehabilitation, and home health care. Obviously, any physical therapy services that require hands-on care are not provided via telehealth. Screening out patients that require in-office care is key to appropriate use of telehealth. Telehealth is just a tool to facilitating best practice and care in physical therapy and should not duplicate any unwarranted services. If telehealth services are not improving the quality of care or improving patient outcomes, they should not be used.
#PTTRANSFORMS: Is telehealth a potential business opportunity for small practices?
Gallagher: Absolutely. A practice can expand its physical reach and offer specialty services to a broader geographical audience.
Lee: This has been a point of contention on social media. Yes, telehealth physical therapy can be an opportunity, but it is more complex than just a simple video chat. Offering telehealth services is the same as establishing professional in-office care. You will need risk mitigation with attorneys, insurance, billing and coding, documentation, and competencies for staff and yourself in policies and procedures for emergencies and handling all situations. Some helpful resources include APTA's telehealth webpage, the APTA FiRST Council, the Federation of State Boards of Physical Therapy (FSBPT), HPSO's telemedicine risk management (.pdf), and APTA's Private Practice Section.
#PTTRANSFORMS: Are services for telehealth being reimbursed differently from those delivered in person?
Gallagher: Our clinic is being paid by insurance at the same rate as for our in-clinic sessions, but it depends on the state legislation regarding payment parity.
Lee: It can be different in some situations where insurance parity is not the law, or if the payers deem that telehealth services will be paid at a lower level. This is where your advocacy, as well as sharing direct patient testimonials from your telehealth services, can be helpful to all stakeholders to educate and deliver high-level care with appropriate payment.
Again, telehealth is just a tool to enhance the patient-provider relationship and engagement, and thus it should be paid at the same level as in-person services. There is evidence of Medicaid telehealth physical therapy services being paid according to CPT codes, when they were deemed medically necessary and there were no in-person services accessible to patients. And, there are private payer examples in Colorado and Minnesota for vestibular physical therapy care, with private practice physical therapists engaging with payers for parity in payment for services.
#PTTRANSFORMS: What licensure or regulatory issues need to be considered?
Gallagher: PTs must know their state practice act to be sure there are no legal restrictions on telehealth, for example, with regard to direct access and scope of practice. The patient must be located in the state in which the PT is licensed during the telehealth session. If your patient vacations in a state in which you are not licensed, you cannot treat them at that time. PTs also need to be aware of any other state telehealth legislation, such as regulations for informed consent language.
Lee: The key is to maintain your license in the state where the patient is located. Currently 18 states issue interstate practice privileges under the Physical Therapy Compact, while eight others have enacted legislation to allow participation. Providers must stay current on licensure compact issues and individual physical therapy practice acts, since some states do have specific telehealth physical therapy language. As of November 2019, 16 state practice acts explicitly state that telerehabilitation is within the physical therapist's scope of practice: Alaska, Connecticut, Delaware, Florida, Georgia, Illinois, Kentucky, Louisiana, Montana, New Mexico, North Dakota, Ohio, Oregon, Tennessee, Washington, and Wyoming. Additionally, two other states, Iowa and Rhode Island, contain open language in their state practice act suggesting that telerehabilitation may be within a physical therapist's scope of practice.
#PTTRANSFORMS: What would you say to skeptics, including PTs, who are concerned about the level of care provided via telehealth?
Gallagher: Competence is key. Telehealth does not have a large body of evidence for clinicians to refer to for best practice; therefore, advanced clinical decision making is a requisite to determine how to best and safely adapt practice via video. In addition, practice to gain competency is important. Telehealth should be used as a means to solving a problem, such as a patient's inability to commute to the clinic, and should not be used simply for the convenience of the PT or because of the novelty of technology. It should be thought of as a mode of delivery of PT services, but delivering the same standards of care.
Lee: If telehealth is low quality and just a simple audio or video chat, this perspective seems true to me as well. Telehealth is not just a quick audio or video chat. The level of care must be similar to or the same as in-office care.
The profession should develop formal competencies for telehealth practitioners, and those discussions are beginning. When we are teaching students, we need to train our students to see differently, to use their eyes and ears as well as their hands. These skills are helpful in the office or in telehealth treatment.
Both patients and providers should be wary of social media telehealth promotion and avoid closed telehealth Facebook groups. These forms of interaction have neither filters nor checks and balances for vulnerable providers and patients seeking best care and education on telehealth. Always check the source for potential bias or for a history of putting out poor or biased information on social media. Always verify the provider's licensure and credentials with FSBPT, including any issues with the physical therapy provider's license.
There are physical therapists doing great work in telehealth; seek them out in person at APTA conferences to learn more about telehealth physical therapy.
Also, the November 2019 issue of PT in Motion featured an article on strategies for use of technology and best ethical and legal practice.
#PTTRANSFORMS: What is the future of telehealth?
Lee: I believe the future of telehealth in physical therapy will depend on rehabilitation providers' advocacy, future research in practice with telehealth for cost savings, high quality of care, and improved access to care. Our profession is not alone; we must collaborate with other telemedicine providers to improve societal needs and address patient preferences in the digital age.
Gallagher: I agree. I also feel there is a short-term need for developing continuing education and training to ensure that we are providing the best standard of care possible. Because the mode of delivery is relatively new and not widespread, telehealth practitioners are mostly self-taught. As more practitioners want to add telehealth to their services, training would help ensure ethical and high-quality care.
Telehealth and other digital practice experts will share their experiences and expertise at CSM 2020 sessions in February, including:
Register today for CSM!