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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.