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  • AARP Announces Support to End Self-Referral Exception for Physical Therapy

    The efforts by APTA, the Private Practice Section of APTA, and other organizations to transform health care by putting an end to self-referral loopholes for physical therapy and other health care services under Medicare received a high-profile boost recently, when the 38 million-member American Association of Retired Persons (AARP) voiced its official support for restricting the practice.

    In a December 11 letter to Rep Jackie Speier, AARP Senior Vice President for Government Affairs Joyce Rogers wrote that the organization is throwing its support behind Rep Speier's efforts to eliminate the in-office ancillary services (IOAS) exception to the Stark law designed to tighten up restrictions on self-referrals. Speier is sponsoring the Protecting Integrity in Medicare Act (PIMA) (H.R. 2914) to close up loopholes that allow physicians to refer patients for certain services—including physical therapy—to a business that has a financial relationship with the referring provider.

    "AARP agrees that restrictions on physician self-referral and provider-kickback schemes must be strengthened," Rogers wrote. "Closing the [IOAS] exception for certain services will save taxpayers and Medicare beneficiaries money and reduce unnecessary care."

    The AARP decision was applauded by APTA President Paul A. Rockar, Jr., PT, DPT, MS.

    "We'd like to see patients put back in the driver's seat, receiving treatment because they need it to be healthy, not because of the profit it will generate," said Rockar. "We are pleased to see AARP join the fight, and we stand behind them 100%."

    APTA Private Practice Section President Terry Brown, PT, DPT, called the AARP letter a "huge win for health care."

    "We've been working hard for years to make these changes, and it is exciting to see a major influencer like AARP join the effort," Brown said.

    The AARP letter is being released as President Obama assembles his 2016 budget. The Obama budgets for 2014 and 2015 included the elimination of the IOAS exception for these services in the Stark law, and supporters of ending the loophole are hoping the next spending proposal from the White House will continue the pattern.

    APTA's years-long work to end the exception included participating in the creation of the Alliance for Integrity in Medicare, a coalition of organizations that includes professional associations affiliated with the health care services affected by the IOAS exception. In addition to physical therapy, those services include advanced diagnostic imaging, anatomic pathology, and radiation therapy.

    Find out more about this issue on APTA's self-referral webpage, and take action now by asking your legislators to close the self-referral loophole. Contact the APTA advocacy staff for more information.


    • This means that a patient with knee pain can self-refer to a therapist and the therapist can diagnose and treat the knee pain without physician supervision or input? Isn't that a bit risky? With a therapist's training vs an MD/DO training, are they qualified to make such assessments? Also, pulling these services out of the physician offices creates hazard for post-op paitients of sub-specialty surgeons, does it not (hand surgeon, foot and ankle...)? These procedures require instant followup from the surgeons post-op exam in therapy, not dealing with a doctor's visit and then referred out for such therapy. I would propose that such support by the AARP puts many patients at risk that are not "simple" therapy matters.

      Posted by Jerald Forrester on 12/12/2014 3:22 PM

    • Agreed

      Posted by Sharon katz on 12/12/2014 4:27 PM

    • Nice to hear this news.

      Posted by Emilian Emeagwali on 12/12/2014 6:05 PM

    • This is great news!! Patients should be given a list of clinic options in proximity of their home VS the usual unethical recomendation for them to be seen at the in house clinic because the "DOCTOR" will supervise the treatment while the patient is in their clinic which is not true! ULTIMATELY it is our fault. The inhouse clinics exist because licensed PT's sabotage the evolution of our profession by accepting these jobs. Without us, these clinics will sieze to exist.

      Posted by Blerim Dibra DPT on 12/12/2014 7:31 PM

    • I have been working in a POPT practice for the past 7 yrs. I enjoy the very close relationship with the physicians and we work as a team in providing adequate, cost-efficient and evidence-based PT treatments. We diligently give the choice to our patients on where they want to receive their treatments and respect their choices. The hospital owned medical practices do not offer that choice to their patients. This model of PT clinic can be efficient and cost-effective and not always driven by profit.

