Ethics and Professionalism in Physical Therapy
•Download as PPTX, PDF•
22 likes•7,651 views
Presentation by Stuart Katzman, DPT and Steven L. Simas, Esq. at the 2015 California Physical Therapy Association Annual Conference.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Viewers also liked (20)
Similar to Ethics and Professionalism in Physical Therapy
Similar to Ethics and Professionalism in Physical Therapy (20)
More from Justin Hein
More from Justin Hein (12)
Recently uploaded
Recently uploaded (20)
Ethics and Professionalism in Physical Therapy
- 2. California Physical Therapy Association (CPTA) © 2014
- 3. Ethics and Professionalism in Contemporary Physical Therapy Practice Stuart Katzman, PT, DPT Steve Simas, Esq. www.ccapta.org www.movecalifornia.org
- 4. Learning Objectives At the end of this program, the learner will be able to: Understand the APTA Code of Ethics Principles Be able to identify where/if potential conflicts of interests exist in various practice settings and arrangements Know the top eight reasons PT’s lose their licenses Understand the process for remediating ethical complaints Be abele to utilize the APTA Code of Ethics and Core Values to establish a foundation for ethical behavior
- 5. Ethics: Definition Ethic: - Rules of behavior based on ideas about what is morally good or bad *Meriam-Webster - Moral principles that govern a person’s or group’s behavior *Oxford Dictionary
- 6. Moral: Definition Moral: - Concerned with the principles of right and wrong behavior and the goodness or badness of human character *Oxford Dictionary
- 7. Morality So - who decides what is right or wrong? Philosophers have debated this since the age of time. For the Profession of Physical Therapy in the United States, it is the American Physical Therapy Association (APTA)
- 8. Ethical Behavior: nobody said it was easy Ethical Dilemmas: What would you do?
- 10. Robbin’s Dilemma
- 11. PT Practice - Guided By: The Law – State Practice Act (Section 2600 of the Business and Profession code) The Physical Therapy Board of California (PTBC) is one of 40 licensing boards governed by the Business and Professions (B&P) Code And – just in case they left anyone off the list… Regulation – all the details pertaining to the law
- 12. PT Practice - Guided By: APTA Code of Ethics Code of Ethics for the Physical Therapist Code of Conduct for the Physical Therapist Assistant APTA Guide for Professional Conduct – helps interpret the COE’s
- 13. PT Practice - Guided By: APTA’s Core Values: Accountability Altruism Compassion Excellence Integrity Professional Duty Social Responsibility
- 14. APTA Code of Ethics Principle 1 – Respect the dignity and rights of others Principle 2 – Compassionate and trustworthy Principle 3 – Accountable in making prof. judgements Principle 4 – Integrity in professional relationships Principle 5 – Fulfill legal and professional obligations Principle 6 – Commitment to lifelong learning Principle 7 – Promote behaviors which benefit society Principle 8 – Help meet the health needs of society
- 15. It Won’t Happen to Me! Just how often are PT’s brought up on ethics violations? In2014, The PTBC issued: - 123 Citations - 50 Disciplinary Actions
- 16. It Won’t Happen to Me! How difficult is it to file charges against a PT? * Not Very! * Simple file a complaint with the Dept of Consumer Affairs “Consumer Protection Services Program” of File a complaint directly with the PTBC *All complaints are investigated – even frivolous ones! ww.ptbc.ca.gov
- 17. Types of Licensing Board Violations Citations Disciplinary Actions
- 18. Citations If an administrative fine is included in the citation, the fine for a violation shall not be less than $100 and shall not exceed $2,500. A citation may include an administrative fine of up to $5,000 if the board determines that at least one of the following circumstances applies: (1) The citation involves a violation that presents an immediate threat to the health and safety of another person. (2) The citation involves multiple violations of the Physical Therapy Practice Act or these regulations that demonstrate a wilful disregard of the law. (3) The citation involves a violation or violations perpetrated against a senior citizen or disabled person. (4) The cited person has a history of two or more prior citations of the same or similar violations.
