Should physical therapists have "direct access" to patients--being able to provide physical therapy services without a physician's prescription?¬†
With or without the passage of "direct access" legislation, should physical therapists be allowed to provide orthotic and prosthetic services and devices, without additional education, training, licensing, and/or certification, as part of their scope of practice?
These are currently hot legislative issues involving both the physical therapy and orthotic/prosthetic professions nationally and in several states. It has been reported that the issue of physical and occupational therapists being considered as "qualified O&P providers"--without additional training and qualifications-- was a large factor in the failure of the Negotiated Rulemaking (NegReg) Committee to reach consensus on who constitutes a "qualified provider." The NegReg Committee was formed to assist Health & Human Services (HHS) Secretary Tommy Thompson in implementing the Benefits Improvement & Protection Act (BIPA). Although practitioners certified by the American Board for Certification in Orthotics & Prosthetics (ABC) and the Board for Orthotist/Prosthetist Certification (BOC) are specifically included in BIPA, the NegReg Committee's failure to reach consensus throws the decision to determine who else may be considered "qualified providers" on HHS Secretary Tommy Thompson--decisions which could have a huge impact on the O&P profession.
Physical therapist direct access is a component in other pending national legislation. At press time, a Congressional conference committee was working to reconcile Medicare bills passed by the Senate and House of Representatives. The Senate's version includes an amendment which would create a three-year, five-state demonstration project in which physical therapists would be able to see Medicare patients without a physician prescription. "The amendment as introduced would also define qualified physical therapist' in a way that would likely impact the ability of state-licensed physical therapists to provide O&P services&," commented Peter Thomas, general counsel for the National Association for the Advancement of Orthotics & Prosthetics (NAAOP).
Thirty-seven states currently have some form of direct access by a licensed physical therapist, according to the American Physical Therapy Association (APTA). "It is time that Medicare beneficiaries have the same access," declares the organization on its website: www.apta.org
How do orthotists, prosthetists, and others feel about direct access, and why? To obtain a sampling of opinions from the field, The O&P EDGE posted some questions on the OANDP-L listserve. (Editor's note: Responses came overwhelmingly from certified orthotists and prosthetists. Physical therapists and healthcare professionals certified/licensed in more than one discipline are also invited to share their views. Please e-mail:firstname.lastname@example.org)
Several issues came up:
1)†Do physical therapists receive adequate training within physical therapy education to competently provide orthotic and prosthetic services and devices?
2)†Is the reimbursement for physical therapists providing O&P devices fair vis-√†-vis payment to orthotists and prosthetists, since physical therapists can bill separately for the device and for their time in providing services, while orthotists and prosthetists must use L-Codes, in which the service component is part of the reimbursement?
3)†What is the effect on the quality of patient care?
Do Physical Therapists Receive Adequate O&P Training?
Mark S. Hopkins, PT, CPO , clinical director, Dankmeyer Inc., Linthicum, Maryland, is certified in both disciplines and teaches orthotics and prosthetics in two masters degree programs, which are transitioning to doctoral programs. He sees two issues involved: 1) physical therapists providing O&P services; and 2) direct access to physical therapy services.
Based on his observations and experience, Hopkins declares, "I do not believe that entry-level physical therapist training at any degree level, whether masters or doctoral, sufficiently prepares physical therapists to provide comprehensive orthotic and prosthetic clinical services. By comprehensive orthotics and prosthetics,' I mean the ability to thoroughly evaluate and provide the most appropriate device."
"Considering the amount of total information these students must learn," Hopkins says, "We have time to provide only the basics of prosthetic/orthotic evaluation, design criteria, basic use and care training, and problem-solving."
However, Hopkins believes that, with additional training, physical therapists can competently fit some types of relatively simple custom-fit orthoses. He adds a caveat: "The difficulty with this is where to draw the line. If physical therapists are not able to provide comprehensive services, then how do they determine if they are providing the most appropriate device?"
Physical therapists also generally do not have the materials, tools, and experience to provide routine adjustments and repairs, he continues. Also, PTs are responsible for follow-up care for devices and being accountable if the device does not fulfill its intended purpose, Hopkins notes, adding, "In my experience, this does not happen."
Regarding prosthetics, Hopkins strongly believes physical therapists are not qualified to provide prostheses unless they receive training equivalent to O&P schools' prosthetic programs. "If a physical therapist wishes to become a prosthetist, orthotist or both, there are schools ready and waiting to enroll and teach him or her. Residency training and certification and/or licensure would then complete the education and training requirements."
Regarding direct access, Hopkins considers it as good in general for patients and payers, but he sees additional issues when it comes to providing orthoses and prostheses. "First, there are Stark-type [legal] issues relating to self-referral that would need to be worked out." Secondly, Hopkins believes that multidisciplinary care, with a physician and prosthetist/orthotist being involved, produces the best outcomes for patients.
Joseph C. Elliott, CP, LPO , area practice manager, Hanger Prosthetics & Orthotics, Birmingham, Alabama, and secretary of the Alabama State Board of Prosthetists & Orthotists, likewise is convinced that physical therapy education is inadequate for providing competent O&P care. "Our profession is one that demands knowledge and skills not gained in one- or two-day familiarization lectures presented in PT schools across the country." Elliott is a lecturer at a physical therapy school, and adds, "Budgetary and curriculum restraints have now limited time to four hours for familiarization lectures."
Licensure is urgent and vital, Elliott believes: "I am convinced that APTA will get all they can for their members if we don't take steps as a profession to protect the interests of consumers of O&P services by moving quickly to urge licensure in all states. Not nearly enough state associations are striving for this avenue to guarantee that only qualified professionals provide prosthetic and orthotic services. The O&P profession's interest in licensure is based on protecting the best interests of amputees and others we serve. I find no best interest' basis in the actions of the physical therapists."
Pam Lupo, CO , director of orthotics and director of post mastectomy care, Wright & Filippis, Rochester Hills, Michigan, shares a personal example: "Six years ago, a gentleman who was six feet, six inches tall came in with a prescription for a custom-made AFO. He had a three-inch wide healing wound on the distal border of his gastroc. I asked what caused the wound. He handed me an off-the-shelf AFO that was fit by a physical therapist in the hospital. As I accessed the orthosis, it was apparent that this off-the-shelf AFO was not tall enough for his stature. Yet, even more remarkable was the jagged proximal edge of the orthosis that had been trimmed with scissors. The jagged edge is what produced the open wound. What I found scary was that the lack of training and knowledge did not hinder this therapist from delving outside her scope of practice." (See photos at right)
"I find that there is a volume of physical therapists who, although not schooled, trained, or certified in providing orthotic care, feel it is appropriate to do so," Lupo continues.
Is Reimbursement Fair?
"The practice of billing physical therapy hours in addition to the cost of orthotic devices is also very common." Lupo says, "I know of no orthotist who professes to have the qualifications to provide physical therapy nor the audacity to charge for it."
"We are the folks trained to design, build, fit, and deliver orthotic and prosthetic services and devices," says Robert A. Bangham, CO, LO , director, Orthotics & Pedorthics, Park Prosthetic & Orthotics Inc., Corpus Christi, Texas. "For years, we have gladly referred our patients to a PT or OT for their ADL and/or gait training." Bangham points out that O&P practitioners are only reimbursed for the device and do not charge separately for adjustments and follow-up visits, although "the PT definitely charges for each minute of time invested, as well as for the device. Hence, our product may look more expensive than the item the PT dispenses."
"The best care for the patient is to receive therapy from a PT and an orthotic device from a certified and/or licensed orthotist," he concludes.
Dennis Vixie, CO , Spectrum Prosthetics & Orthotics, Grants Pass, Oregon, also notes that physical therapists are paid both for the product and the time they spend with the patient. "So, if the patient is a hard fit, he will be paying more for the appliance. I have been in the O&P business for over 40 years, and the same argument was made by the OTs," he continues. "They took most of the upper-extremity bracing away from orthotists, giving the reason that they could do the same job cheaper and more conveniently for the patient. What happened was a perceived cheaper product with more cost to the patient."
Al Pike, CP , a former president of the American Academy of Orthotists & Prosthetists (AAOP), points out that O&P practitioners themselves have "direct access," when a patient simply walks in and self-pays for the care and device. "The prescription only becomes an issue when we want a third-party payer such as Medicare or an insurance company to pay the bill."
Pike calls attention to the ABC Canons of Ethical Practice, which includes a statement that the orthotist or prosthetist must receive a prescription from a physician or appropriately licensed healthcare provider before providing any orthosis or prosthesis to a patient. "It would seem some practitioners do not know about this section," he adds. Pike sums up: "Direct access can benefit patients and reduce costs when accomplished in an ethical and professional manner. Regretfully, we are well aware of abuses in the healthcare system today."
Jeff Arnette, CO, BOCP, LPO , Progressive Orthotics & Prosthetics, Claremore, Oklahoma, sees a possible benefit in direct access through professional consolidation: "Combining the physical therapy and O&P professions could be beneficial through direct access by bringing the professions to an equal footing." This would allow orthotists and prosthetists the ability to treat patients without a need for referrals and would raise the level of respect for the profession, he adds.
Arnette points out that bringing together the rehabilitation disciplines would prevent practice seepage from other programs into a defined field of practice, increase the legislative "war chest," and unify the rehabilitation industry into one voice.
Arnette would like to see certified O&P practitioners, both ABC and BOC, along with certified pedorthists as one specialty group, with physical therapists, occupational therapists, and certified athletic trainers as another specialty group. These rehabilitation disciplines would then be combined under one umbrella organization. Each group would receive education and training to qualify them for orthotics, prosthetics, pedorthics, and physical/occupational therapy. A minimum of a bachelors degree would be required, advancing to a doctorate within ten years. A grandfather provision would be made for credentialing of those already practicing; however, these would need to meet the educational standards and guidelines within ten years.
"We need to view one another as a rehabilitation team and work together as a team, not only clinically but also for legislative clout," he said. "Too often we view one another as enemies."
Arnette continued, "Medicare is less and less willing to pay for custom-fabricated and custom-fit devices. By combining our rehab specialties, we not only can eliminate practice encroachment, we can expand our practices."
Then, combining credentialing boards at both state and national levels to work out reciprocal credentialing would make filling practitioner needs less cumbersome and reduce credentialing fees.