      Posted by Thierry Urbain on 12/12/2014 7:44 PM

    • I think some of us are confusing the concept of "direct access" with the issue of "POPS" clinics and the referral for profit practices of some physicians. The Stark Law loophole has nothing to do with direct access to therapy services. It has to do with a physician owned therapy clinic giving full disclosure of financial interest to its patients. When a physician self-refers patients to their own therapy clinic, that physician must disclose to the patient that the physician has a financial interest in the clinic and will not only be reimbursed for the physician's office visit but also for the therapy visit as well. The physician cannot force the patient to receive services from his/her clinic, but rather give it as a choice. Many physicians that own therapy clinics were in the habit of referring patients for unnecessary therapy services, or referring for "conservative" treatment when more invasive procedures were clearly the better option just to make more money. Services were being provided by staff that were not licensed PTs but rather athletic trainers or rehab techs. This loophole allows this practice to continue in a more discreet manner. The APTA wants to abolish this practice as it takes away business from PT owned therapy clinics. And to my next soapbox...PTs are VERY adequately trained to diagnose and treat knee pain. IT IS WITHIN THE SCOPE OF OUR PRACTICE AS PER THE GUIDE TO PHYSICAL THERAPY PRACTICE AND MANY STATE PRACTICE ACTS! Even though we cannot order diagnostic imaging tests, we can communicate our findings to a physician and request further follow-up (including orders for diagnstic testing). Why would we learn the concept of differential diagnosis in PT school if we should then rely solely on a physician to diagnose musculoskeletal conditions or tell us who needs therapy and who doesn't. That defeats the entire purpose of our higher education and the push for PT to move toward the doctoral degree.

      Posted by Crystal Ardo on 12/12/2014 9:45 PM

    • Rep Speier's efforts to eliminate the in-office ancillary services (IOAS) exception to the Stark law designed to tighten up restrictions on self-referrals. Speier is sponsoring the Protecting Integrity in Medicare Act (PIMA) (H.R. 2914) to close up loopholes that allow physicians to refer patients for certain services—including physical therapy—to a business that has a financial relationship with the referring provider. There is nothing in Mr. Forrester's position that could be a problem. If those procedures require, "instant follow up" in "Post-Op Exam", then have a Post Op Exam! The idea that the IOAS somehow helps the patient is obsurd. This is all profit driven and the patient rarely if ever has a same day appointment which is the way that they coaxed the Legislature to pass it. This happens so rarely that there is no validity to it. To have the Therapy by Highly Skilled Practitioners which are primarily in Private Outpatient facilities puts quality and patient care first instead of profit. Physicians see the writing on the wall that their Cash Cow's are about to end.

      Posted by Gregory S. Beaton on 12/12/2014 9:46 PM

    • Jerald and Sharon, Are you licensed Physical Therapists?? If so list your license number. What year did you graduate?? We all carry liability insurance as MD's do and we are fully trained to recognize, treat and refer out any musculoskeletal disorders. If you are incapable of practicing under those conditions, then you should continue to work under the safety net of an institution until you retire if you happen to be a licensed PT, which i doubt based on the comments you posted. I own a OP clinic and we are faced dailiy with errors in diagnosis from the referring MD's such as: "Shoulder sprain" when upon differential diagnosis we find RC tear and send them back for an MRI to only confirm our findings. "Lumbago" when upon differential diagnosis we find Disk involvement and send them back and our findings get confirmed by an MRI "Hand discomfort" when upon differential diagnosis we find cervical involvement such as facet impingement. "Ankle sprain" when the patient comes with post op boot only to find out they had Trimalleollar fracture resulting in ORIF. No op report was provided nor any other indication of surgery. "Groin Pain" When upon differential diagnosis we confirm labral tear and send back for imaging to confirm labral tear. " Shoulder surgery" No op report sent. No infication of which RC muscle was repaired. Pt gets to us 8 weeks post op and ends up with frozen shoulder. We call the surgeon which states that thats not his problem. Or having an RN supervise our ACL post op rehab POC?? Anymore insulting scenarios?? This is realtime. It happens daily. Its sickening! So if you think we would be endangering the patients?? think again.

      Posted by Blerim Dibra DPT on 12/12/2014 10:42 PM

    • Incorrect Jerald: the above means that PT's still work under doctor's orders, who has written a PT referral with a diagnosis for that particular patient. Physician office Physical Therapy tends to lead to over utilization of therapy services. Good job AARP

      Posted by Paul Vissers PT on 12/12/2014 11:26 PM

    • @ Mr. Forrester: studies show a PT's ability to physically assess an ortho injury surpasses that of a family practice MD and is on a par with the orthopedic surgeon. Unfortunately, it would seem from the rest of your comments you know little of the training of a PT; this is the bain of our profession it seems. Like all professionals, skill level varies but the vast majority of PTs that have achieved specialty board certification have exam skills that FAR exceed those of MDs that are not surgeons. I too worked in my early years at a POPTS but after a year I couldn't take the pressure of rapid fire patient visits, standing orders for ALL patients to always receive modalities, and stress of having to tell a patient they have a different injury than the doc who saw them for a total of 5 min just dx them with. You can have a close relationship with referring docs without subjugating yourself. Here's a quote from the American College of Physicians blog from 2011 in regards to physician self referral: it leads to over-utilization and higher costs and doesn’t really represent a convenience to patients. This is the gist of two studies by staff employed by the American College of Radiology, published in the December issue of Health Affairs.