- 19. The Top 8 Disciplinary Actions: Unprofessional Conduct (patient neglect/safety) Unprofessional Conduct (sexual misconduct) Lack of supervision of assistive personnel Lack of documentation Unprofessional conduct (illegal practice of medicine/diagnosis of disease) Unprofessional conduct (illegal practice of acupuncture/dry needling) Unprofessional conduct (failure to document wellness services) Unprofessional conduct (DUI)
- 20. Disciplinary Action Resolution Decision - The order issued by the Board in a disciplinary action Stipulated Decision - A Settlement agreed to by the parties in lieu of a formal hearing to resolve the accusation and impose discipline. Default Decision - Licensee fails to respond to an Accusation by filing a Notice of Defense or fails to appear at administrative hearing. Public Reproval - A formal reprimand issued by the Board. Revoked - The right to practice is ended. Revoked, Stayed, Probation - "Stayed" means the revocation is postponed, put off. Professional practice may continue so long as the licensee complies with specific probationary terms and conditions. Violation of probation may result in the revocation that was postponed. Surrender of License - The licensee turns in the license, subject to acceptance by the board. The right to practice is ended. Suspension - The licensee is prohibited from practicing for a specific period.
- 21. www.PTBC.ca.gov
- 22. Actual Decisions 1. Accusation Filed 02/28/14. Violation of B & P Codes: 490 Conviction of a Crime, 2239 Self-Use of Drugs or Alcohol, 2239(a) Unlawful Use or Prescribing, 2660 Unprofessional Conduct, 2660(a) Use of Alcohol in a Dangerous Manner, 2660(e) Conviction of a Crime Substantially Related to the Practice, 2661 Conviction of a Crime. Violation of CCR: 1399.20 Criminal Substantial Relation, 1399.24 Unprofessional Conduct. Default. Decision and Order Effective 08/18/14, license revoked. 3. Accusation Filed 09/03/13. Violation of B & P Codes: 2234(c) Repeated Negligent Acts, 2620.7 Failure to Properly Document Treatment, 2660(g) Gross Negligence, 2660(h) Violating the Code. Violation of CCR: 1398.13 Failure to Properly Document Treatment. Stipulated Settlement and Disciplinary Order Effective 09/29/14, revocation stayed, 3 year probation.
- 23. Avoidable Conflicts of Interest
- 24. Avoidable Conflicts of Interest Referral for Profit scenarios Who do you work for? How is the business structured? How are your services being billed? Who decides how long to continue care?
- 25. Avoidable Conflicts of Interest Is it all about money? Absolutely not! But quite often it is
- 26. Our Old Friend: “Referral for Profit” What every therapist should know
- 27. Avoidable Conflicts of Interest Referral for Profit (RFP) Definition “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.”
- 28. Avoidable Conflicts of Interest—Referral for Profit Physician Ownership & Referral Act of 1993 (“PORA”) –Business and Professions Code Sections 650.01 It bans physicians, chiropractors, optometrists, and some psychologists from referring patients for specified healthcare goods and services, including physical therapy, in which the licensee or licensee’s immediate family has a financial interest. Thus, under PORA, a physician generally cannot refer a patient from his or her practice to a physical therapy practice in which the doctor has a financial interest.
- 29. Avoidable Conflicts of Interest—Referral for Profit PORA Exceptions are many (B & P Code sec. 650.02) Physicians in Rural Areas – Where there is no alternative provider within 25 miles or 40 minutes travel time. University Faculty Health Facilities, Hospitals and Emergency Services Non-profit Corporations Knox-Keene (HMO) Enrollees Multi-Specilaity Clinics (and more)
- 30. Avoidable Conflicts of Interest—Referral for Profit Labor Code sec. 139.3 –similar prohibitions in workers compensation Federal Law: Stark Law - 42 USC sec. 1395nn Anti-Kickback Statute – 42 US Sec. 1320
- 31. Avoidable Conflicts of Interest One form of Referral for Profit has long been known as POPTS; Physician-Owned Physical Therapy Services – Legal since AB 1000 in 2014 Financial relationship exists between a physical therapist and a referring practitioner – perhaps each owns a piece of the other’s prof. corp – Legal since AB 1000 in 2014 MD/DO, DDS, DPM, DC or PT refers a patient for PT treatment and receives financial gain, in the form of a “kickback” – Illegal A PT rents space from a referral source and the rent/lease fee is dependent upon the volume of patients referred – (in most cases)
- 32. Avoidable Conflicts of Interest RFP: Discussion Points What would CONSTITUTE a quality Non-PT-Owned PT practice? If all things were equal, why would a PT choose to work in a clinic owned by anyone other than a PT? Why do you think a Non-PT-Owned clinic would be able to pay significantly higher salaries to a PT than a PT owned practice? Why doesn’t APTA just prohibit PTs from working in self referral arrangements?
