Monday, June 02, 2014 GAO Analysis of Physical Therapy Self-Referrals Lacks 'Definitive Conclusions' A long-awaited report from the US General Accountability Office (GAO) on physician self-referral in physical therapy is short on "definitive conclusions" and overlooks many of the realities of physical therapist practice and patient populations, according to a recent statement from APTA. The association statement reaffirms APTA's commitment to working with GAO to foster a better understanding of self-referral and its impact, but also reasserts its position that physical therapy should not be characterized as an "in-office ancillary service" and should have never been included in the self-referral loophole to begin with. In a report that APTA says "underscores the need for further research," GAO turned its attention to physical therapy, the last of 4 health care professions that were studied to determine the causes and percentage of increases, if any, in procedures when a physician refers a patient for treatment or services in facilities owned by the physician. Earlier studies that focused on imaging services, anatomic pathology, and radiation therapy for prostate cancer showed that the number of procedures—and costs—do in fact increase in self-referral arrangements. The study on physical therapy yielded less definitive results, due in large part to methodology limitations that GAO readily acknowledged. Among the shortcomings cited by the association: a lack of data on severity of condition, impairments, and comorbidities, as well as on quality of care provided. "Data on the frequency of visits and total expenditures are irrelevant without knowing patient severity and outcomes," according to the statement. The few areas in which definitive findings could be reached involved data that show a "sharp increase" in referral rates for physicians who transition to a self-referral practice model, according to the statement. The statement also questions the report's classification of all institutional care as "non-self-referred" care, which APTA argues is more likely to involve patients with complex conditions. Given that 40% of physical therapy services billed under Medicare come from skilled nursing facilities alone, APTA says, the unbalanced nature of the 2 groups being studied "clearly skews data and clouds results." "The bottom line is that the GAO report is unable to reach any definitive conclusions ... so the need for further research continues," according to the statement. At some level, GAO seems to agree. The report acknowledges limitations in the methodology used, and states that "it is outside the scope of this report to examine the medical necessity, clinical appropriateness, or effectiveness of [physical therapy] services beneficiaries received." In addition to calling for a more informed analysis, APTA is also urging policy makers to require all self-referring providers to notify patients of their right to see the provider they choose, and share lists of a variety of local physical therapists with patients. To help refine data collection, the association is also recommending that Medicare claim forms require a unique modifier that identifies when any service is being received through self-referral. APTA also continues to advocate for H.R. 2914, federal legislation that would remove physical therapy from the in-office ancillary services exception to the Stark law.