      Posted by Ralph Simpson on 12/13/2014 12:17 AM

    • Jerald, I appreciate your comment and your concerns. Please note that as a doctoring profession and musculoskeletal specialists, PT's are adequately trained to screen for potential serious medical conditions that requires a physician's evaluation. We collaborate with other health care providers including our medical colleagues to ensure patient receive the best care possible. I'm wondering if you could please cite any evidence related to your questions of "hazards', "risks", and "instant follow-up" with physicians makes us less qualified? Thanks.

      Posted by Jesse Resari, PT, DPT, OCS on 12/13/2014 1:16 AM

    • I would like to say that I totally support the APTA's efforts to strengthen our profession. I support Direct Access and all those in private practice. I know that POPTs have taken away a significant amount of business from private practices. Many of my professional friends and colleagues have suffered from this. Having said that, there needs to be a middle ground. And the primary focus needs to be on patient care. I have been a PT for 34 years. I have practiced in the private setting for 10 of those years. Most recently, I have worked for 2 different orthopedic surgeon group's POPTs. I have to emphasize that I now have instant access to patient records, MRI reports, x-ray images, MD notes and evaluations. We can see patients the same day of surgery in some cases or within a few days in others. The continuity of care is fantastic. I can walk down the hallway and discuss a patient's care at any time. It is also easier for the patients to start PT quickly from an insurance perspective. We are all providers on the same plans. Many private practice PTs don't take HMOs because they can't make a profit and provide quality care at the same time. Our POPT takes a hit on profit so that the patient gets the care they deserve. They also refer out based on where patients live. So they do support private practices in that way. My hope is that both patient care models can prosper.

      Posted by Andrew Harrah, PT on 12/13/2014 2:07 AM

    • Jerald, you obviously do not comprehend what PTs actually can do based upon their education, training, and differential diagnostic capabilities. Physicians are not the end all be all of diagnostic medicine and PTs are specialists in the neuromusculoskeletal aspect of health care. We do not claim to know it all. But we are well versed in the ability to diagnose and treat more that your so called "simple therapy" issues. And for the POPT therapists. My wife and I own clinic and I tell you first hand, POPTs kill our referral base. No matter what you says your Physicians do, the fact is the research shows over utilization of ancillary services when owned by MDs. PTs do not own MD clinics, and the reverse should not be allowed.

      Posted by Ron Pavkovich on 12/13/2014 7:40 AM

    • This will be a great achievement for the healthcare of many elderly ,who suffer from joint and musculoskeletal dysfunction. Having a choice truly matters to patients i treat. It's funny how clinician's can be convinced to oppose this free choice,transparency and open disclosure for patients to be properly informed in making the best decision for their health. There are few exceptions where physician's are you using POPT's as originally intended but unfortunately this is a rare occurrence as supported by objective statistics. That doesn't lie. I personally see too much fraud and irresponsible incompetence on the part of physicians and surgeons alike. It's time for a responsible change to correct a broken system and burden of stress placed on the economics of healthcare. This initiative has my full support and i will do my part with communicating to my congress to help this happen. I advise all responsible healthcare practitioners involved to do the same.

      Posted by Matthew St.Aimee, PT, DPT on 12/13/2014 9:39 AM

    • Hello Andrew, Nice comments. Just wanted to update your opinion of private practices and HMO's. You are incorrect on that topic. The true issue is that private practice clinics have a very hard time getting in network with the HMO's. Private practices struggle because of this. I know many owners in Miami dade county that would love the option of being able to accept all the HMO's. Most of the time they are controlled by hospital systems so they get all the business. As far as inhouse clinics taking a hit as a courtesy of the patients, that is impressive. I would love to see that happening in Miami where the Surgeons put the patient first and work for free or for a lesser fee. Bottom line is that the consummer should have a choice where to go. As of now the market is monopolized by the inhouse clinics. They only refer out the patients that have a cheap insurance or the complicated cases that they cant handle since the assistant or the tech cant manage. This is realtime information.

      Posted by Blerim Dibra DPT on 12/13/2014 9:41 AM

    • I do not think it is appropriate to insult another PTs skill level or knowledge simply because they have a different opinion. I appreciate the efforts of the APTA to protect the profession but I agree with Andrew Harrah - there has to be a middle ground.