- 33. Avoidable Conflicts of Interest APTA Resources on RFP APTA “White Paper” on Referral for Profit APTA Resource Manual on Referral for Profit APTA POPTS Survival Guide POPTS “Take Action Packet” “Referral for Profit & Physical Therapy” legislator brochure APTA website apta.org or call (800) 999-2782
- 34. Avoidable Conflicts of Interest Who Do You Work For? Corporate Employment in Healthcare Moscone-Knox Professional Corporation Act (Corporations Code 13401.5) Health professional corporations listed in the Moscone-Knox Act may employ other professionals included in the Business and Professions Code (B&P Code), including physical therapists. Physical therapy corporations may equally employ other health professionals and of which a majority of the shares must be owned by physical therapists.
- 35. Avoidable Conflicts of Interest If a physical therapist is employed by, or employs, a referral source, an inherent conflict of interest may exist: Physician/Therapist judgment regarding need for physical therapy may be compromised. Physician/Therapist judgment regarding the need for continuing care may be compromised. Physical therapist may face pressure to manage all patients referred by a particular physician.
- 36. Professional Corps Disclosure Requirements Section 2406.5 Business and Professions Code When a physician or surgeon, podiatrist, or other referring practitioner refers a patient to receive services by a physical therapist employed by a professional corporation as defined in Section 13401 of the Corporations Code, the referring practitioner shall provide notice of the following to the patient, orally and in writing, in at least 14-point type and signed by the patient: That the patient may seek physical therapy treatment services from a physical therapy provider of his or her choice who may not necessarily be employed by the medical or podiatry corporation. If the patient chooses to be treated by an employed physical therapist, any financial interest the referring practitioner has in the corporation.
- 37. Disclosure Rules: If Only So Transparent
- 38. Ethics Which Rule Conflicts of Interest Who makes “plan of care” decisions for your patients? Principle #3 – PT will be accountable for making sound professional judgments 3A – PT will demonstrate independent and objective professional judgment 3D – PT will not engage in conflicts of interest that interfere with professional judgment
- 39. Ethics Which Rule Conflicts of Interest Principle #7 – PT shall promote organizational behaviors and business practices that benefit patients/clients and society 7A – PT shall promote practice environments that support autonomous and accountable professional judgments 7F – PT shall refrain from employment arrangements, or other arrangements, that prevent PTs from fulfilling professional obligations to patients/clients
- 40. Ethics Which Rule Conflicts of Interest Physicians also have Ethical Standards to adhere to: “Under no circumstances may physicians place their own financial interests above the welfare of their patients” -From the American Medical Association Code of Ethics
- 41. Ethics Which Rule Conflicts of Interest
- 42. Over Utilization’s Poison to the Profession The Trickle-Down Effect: Over-utilization leads to diminished value of service by payers Which may lead to lower payment for PT services Which may adversely affects PT salaries and practice revenue Which may reduce PT work force demand
- 43. Ethics Which Rule Conflicts of Interest Being held accountable for the behavior of other’s Principle #4 - :Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public. 4C. Physical therapists shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate.
- 44. Ethics Which Rule Conflicts of Interest How are your services being billed? Are they coded to accurately reflect the interventions provided? Are the charges within the realm of usual and customary? Are the patient’s estimated “out of pocket” expenses explained before the services are rendered?
