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  • 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.

    Direct Access to PTs Now a Reality in Oklahoma

    Oklahomans now have direct access to evaluation and treatment by physical therapists (PTs). On May 23, Oklahoma Gov Mary Fallin signed HB 1020, which allows patients to be evaluated and treated by a PT for 30 days without a referral from a physician or other provider. Previously, state law required a physician referral for any kind of treatment, though PTs were allowed to provide an evaluation without a referral. The new law takes effect November 1, 2014.

    "Ensuring patient access is a cornerstone of APTA's vision and mission," said APTA President Paul A. Rockar Jr, PT, DPT, MS, in a news release. "I want to thank Rep Arthur Hulbert, PT, DPT, for authoring this bill, and Rep Sean Roberts, PT, for coauthoring. As physical therapists, Rep Hulbert and Rep Roberts truly understand how important this legislation is and the positive impact it will have on individuals who need the services of physical therapists."

    The bill was promoted by the Oklahoma Chapter of APTA (OPTA). OPTA President Debra Christian, PT, DPT, said, "This is an historic time for the Oklahoma Chapter and the culmination of many years of work by numerous individuals. I want to thank the OPTA Board of Directors for their commitment to this effort, as well as our membership who stepped up in a big way over the past couple of months." Christian also acknowledged the leadership of Jeffrey Jankowski, PT, immediate past president of OPTA.

    Brandon Trachman, PT, MPT, OCS, OPTA legislative chair, added, "HB 1020 is an enormous victory for Oklahomans, who will now be able to take a more active role in their own health care and choose safe and effective treatment directly from physical therapists. The passage of HB 1020 would have never been possible without the diligent and tireless efforts of Reps Hulbert and Roberts, as well as Sen Kim David, who authored a version of this bill in the Senate."

    APTA provided a direct access grant to the Oklahoma Chapter, as well as additional financial support for the chapter's lobby day at the state capitol.

    The success in Oklahoma means that 49 states and the District of Columbia now allow some level of treatment by a PT without referral. Direct access legislation is pending in Michigan, the final state with no form of direct access to treatment by PTs. Michigan SB 690 recently received a unanimous vote in the Senate and now awaits action in the state House of Representatives.

    Obesity Goes Global

    When it comes to rates of obesity, the world isn't so small after all.

    A new study published in the May 29 Lancet reports the results of a worldwide study of obesity and overweight, and found that rates have increased between 1980 and 2013 by 27.5% for adults and 47.1% for children. Although rates vary by region, increases can be found almost everywhere in the world, authors write, and when it comes to the battle against obesity, "no national success stories have been reported in the past 33 years."

    During the 33-year timeframe reviewed, worldwide obesity rates rose from 28.8% to 36.9% in men, and from 29.8% to 38% in women. Children and adolescents also experienced "substantial" increases in obesity and overweight, with developing countries rising from 8.1% to 12.9% in boys, and from 8.4% to 13.4% in girls. Among developed countries, the child and adolescent rates rose from 16.9% to 23.8% of boys, and from 16.2% to 22.6% of girls. Authors defined overweight as BMI between 25 and 30 kg/m2 and obesity as BMI of 30 kg/m2 for adults, and used the International Obesity Task Force definition for children.

    The findings "show that increases in the prevalence of overweight and obesity have been substantial, widespread, and have arisen over a short time," authors write.

    The United States continues to lead the world in the sheer number of obese people in the world, accounting for 13% of the estimated 671 million obese individuals worldwide. China and India were, respectively, the next largest countries with the highest populations of obese individuals, but combined they only accounted for 15% of the world's obese people. Current estimates are that about one-third of all adults in the US are obese.

    Among other findings in the report:

    • In developed countries, more men than women were overweight and obese; in developing countries, the opposite is the case.
    • Obesity rates increased most rapidly between 1992 and 2002, and have slowed somewhat, particularly in developed countries.
    • Overweight and obesity rates peak at about 55 years for men and 60 years for women in both developed and developing countries, but rates are much higher in developed countries.
    • Prevalence of obesity was greater than 50% for men in Tonga, and for women in Kuwait, Kiribati, the Federated States of Micronesia, Libya, Qatar, Tonga, and Samoa.
    • The largest increases in the rates of obesity during the study period were in Egypt, Saudi Arabia, Oman, Honduras, and Bahrain for women, and in New Zealand, Bahrain, Kuwait, Saudi Arabia, and the US for men.

    Authors did not offer an explanation for the rates of increase but pointed to other studies that cite increased calorie intake, changes to diet composition, decreased activity, and changes to the gut microbiome.

    The report says that without a significant increase in attention to the problem through both research and policy, the upward trend is likely to continue, despite a World Health Organization effort to stop the rise in obesity rates by 2025. "No countries have well documented downward trends in the past 3 decades," the authors write. "Our analysis suggests that this target is very ambitious and unlikely to be attained without concerted action and further research to assess the effect of population-wide interventions, and how to effectively translate that knowledge into a national obesity control program."

    APTA strongly supports the promotion of physical activity and the value of physical fitness to prevent obesity, and has representatives on the practice committee of Exercise is Medicine and the board of the National Physical Activity Plan Alliance. The association offers several resources on obesity, including continuing education on childhood obesity, and a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.