      Posted by Caroline Peyrone on 12/13/2014 10:01 AM

    • Physician owned practices/financial arrangements have gutted my private practice. The few who refer to me outside the tier one clinics,ie, the ones they are in partnership with, do so on a limited basis so as not to wave red flags at their owners. In fact, if they do refer to me, thier 3rd tier, they have to file a written justification. And we know how much time they have to do that! Bravo AARP!

      Posted by Sandy Brooks Carr, PT/ owner on 12/13/2014 1:53 PM

    • This statement is for those above who are unfamiliar with a PTs extensive training to differentially determine and diagnosis if the problem is mechanical or not, you and the public and physicians need to be better informed that the didactic training of a Doctor of Physical Therapy is more than thorough enough to provide early access to treat a patient's movement dysfunction. In addition, that is the reason that many patients are referred from PT to a physician or physician extender appropriately when there is a non mechanical determination. These are the cases than the Medical Doctor, who initially saw the patient, misses the basic scientific differential diagnosis and the PT catches it because of PTs doctoral level training. It is about time Physicians discontinue this erroneous argument and began realizing that early access to other specialist such as physical therapist is essential towards the improvement of our US healthcare dilemma. I can tell you all that this conversation is more about P&L for doctors vs patient care quality. That is the reason that in many practices the NP and PA see more patients than the physician and handle the complex cases, all the while the physician sits in their office and still wants to be called doctor without acting like one. I have personally witnessed this poor professional behavior.

      Posted by TS on 12/13/2014 5:17 PM

    • This comment area is open to anyone. However, respectful discussion is mandatory. Any comments that violate our terms and conditions (see link at the bottom of our website) or that go past debate of the issues into personal attacks won't be approved.

      Posted by PT in Motion News Staff on 12/13/2014 6:09 PM

    • Freedom of speech is a wonderful and I love that we can all get on here to have a scholarly debate and express our views. I have worked in all settings including a orthopedic surgeon's POPT's early on in my 16 years as a clinician. He was a fairly honest orthopedic surgeon who no longer performed surgeries so he believed even more in PT. However the one problem was that majority of his patients were referred to PT 3x/wk x 4 wks whether they required that many sessions or not. I often had to discontinue PT prior to this and he'd sometimes challenge this and refer the patient to finish out the 12 sessions. I truly didn't understand this at the time, being wet behind the ears with 3 years experience. I've also seen surgeons referring to my practice in later years who have prematurely discharged patient's post rotator cuff repair after only 1 month of PT. This is even after they have signed agreeing to my progress note recommendations to continue PT. Ironically these patients somehow find their way back to me weeks later with Rx from the same physician due to joint stiffness and diagnosed cuff weakness. This usually due to patients complaints. Go figure. There's direct personal experience from both sides of the equation. Needless to say I fully support this initiative.

      Posted by Matthew St.Aimee, PT, DPT on 12/13/2014 6:37 PM

    • I wonder why we cannot copy the Canadian model where you mostly cannot own a PT clinic except your are a licensed PT. in few cases where a clinic is jointly owned, the PT has to, by law, own at least 75% stake in the venture. This puts power in the hands of the PTs and thus are able to serve their patients better. Muideen.

      Posted by Muideen on 12/13/2014 7:37 PM

    • Great news that AARP took a stand against these POPTS scenarios. There is a big point that is getting lost in all of this discussion. Some of the previous replies, mainly by PTs who have worked in POPTS clinics, note that "the continuity of care" is fantastic and "we aren't always about profit", etc. It is not accurate to say that care delivered by all POPTS is inadequate or poor. There are FANTASTIC clinics, many that are much better operated than privately-owned clinics. But, that's not the issue. The gripe with POPTS has nothing to do with the care that is delivered. The issue is that a PHYSICIAN is the financial backing and reaping benefits of the PHYSICAL THERAPY clinic. I, too, would love to be able to walk down the hall and speak with the surgeon who just repaired my patient's RTC. But, that can still happen even without a POPTS. The Physical therapy clinic would simply rent space or join the lease of the MD office, is a completely separate business entity from the MD practice, and the MD does not receive a financial kick-back from PT treatment. This can be a very successful solution for all parties, in terms of continuity of care, treatment of patients, and financial benefit. And most of all, IT ISN'Y UNDERMINING A PROFESSION (PT) WHILE FINANCIALLY INFLATING ANOTHER (MD).

