Take Home Message from APTA State Government Affairs

I recently attended the American Physical Therapy Association(APTA) State Government Affairs meeting in Portland, Oregon as one of the Florida delegates. This meeting is intended to create advocates for the physical therapy profession by creating awareness of the common struggles we all face at the state level.

State level advocate physical therapists keep politics local and create national awareness of the inherent value physical therapy brings to medicine and to society. A local "grassroots" effort can complement the Federal advocacy by APTA in Washington DC as well as the more expensive and long-range public relations and "branding" campaigns initiated by our leaders.

State of the States – many issues are dealt with at the state level but have national commonalities from which we can all learn. This was an inspiring subject because of the many “success stories” told by our peers in other states.

• Dry Needling
• Dry needling is NOT mentioned in the Guide to PT Practice. Many therapists in Europe and the USA are learning dry needling techniques.

• Infringement
• massage therapists want to practice joint manipulation.
• Physical Therapists successfully partnered with chiropractors in Virginia to prevent advertising the term “physical therapy” without a PT present.
• Medicaid
• PT is an optional service for adults but will be required for children under Health Care Reform.
  
• Direct Access
  
• PTs can “diagnose” and should avoid equivocating between a “physicians’ diagnosis” and a “physical therapists' diagnosis”.
  
• Excessive Co-Payment Barriers
• New York is fighting a tough battle with $50 co-pays for plans with a $50 PT benefit.
• New York has crafted their own legislation that would mandate co-pays no more than 20% of the benefit amount.
• Vetoed by the Governor as a tradeoff for increased Work Comp fee schedule.
• Any states seeking such legislation need to ensure that PT is a “mandated benefit” otherwise insurance companies will allow the co-pay but drop the benefit.
  
• Federation of State Boards of PT
• Seeking a recertification process to protect public safety.
• APTA is not disagreeing with FSBPT.
• Consistent with physician licensing, but…
• …is there a demonstrated need (eg: evidence of harm from malpractice insurance carriers?)
• Many state boards are controlled by physicians (not in Florida!)
• In states where the Board is controlled by physicians or agendas set by powerful administrators PTs need to develop a “culture of autonomy”.

Health Care Reform (HCR) – this is a “hot topic” made even hotter by the concise, hard-hitting analysis by Justin Moore, PT and two outside experts – quality “gurus” who were passionate about the next stages in HCR.

• the regulatory approach (influencing policymakers) is preferable to the legislative approach (eg: South Carolina and Washington state).
• Anti-POPTs legislation too expensive.
• HCR will unfold over the next 5-6 years, allowing PTs time to influence policymakers.
• Cost arguments will dominate the conversationDr.

"Quality Gurus"

Edward Keenan, PhD from The Foundation for Medical Excellence spoke on Achieving Health Care Reform Require Transformation Not Reform

• HCR grants access, NOT quality
• 15-minute visits (encoded in CPT) prevents quality and encourages “silos”.
• “Health Care” may contribute only 10% to “Health” but education may contribute 40-50% to “Health”. 
•  Lifestyle, genetics and culture also contribute to “Health”.

Jack Friedman, CEO of Providence Health Plan spoke on The Impact of Health Care Reform on Health Benefit Design

• HCR will create “tiers” of healthcare;
• primary care is 1st tier,
• PT may be 2nd tier 
• instrumented spinal fusions should be 3rd tier.
• Small practices will have to integrate with Accountable Care Organizations (ACOs) to participate in bundled episodes of care.
• PT’s need to demonstrate “Value” to the ACO.

Starke Anti Self-Referral Laws

• Starke affect Medicare patients only but needs revision:
• Sharing of health IT (EMR) is currently prohibited among providers.
• Integrated Accountable Care Organizations (ACOs) may be prohibited under Starke.
• PT is a professional service, NOT an ancillary service (Hogan/Hartz whitepaper)
• PT is more akin to radiation oncology than any other service in its scope, usage patterns and timing.

AMA Scope of Practice Guidelines

• The AMA is attempting to write the PT scope of practice ‘for’ us.
• Physicians have an unlimited scope of practice.
• The APTA rejected the AMA's premise that the AMA can define the PT scope of practice.
• Physicians define everybody else (including PTs) as “limited license practitioners”
• APTA believes that physical therapists should define our scope of practice through updated versions of the Guide to PT Practice.

Action Plan for the Future: In the private practice setting innovation may become more rewarding.  Traditionally, the words innovation and Medicare have seldom been used together.

How Can Private Practice Physical Therapists Innovate?

1. Choose the lowest cost means of communicating with your patient - (e-mail)
2. Assume all the performance risk of the outcome - what can you do to improve the outcome that you have not traditionally done? For outpatient physical therapists, this might mean home visits to visualize the patients' home environment assessing for specific risks, eg: in older patients throw rugs, pets and stairs may increase falls risk. As the therapist you can modify these risks to prevent future resource use.
3. Is the small private practice the way to go? ACO's will want to contract with ONE therapy provider. Would a Independent Practice Association (IPA) of several small PTPP practices enable better negotiation with the ACO? What about a merger? A sale?
4. Stay tuned - there is no fixed definition of an ACO.  Some will be hospital-based and some will bebased on large physician practices .