Physical Therapy: Ancillary Service For Patients Or Referral For Profit?

I am writing in response to the recent feature article, “How To Provide Physical Therapy As An Ancillary Service,” written by Jonathan Moore, DPM (see pg. 36, February issue). Unfortunately, the article may lead some readers to believe that adding physical therapist services to a physician/medical practice is not without potential harm or controversy.    Dr. Moore stresses that providing such services can improve your “bottom line” and that the profit potential is mostly dependent on the number of referrals the investor directs to his or her physical therapy program. This describes a practice that, in many situations, is referred to as “referral for profit.”    Referral for profit arrangements can create relationships between physical therapists and referring physicians that are based on financial incentives rather than patient care, professional collaboration and mutual respect. In many cases, such as the cases Dr. Moore appears to encourage, patients would be referred to highly qualified independent physical therapist practices except for the fact that physicians can create arrangements to profit from the patient referrals.    Issues related to financial conflicts of interest in healthcare, including the recent growth in physician ownership of physical therapy services around the country, are drawing increasingly serious concern from government agencies. Entering the physical therapy “business” may not be as risk-free and profitable as the article may have suggested. The ethical, business and legal aspects of these types of relationships are being closely scrutinized in terms of restraint of trade and competition, and interference with consumer choice.    The American Physical Therapy Association (APTA) opposes situations in which physical therapists or physical therapy assistants are employed by or under agreements with referring practitioners in which the referring practitioner receives compensation either directly or indirectly as a result of referring for, prescribing or recommending physical therapy. The APTA believes these arrangements inherently create a serious potential for abuse that your readers need to be aware of and that the effective provision of physical therapist services is enhanced when such arrangements are avoided.    Given their professional history, podiatrists should recognize that physical therapy is a separately licensed, regulated and recognized profession. The purpose of the rehabilitative care and services provided by both podiatrists and physical therapists is to better the lives of our patients, not to be a revenue source for other health care providers.    — Fran Welk, PT, DPT, MEd    Chair, Task Force on Referral for Profit    American Physical Therapy Association

Defending Physician-Owned Physical Therapy As An Ancillary Service

Dr. Moore responds: Thank you for your letter of concern. It is well known and documented that the American Physical Therapy Association (APTA) has for years vehemently battled (and continues to do so across the country) against all forms of physician-owned physical therapy. Before I bring up a few important points to highlight from your letter, it is important to point out (as I did many times in my article) that providing physical therapy as an in-office ancillary service should be done for the express purpose of providing a patient service that improves outcomes.    As this article was written as a practice management article, would it not be natural to discuss practice growth and issues surrounding one’s “bottom line”? Although the APTA would love to make my article sound like a “referral for profit” scheme, nothing could be further from the truth. The main emphasis of my article is, in fact, how to improve patient outcomes, compliance, convenience and patient satisfaction through a very legal and ethical collaboration with physical therapy.    To quote from my article: “If you cannot offer better lower extremity physical therapy than anyone in your area, you should not be doing it. Patient outcomes and satisfaction should drive your therapy program in all aspects.” I have daily and sometimes hourly conversations with the therapists who work in my office regarding patients’ progress, concerns and changes. This would not be possible if these patients were treated outside of my office. To tell me this level of communication, continuity and commitment to care provides only a financial gain is ludicrous.    When I refer a patient to physical therapy in my office, I do not decide the number of visits, the frequency of the patient’s therapy sessions or the types of modalities to be used. It is the physical therapist who makes these decisions. When you see a referral in your independently owned physical therapy center, who decides the frequency of the patient visits and the types of modalities the patient will receive? You, the physical therapy practice owner. In a business that depends on making revenue to pay to keep the lights on, where do you think more “over-utilization” would occur: in my office or yours? To me, the answer is obvious.    As a physician, it is my duty to recommend to my patients the best alternatives for their physical therapy treatment. If I offer the best physical therapy services for lower extremity in my office, is it wrong or unethical for me to offer or recommend these services for my patients? No patients should ever be coerced or manipulated in any way to go one place or the other for their therapy, but it is my job to see that my patients get the best care possible.    I believe it has long been the mission of the APTA to abolish any and all forms physician-owned physical therapy services under the banner of “over-utilization” and “self-referral.” The question is if the APTA were to succeed in its efforts, who would be the one eliminating options from the purview of the patient while gaining financially? Naturally, the physical therapist.    — Jonathan Moore DPM, MS    Board of Trustees    American Academy of    Podiatric Practice Management