      Posted by Preston Collins, PT, DPT on 12/14/2014 6:02 PM

    • I am an Australian PT who has practised in the US and Australia for more than 25 years. It is interesting to compare Physio/PT status and practice in the 2 countries, and the attitudes to the profession from the medical fraternities. Physios in Australia have had direct access to assess and treat since the mid seventies, and it has only ever worked to the benefit of the patients. PT assessment and diagnostic skills far exceed those of family doctor level practice in both countries, they have to, they are seeing injured people every day, and it is only by good diagnosis that you get good outcomes. However it is only in the US where this is regarded as a challenge to the medical fraternity. I have heard Aussie doctors say, "I don't know what is wrong with you, go and see the physio", without any feeling of insecurity. However in the US, I have heard comments like, 'but you are not a doctor', even when the the PT has the right diagnosis, and the referring doctor not, and had the hospital backs up the MD rather than the PT, to keep the doctor happy, and using their facility. Very professionally frustrating and of no benefit to the patient involved. PT's in Australia can also order MRI's, CT, US and xray tests, issue off work certificates and act a professional witnesses in hearings. This is so useful when faced with difficult clinical presentations and histories, and again, only benefits the patients and keeps costs down as PT's order less radiological tests per patient than the medical fraternity. Probably due to their assessment skills. PT's in Aus respect MD's, and work well with them collegially, but do not give obsequious deference which some here seem to expect in the US. MD's are not permitted to own PT clinics in Australia, but happily refer to Physio's because they genuinely recognise the skill levels of the PT, and do not see it as a threat, as many, many US doctors seem to. Not all for sure, but in my experience, probably the majority. I have treated approximately 10 US doctors in the past decade, and every one of them, be they GP, surgeon, neurologist, sports medicine doctor more or less comment, "I had no idea you assess like this and do all these types of treatments, I thought I was coming for some ultrasound and exercise!" One asked me to speak to her neurology special interest group to get them to understand that PT is more than Ultrasound, e stim and exercise. I just wish that more doctors in the US could be more collegiate towards Physical Therapists as they are in Australia and Europe, as they and their patients are the ones who will benefit. If you don't believe this, ask your Australian medical colleagues, who generally have nothing but good, AND equal, professional relationships with Physios. They view PT's in neuro musculo skeletal health as they view Dentists in relation to oral health, not as exercise technicians who need to be told what to do. Those who see independent PT's as a threat should try it and see how useful it is to respect PT's rather than someone to control in a POPT clinic. You will be pleasantly surprised.

      Posted by Kevin Mulvey PT RN APAM on 12/14/2014 9:20 PM

    • Amen Kevin Mulvey! Only in the US, sad but true. The only place different is in the military system where PTs can do what you just alluded to. I think one of the reason is the history of PT in the US itself. Started as reconstruction aids at Walter Reed (if I'm not mistaken)under the "orders" of MDs. I think another BIG reason is the pervasisve practice variability in our profession. Unfortunately, a lot of PTs still do a ton of passive modalities no matter what, still reluctant to embrace direct access in whatever form, and frankly just don't have the fortitude and confidence to educate our patients, the public at large and our medical colleagues on who we are, what we do, and the VALUE we have. We have to do it every single day because the perception of what PT is, is based on archaic model.

      Posted by Jesse Resari, PT, DPT, OCS on 12/15/2014 4:12 PM

    • POPTS kill the marketplace, whether intentionally (greed & overuse) or unintentionally (accepting a loss just for the good of the patient). The latter I would have to see to believe but I will take the poster's word. Both put downward pressure on the valuation of therapy services. Think OPEC for the latter if you are still stumped. BCBS, Aetna, Cigna, UHC all offer approx $50-60/ visit caps in South Florida, if you can get in network. What a treat. It is burying private practice. Side note; had a top level BCBS network manager tell me that they consider having a provider within 60 miles of a patient adequate coverage. Seriously contemplating dumbing down my degree to massage therapy and being able to accept cash pay services without eventual MD oversight after 3 weeks 😜 This is a power and leverage game. All healthcare practitioners are under pressure ( including MD's) due to the boomers coming of age. The AMA has prioritized the protection of POPTS as it has been a top 3 expenditure legally the past several years. This is because POPTS have been a stop gap for the MD's since the 90's. A way to make up for their own cuts in reimbursement. Thank you to AARP most importantly. POPTS are the elephant in the room. AARP is a large, becoming larger every day, voting block and will get politicians' attention.

      Posted by Erik Bleeker on 12/16/2014 10:45 PM

    • Sadly PT reimbursement cuts have hurt Pvt practice PT But on the Bright side cuts worked to make PT a less desirable profit center for physicians! Therefore MDs may not be as aggressive to defend against movements like this AARP position. Hope APTA strikes while the iron is hot!!!!

      Posted by JPalazzo on 12/17/2014 10:33 PM

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