- 45. Ethics Which Rule Conflicts of Interest Principle #7 – PT shall promote organizational behaviors and business practices that benefit patients/clients and society 7B – Physical therapist shall seek remuneration as is deserved and reasonable for physical therapist services 7E – Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided
- 46. Ethics Which Rule Supervision of Personnel Principle 3E – Physical therapists shall provide appropriate direction and communication with physical therapist assistants and support personnel Principle 4B – Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority Principle 5B – Physical therapists shall have primary responsibility for supervision of physical therapist assistants and support personnel
- 47. Legal Requirements Regarding Supervision of Personnel PT Board Regulation – Title 16, Cal. Code Regs., Section 1398.44 “Adequate Supervision Defined” –PT Assistants PT Board Regulation – Title 16, Cal. Code Regs., Section 1399 “Requirements for Use of Aides” PT Board Regulation – Title 16, Cal. Code Regs., Section 1399.10 “Supervision of PT License Applicants” PT Board Regulation – Title 16, Cal. Code Regs., Section 1399.12 “Superviison of PT Assistant License Applicants”
- 48. The Top 8 Disciplinary Actions: Unprofessional Conduct (patient neglect/safety) Unprofessional Conduct (sexual misconduct) Lack of supervision of assistive personnel Lack of documentation Unprofessional conduct (illegal practice of medicine/diagnosis of disease) Unprofessional conduct (illegal practice of acupuncture/dry needling) Unprofessional conduct (failure to document wellness services) Unprofessional conduct (DUI)
- 49. Ethics Related to Practice Structure Who owns the Practice? PT MD Partnership
- 50. Ethics Related to Practice Structure Who can a PT “partner” with in a corporation in 2015? Anyone listed in Moscone-Knox Professional Corporations Act (Corps. Code sec. 13401.5) No such thing as PT “general corporation” any longer Defines “PT Professional Corp” Allows most healthcare licensees to work for other healthcare professional corporations (Corps. Code sec. 13401.5).
- 51. Ethics Related to Practice Structure Principle #5 – 5A – Physical Therapists shall comply with applicable local, state and federal laws and regulations.
- 52. Ethics Related to Practice Structure “Creative” office lease and use arrangements: A Form of “Referral for Profit” Kickbacks Sliding Lease/Rent Scale Depending Upon Referral Volume
- 53. Corporate Concerns? Consolidated Healthcare – Multidisciplinary services being provided under the umbrella of a single business entity (The Kaiser’s of the world) Is this a legal form of referral for profit? How can you (a PT employee) be sure the business structure, operations and billing practices are not jeopardizing your license?
- 54. Consumer Direct Access Business & Professions Code 2620.1 “A person may initiate physical therapy treatment directly from a licensed physical therapist if the treatment is within the scope of practice of physical therapists, as defined in Section 2620, and all of the following conditions are met.”
- 56. Consumer Direct Access Conditions imposed by the law: If, at any time, the physical therapist has reason to believe that the patient has signs or symptoms of a condition that requires treatment beyond the scope of practice of a physical therapist…the physical therapist shall refer the patient to a physician, surgeon, or a chiropractor. The physical therapist shall disclose to the patient any financial interest he or she has in treating the patient. With the patient's written authorization, the physical therapist shall notify the patient's physician and surgeon, if any, that the physical therapist is treating the patient.
- 57. Consumer Direct Access Conditions imposed by the law: “The physical therapist shall not continue treating the patient beyond 45 calendar days or 12 visits, whichever occurs first, without receiving, a dated signature on the physical therapist's plan of care indicating approval of the physical therapist's plan of care. Approval of the physical therapist's plan of care shall include an in-person patient examination and evaluation of the patient's condition.”
- 58. Consumer Direct Access Conditions imposed by the law: The 14pt disclosure notice
- 59. Sample 14pt Disclosure Direct Physical Therapy Treatment Services Disclosure Statement You are receiving direct physical therapy treatment services from an individual who is a physical therapist (PT) licensed by the Physical Therapy Board of California. Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist. ___________________ ____________________ ___________________ Patient Signature Printed Name Date
- 60. Consumer Direct Access Business & Professions Code 2620.1 “Nothing in this section shall be construed to require a healthcare service plan, insurer, workers' compensation insurance plan, employer, or state program to provide coverage for direct access to treatment by a physical therapist.”
- 61. Consumer Direct Access Treating without a Diagnosis??? Currently PTs are not authorized to diagnose disease/pathology—so, what do we put in the Dx box for billing? The Physical Therapy Board of California (ptbc.ca.gov) has affirmed that assigning an ICD-9 code to describe a persons functional impairment will not be construed as unlawful practice of medicine in the form of diagnosis of disease.
- 62. Consumer Direct Access Professional Obligations = Ethical Obligations Clinically competent in medical screening: Is the patient appropriate for PT? 14-point font Disclosure – Disclose time limitations to patient Appropriate treatment utilization
- 63. Consumer Direct Access: Professional Opportunities Practicing at the full extent of your professional preparation, education and training. To uphold professional values and practice as a musculoskeletal primary care provider. Develop life long relationships with your patients: They begin to identify you as “their” physical therapist! To be able to promote yourself and your unique expertise directly to your target audience – and know that you can see “anyone” that comes through your door. Opportunity to foster collegial relationships with local specialists and primary care providers.
- 65. Remediating Ethical Complaints *Why People Break Rules: - Human Error - Stuff Happens - Negligence - Recklessness *Kirsch, N: 2008 Federation of State Boards Annual Meeting
- 66. Remediating Ethical Complaints More Questions than answers: Do licensing boards address “legal” component of infraction and the “ethical”? How do we assess “ethical decision making?” Should a license be revoked temporarily or permanently? Can individuals adopt higher standards of behavior” Do we punish “human error”? Especially in the case of a first offense? Do offenders really change behavior or just learn to deal with the system?
- 67. Remediating Ethical Complaints What we do know: - Studies reveal ethical decision making declines over years of practice. - Ethical decision making is evolutionary - Some people are not able to differentiate between kinds of behaviors. - We all need the skills to recognize and deal with ethical situations responsibly. - We are not exactly sure the best way to teach the skills!
- 68. Remediating Ethical Complaints What’s Available for Learning: * Online learning modules - APTA “professionalism”module - Various online CE providers; and there are many! *Reading Material – self study - APTA Documents
- 70. Ethical behavior is what you do when nobody is looking!
- 71. Open Q & A
Editor's Notes
- Looks like we truly can not understand “ethics” wthout knowing the definition of moral
- So ethics are based on guiding moral principles and morals are based on what is right vs. wrong. Who decides?
- Morality is defined by society with significant variation from one society to another. Socrates, 2500 years ago, was one of the first to encourage scholars and common citizens to turn their attention from the outside world to the condition of humankind. Aristotle followed a few hundred years later and the discussion/debate has not stopped since.
- You are a doctor at a top hospital. You have six gravely ill patients, five of whom are in urgent need of organ transplants. You can’t help them, though, because there are no available organs that can be used to save their lives. The sixth patient, however, will die without a particular medicine. If s/he dies, you will be able to save the other five patients by using the organs of patient 6, who is an organ donor. What do you do?
- You are an eyewitness to a crime: A man has robbed a bank, but instead of keeping the money for himself, he donates it to a poor orphanage that can now afford to feed, clothe, and care for its children. You know who committed the crime. If you go to the authorities with the information, there’s a good chance the money will be returned to the bank, leaving a lot of kids in need. What do you do?
- Fortunately, our day to day activities do not (hopefully) require such heart wrenching difficult decisions. For the most part, the law, regulation and Code of Ethics we are all held accountable to is fairly objective and straight forward. The unique rights, privileges, limitation and scope of physical therapist practice is defined in section 2600 of the California Business and professions code. Hence – the name of our Political Action Committee’s club of annual donor’s of $500 or more being called the 2600 club. Everything from the Medical Board of California, the Structural Pest Control Board, State Board of Guide Dogs for the Blind and The Cemetery and Funeral Bureau – we are diverse lot of licensiates. And, get this, just in case they forgot anyone, or decide they want to come after anyone, the 41st line reads; “any other Boards, offices or officers subject to its jurisdiction by law” Regulation – once laws pass, the specifics needed to enact, clarify and enforce the law are created. Not always really concise. The affordable care act’s regulations, also known as Obamacare, exceed 11,000 pages.
- Beyond the law and regulation, there are ethics and professional behaviors. Not quite as objective and the law, yet clear enough that there should be little doubt that the decisions you make in your day to day practice are ethical. When ethics charges are brought against a licensee, the licensing body often looks to that particular profession’s professional association or society to provide the community standard. For PT’s and PTA’s this is clearly the APTA and the APTA is well prepared. The Standards of ethical conduct for the PT and PTA outline acceptable behaviors and expectations for conduct for all aspects of practice. Character traits such as integrity, accountability, respect, etc… are all covered These preferred values, as developed, adopted and periodically amended by the APTA Board of Directors – and then subsequently approved by the House of Delegates, are referred to as our Core Values The “Principles” as they are referred too, are not complex, yet, just to be sure, the APTA has published a companion document to help licensees understand the COE’s and provides every day situations to assist in the interpretation. We will not be going over each of the 8 principles and the preamble line by line; rather, we will be taking you through real and/or potential practice situations and then referencing the specific piece of the COE’s or practice act being used to guide our judgement. Please understand, this course is not intended to scare you out practice or suggest that most PT’s are practicing illegally or unethically; rather just the opposite. The best way to make sure you are in compliance is to be fully aware of and understand the laws, regulations and standards expected of you. We strongly encourage you keep a copy of the COE’s and the practice act on your desktop. They are both easily obtained by the PTBC and APTA web sites in pdf format.
- The formulation of APTA’s code of ethics is based upon the acceptance of certain core values. The APTA has a document entitled ‘Professionalism in Physical Therapy: Core Values” where each of these values is defined and sample indicators of appropriate behavior are provided.
- Put is all together and you have a comprehensive “code of ethics”. Eight principles, each of which is further defined by several sub-sections and each principle speaking to at least two or more of the Core Values. We will not be going through every principle and sub-set in detail; rather we will look at them relative to specific practice situations. You will notice that principles 1 and 2 really speak to character, 3 and 4 to practice, 5 and 6 to the law (of which mandatory CEU’s is now the law) and 7 and 8 to altruism. Before we dive in, let me ask you to consider – How often do you believe PT’s in Calif are brought up against practice violations by the PTBC? Often? Rarely? Raise your hand if you can think of a physical therapist or PTA who has been charged with practice (legal or ethical) violations.
- Here are some numbers. More than you thought? Less? None of us plan on violating the tenants of legal or ethical practice – at least not most of us. As with any large population of individuals (and there are ??? Licensed PT’s in Calif) there are always a few bad apples. But the large majority of us are intent with staying out of trouble. But it does happen and none of us foresee it happening to us.
- The process for filing a complaint against a PT is quite simple. There is a form available online, either through the dept of consumer affairs or the PTBC. Whether filed with the DCA or PTBC it is the PTBC which will be charged to investigate. Interestingly, nowhere on the form does the filer of the complaint need to sign a statement of being truthful. We will get into the remediation process later, but it can be a time consuming and costly process. In some cases, even when cleared, the fact that a “complaint” was filed remains on your record for a period of time. If you are curious, go
- If you hear from the PTBC it is because of one or two types of violations. Citations which generally are punishable by a fine and, disciplinary actions which are much more punitive and can affect the status of ones license. Citations are much more common and the majority are simply for failure to report a change of address. How many of you (and be honest here) knew that failure to report a change of mailing address and email address is punishable by the PTBC?
- An administrative fine
- Here are the top 8 reasons California PT Licensiates experienced disciplinary action Unprofessional conduct (patient neglect/safety) – ignoring precautions, not thoroughly understanding patients co-morbidities, generally, this is where clinical malpractice happens Sexual Misconduct: - No, you may not have a sexual relationship with your patient! This could mean any sexual relationship such as inappropriate speech or touching, gestures, etc. Therapists also need to be reminded of patient misperceptions of treatment; there are cultural, age or gender differences where it is inappropriate to touch. These may be common-sense things, but it happens! Don’t forget to get informed consent if the appropriate treatment requires touching sensitive areas. Lack of supervision or misappropriate use of support personnel Documentation – this includes content and legibility and the simple lack of documentation Unprof conduct – illegal practice of medicine/dx of disease. Fairly self explanatory and it does happen. If suspicious of disease or feel the patient needs a new/different medication, communicate with the referring physician or suggest the patient consult with an MD, but do not use disease terminology. Same with dry needling – as much as you may believe in its clinical utility, Calif PT’s can not do anything which punctures the skin unless specifically licensed to do needle electromyography Failure to document wellness services – documenting your services as rehabilitative and billing for services which are more appropriately labeled “wellness” and not the responsibility of the patient’s insurance carrier? DUI and other drug offenses - self explanatory
- All disciplinary actions are ultimately resolved, or decided, by one of these outcomes. None are really all that favorable. If the PTBC finds merit to take on a case and file disciplinary action, the best outcome is that the parties involved settle without disclosing terms. The file number, accusations and decision, “stipulated decision” remain tagged to your license number and there for all to see for sever years (I think?). And this stuff really happens.
- Hopefully this looks familiar. The PT Board website is your source for just about anything pertaining to your license; including information you didn’t even know you needed to know. There was a time when written notices were sent prior to any new laws going into effect. No longer. The DCA and PTBC now expect licensiates to periodically check the web for updates and notices. Breaking news, new laws, changes to existing laws and requirements usually get front page status. A good time to check is Jan. 1st and July 1st – these two dates are the most common for new laws to take effect. Another great way to stay up to date is via CPTA communication. A staff or Board member is at every PT Board meeting licensing board info is distributed through Cal PT Notes and the newsletter. Ignorance does not excuse one from the law. I mentioned the citations related to change of address violations; most PT’s have no idea they are required to report a change of address, change of name and email addresses changes within 30 days (what is the fine?)
- These are real. They are available to the public on the PTBC website. Except on the website, the licensee’s name and license number is there right next to all of this info. Now I’ve been around and practicing a bit longer than many of you, and I do not regularly peruse the board’s website looking for familiar names, but I did take look in preparing for this meeting and there was a name or two I recognized.
- Most of us aspire to do an honest days work, utilize our unique expertise to help our community members in need and stay out of jail. Here’s the problem, in the course of what you think is an honest day’s work, there are several scenarios in which the actions of other’s, or due to a lack of due diligence on your part, you are in fact compromising your license with your actions. Most of these are what’s referred to as ‘Avoidable Conflicts of Interest”. Some are easier to spot than others. While the conflicts of interests which jeopardize a PT’s license are not always (in fact rarely) transparent, the information needed to assure oneself of ethical practice is readily available.
- Referral for profit has long been a hot topic, not only in PT, but in healthcare in general. But look at some of these other questions. The answer to which have huge consequences relatively to you meeting the legal and ethical requirements of your license.
- Is it all about money? Well….. Conflicts of interest relative to physical therapy are not entirely motivated by money – or, at least the don’t need to be. Each of the scenario’s we’re about to go through could all occur without violation of ethics or professional standards. Yet, in nearly every case, when there is wrong doing, the motivation is often financial gain. Which begs the question, “Who” and/or “for what” are you willing to risk your license for? Hopefully nobody!
- So let’s go back and look closer at our old friend “Referral for profit’ Referral for Profit situations have widespread impact on the physical therapy profession – potential to exist in almost every setting where therapists work
- Definition: “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.” The concern about Referral for Profit relationships is not about the individual therapist, but about the situation and the impact on our profession and the consumers of physical therapy services- because this is not illegal, yet can be difficult to engage in without being unethical. Let me explain
- Definition: “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.” The concern about Referral for Profit relationships is not about the individual therapist, but about the situation and the impact on our profession and the consumers of physical therapy services- because this is not illegal, yet can be difficult to engage in without being unethical. Let me explain
- Definition: “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.” The concern about Referral for Profit relationships is not about the individual therapist, but about the situation and the impact on our profession and the consumers of physical therapy services- because this is not illegal, yet can be difficult to engage in without being unethical. Let me explain
- Definition: “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.” The concern about Referral for Profit relationships is not about the individual therapist, but about the situation and the impact on our profession and the consumers of physical therapy services- because this is not illegal, yet can be difficult to engage in without being unethical. Let me explain
- Definition: “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.” The concern about Referral for Profit relationships is not about the individual therapist, but about the situation and the impact on our profession and the consumers of physical therapy services- because this is not illegal, yet can be difficult to engage in without being unethical. Let me explain
- Definition: “Referral for profit” in physical therapy describes a financial relationship between a physical therapist and a physician in which a physician (medical doctor, doctor of osteopathy, podiatrist, dentist or chiropractor) refers a patient for physical therapy and derives a financial benefit from the physical therapy services provided to the person who is referred.” The concern about Referral for Profit relationships is not about the individual therapist, but about the situation and the impact on our profession and the consumers of physical therapy services- because this is not illegal, yet can be difficult to engage in without being unethical. Let me explain
- All of these arrangements can come in many flavors. The legal forms of referral for profit are related to laws which govern the structure and ownership of professional corporations: they do not, however, provide an exemption or free pass from practicing ethically. