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  • Physician Self-Referrals for TKA Physical Therapy: Twice as Many Visits, but Lower Intensity

    In the end, the self-referral issue could be boiled down to a quantity vs quality debate, at least for patients who receive total knee arthroplasty (TKA).

    The "quantity" part of the debate: patients who undergo TKA and are referred to physician-owned physical therapist services average about twice as many visits as patients who receive physical therapy from an independent provider. The quality part? Despite the higher number of visits, the self-referred patients receive less "intensive" physical therapy, with far fewer individualized therapeutic exercises than their non-self-referred counterparts. Both conclusions were reached in a new study published in Health Services Research (abstract only available for free).

    Researchers looked not only at the differences in treatment among physician-owners and physicians with no financial ties to physical therapist services, but also at what happens when patients of a physician-owner don't end up going to that physician's facility. In those instances, researchers found that much like the patients whose physician doesn't have a financial stake in physical therapy, these patients also receive fewer visits but more intensive treatments.

    To get at these conclusions, researchers analyzed Medicare data from 3,771 TKA episodes between 2007 and 2009. Of those, 709 were designated as self-referrals, in which there was a financial connection between the physician and a patient's physical therapist services. The remaining non-self-referring cases were further divided into 2 categories—2,215 episodes in which the referring physician did not have any financial interest in physical therapist services, and 847 episodes in which the referring physician did have a financial interest, but the patient received physical therapy from an independent provider.

    Authors of the study were hoping to test 3 main hypotheses: that self-referrers would prescribe more visits than non-self-referrers; that the self-referred episodes would generate more service units; and that a physician-owner "might shirk on quality and substitute lower-cost unlicensed medical assistants to perform physical therapy."

    Researchers were able to achieve what they considered conclusive results for 2 of the 3 hypotheses. They found that the self-referral group averaged 15.51 visits per patient, compared with 7.19 visits for the non-self-referrals. Yet when it came to service units, the self-referred episodes generated an average of 3.03 fewer relative value units than the non-self-referred cases. Authors write that when taken together, the findings indicate that PTs who were not involved in a self-referral setting "saw patients for fewer visits, but the composition of services received was more intense."

    The third hypothesis—that the self-referred episodes were of lower quality due to the more prevalent use of unlicensed medical assistants and not PTs—was impossible for the authors to directly test, given that the Medicare data did not identify exactly what type of health care personnel provided the physical therapist treatments. But what the data did reveal is that regardless of who was providing the treatments for self-referred patients, patients in this group were receiving a larger proportion of services "not requiring the training or expertise of physical therapists," rather than "hands-on or patient-engaged physical therapy."

    The study found that based on coding records, more than 72% of the physical therapy delivered in the non-self-referral group consisted of "individualized therapeutic exercise to develop strength, endurance, range of motion, and flexibility," compared with a 64% rate among the self-referrals, a difference authors say is "highly significant." Researchers also found that non-self-referral patients received a higher proportion of services aimed at improving functional performance—7.5% compared with 5% for the self-referral group. The self-referral cohort also received more group therapy (and thus less 1-on-1 interaction) than the non-self-referral patients.

    Making the issue even more intriguing were the researchers' finding that these differences—number of visits, service units delivered, intensity of treatment, group therapy—existed in roughly the same proportions among patients whose physician had a financial interest in physical therapist services, but who received treatment elsewhere. "It appears that when orthopedic surgeon owners do not benefit financially from referring [TKA] patients for physical therapy, their patients received essentially the same bundle of physical therapy services as patients treated by surgeon nonowners," authors write.

    Beyond the clinical implications, authors believe their study adds more weight to the argument against the in-office ancillary services (IOAS) exception to the Stark laws—federal legislation that prohibits most self-referral practices in Medicare. IOAS allows physicians to self-refer for several "common sense" or same-day treatments; unfortunately, it also creates loopholes for services that are rarely provided on the same day, including physical therapy, anatomic pathology, advanced imaging, and radiation therapy. Authors write that most research on these exceptions has reached the same conclusion as their own study: "that self-referral results in increased use of services and higher health care expenditures."

    Like an earlier study that questioned the quality of care provided by self-referrals for physical therapy for LBP, the TKA study lends further support to the APTA’s efforts to advocate for the elimination of the exceptions, a position also supported in current and past federal budget proposals from the Obama administration.

    Those efforts are also ongoing at the state level, where Missouri and South Carolina are dealing directly with the issue of physician self-referral (sometimes called physician-owned physical therapy services, or POPTS). In Missouri, 1 of only 4 states with anti-self-referral laws on the books, legislation has been introduced to nullify the prohibition. The Missouri Chapter of APTA is fighting the legislation. In South Carolina, the state's Supreme Court is expected to issue a long-awaited ruling on the constitutionality of that state's anti-POPTS law later this year.

    Authors of the study write that while the debate about elimination of the loopholes continues on Capitol Hill and in statehouses, facts on the ground could change self-referral practices regardless of any action taken by lawmakers; namely by way of alternative payment arrangements, such as bundled care, that emphasize cost-effective, outcomes-based care, with payment made for an entire episode of care. The first such mandatory bundled care provision for Medicare and Medicaid—for TKA and total hip arthroplasty—is set to debut in multiple areas across the country in April.

    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.


    • We are the problem. Physicians cant perform physical therapy on their own. The issue remains why physical therapists are accepting to work for these clinics. For a couple of dollars more per hour they are damaging the evolution of our profession. The only way that relationship would work is if the physical therapists are respected and accepted as "partners" in these groups. If these clinics seize to exist then more physical therapist owned practices will flourish. When that will happen there will be more high paying jobs and partnership opportunities for all of you. If we continue at this path and sabotage our profession from within, then we will continue to be used as slaves and disrespected by these groups while only making 65-70K per year after coming out of school with loans ranging 100-200K at 6-8% interest.

      Posted by Blerim Dibra DPT on 2/26/2016 12:22 PM

    • In reviewing this study (which consisted of only 709 episodes that occurred 7-9 years ago), I found it interesting that the average duration was only a week longer for the self-referred group. Furthermore, in addressing the "nonevaluation physical therapy services", the study states that "72% of the physical therapy delivered in the non-self-referral group consisted of 'individualized therapeutic exercise to develop strength, endurance, range of motion, and flexibility,' compared with a 64% rate among the self-referrals". That's a fancy way of saying therapeutic exercise (97110) which is what is stated in the study. For the last decade, therapists have been hearing that 97110 is often over-utilized, that payors often view excessive units of 97110 as nonskilled, and that we should scrutinize our coding and documentation to ensure that we are not devaluing our services by lumping everything under therex. Furthermore, this study showed a HIGHER utilization of functional therapeutic activities (97530) and manual therapy (97140) with the self-referred group. I found it curious that the study stated manual therapy is "not used heavily in joint replacement rehabilitation other than to reduce swelling or inflammation". Say what? We perform a considerable amount of manual therapy with our total joint patients, including contract-relax, manual stretching, manual resistance, etc. If anything, it's one of the more skilled components of treatment and one of the most valuable from the patient's perspective. As for the study's statement that 97530 is "frequently used to account for time spent to train the patient to get out of bed or to rise from a chair", I would suggest that the 97530 code encompasses much more than just those activities, especially in the outpatient setting. So in looking at the data in this study, it actually appears that the self-referred group is getting more skilled interventions rather than just going through a list of exercises on a flow sheet.

      Posted by Robert on 2/26/2016 3:55 PM

    • This is a timely article for PTs in Missouri since the law against Physician owned PT services is being challenged in our state. Thanks for sharing.

      Posted by Mary Martin on 2/26/2016 4:04 PM

    • These studies demonstrate our week evidence lacking attempts to defend why we should be autonomous practitioners. Need more objective peer reviewed articles and medically supported evidence. This will support our arguments

      Posted by Matthew St.Aimee on 2/26/2016 6:22 PM

    • Here is a link from AAOS: http://www.aaos.org/Search.aspx id=32&srchtext=physical+therapy This is how they are pushing the issue. The main objective is to increase the revenue for their clinics.

      Posted by Blerim Dibra DPT on 2/26/2016 6:24 PM

    • Regardless of whether you work for a physician owned clinic or a private practice, as a professional you should be making your own evidence based decision on how to treat and for how long to treat your patients. PTs need to dictate the care and I would argue that being part of a physician group gives you more respect in the surgeons' eyes because you can have those discussions directly with the MD as to how and why you treat as you do. There is just as big a push to increase revenue in every setting whether private, physician owned or hospital based and to keep the money "in house" and that is the current reality for all of medicine. We need to take it upon ourselves as PTs to be ethical and research based in our treatments and that would solve any discrepancies in treatments regardless of clinic ownership.

      Posted by Jason Willer PT on 3/2/2016 9:07 PM

    • I have said it before and will say it again...physician practices are not the only place that PT's are undervalued and overworked...hospital systems--which get larger every day--are "using" PT's in the same "cash cow" sort of way--AND NOT treating them as autonomous professionals-- but we are not wasting thousands and thousands of PAC dollars and publication and research dollars trying to stop what happens there! We should be spending these dollars educating the public about what WE ARE as PT's!!! Not fussing over where we work and who gets to take home the money. There are plenty of workplaces, YOU choose yours, I will choose mine and let's get people ASKING for PT, not being directed absent-mindedly by their physician to go to PT!

      Posted by Beth on 3/2/2016 9:46 PM

    • I will say that this article, while a good argument for our private practices, (I am a practice owner), has limitations regarding the use of fair objective data (billing codes only). Without truly being in a clinic, seeing the amount of intervention and the manner that it is being carried out, and getting patient feedback, it is difficult to see what is and isn't more effective. It is literally the most challenging aspect of our profession, quantifying the VALUE of our unique services and skill set. Yet we know we are a value and will continue to press on. Another thing that this strongly highlights is the importance of getting accurate billing codes and being diligent in our constant self reflection of the services we are carrying out, such as Ther Ex v/s Therapeutic intervention.

      Posted by Alisha Jarreau< PT, DPT on 3/3/2016 8:47 AM

    • I call bias on this study. If you set out to prove your own preconceived notion(s) it is not an unbiased study. The study design and conclusions prove this. It’s funny how the authors did not consider any outcome data or initial severity at onset of care. The difference in number of treatments could be a result of several things: 1) Self-referred patients could have had a higher severity or have more co-morbidities at start of treatment, physicians may have sent complex patients to their in house PT. 2) The study did not indicate whether either group had any inpatient rehab or home health PT prior to Initiating outpatient therapy. This could bias the numbers. I have to be honest 7.19 visits sounds very low for TKA. Outcome data give some clues whether the non self-referred group were discharged too early prior to reaching functional goals would be helpful. Less visits does not always equate to better care. Finally, the codes therapists charge do not always represent what is performed in the clinic when differentiating between 97110, 97530, and 97112. This requires training and privately and corp. owned therapy clinics probably do a much better job charging for higher value codes. I work for POPT clinic that treats exclusively spine which requires more one on one care than other orthopedic injuries (knees, shoulders ect.) We have 5 PT’s and 4 PT aids/techs (3 BS, 1MS). Our model is 1 on 1, the PT sees the patient roughly half the time and a highly trained and direct line supervised PT aide the other half. We do very little passive care. The 4 codes charged most frequently are 97140, 97530, 97112, & 97110 indicating skilled treatment active based treatment. You will be hard-pressed to find a non-POPT practice that has this level of care. This is why I left my last outpatient position at a privately owned clinic. The patient to therapy ratio was horrid during peak times resulting in poor care that I could no longer stomach. So don’t pretend or kid yourselves that the care provided in non self-referred is better than self-referred clinics. This can vary greatly from clinic to clinic. We do not have to alienate physicians in our pursuit of autonomy. Don’t forget that one of the APTA’s guiding principles is collaboration.

      Posted by Jason on 3/3/2016 3:20 PM

    • Alisha, Thanks for being honest in regards to the study's limitations. You make some good points in your post. There are too many PT's out there making blanket comments and assumptions about POPTs practices (including the author of this study). I might remind them that private practices, corporate partnered and hospital based practices are not immune to the same profit seeking behavior that POPTs are accused of. Corporate partnered clinics are probably the worst because the share holder is ultimately the customer and not patients. I left this environment for this reason. Hospital based clinics are often indirectly owned by physicians so they are not without potentially negative influences. There is no reason why POPTs can't exists along with other ownership models. Patients are becoming more savvy consumers of healthcare and will not tolerate poor care. Patient care and outcomes will ultimately determine if a clinic survives. Many of the POPTs that were only in it for the money have closed shop when reimbursements dropped to near levels of private practice. I work for a practice that sees therapy as a necessary part of patient treatment, not a cash cow. They are content to break even to provide PT services. The challenge for the field of physical therapy as it grows into a doctoring profession will be maximizing the physical therapist's role in the health care system without minimizing the roles of physicians, physician assistants and nurse practitioners as first line providers. Collaboration not alienation will be increasingly important as we move forward.

      Posted by Jason on 3/4/2016 3:38 PM

    • Did anyone notice that Mitchell's data shows that private PT practices averaged over 55 procedures over 7 visits for an average of close to 8 procedures per visit? Also, her data re breakdown of procedures shows that private PT practices averaged over 115 minutes of charges per visit. I would think that some of the physical therapists she says she consulted would have raised a red flag on that one. Also, her conclusion that therapists in private practice delivered more "intensive" care because they had a higher proportion of therex (and lower proportion of manual and function act) than therapists in physician groups makes no sense at all.

      Posted by Cary Edgar on 4/3/2016 11:47 AM

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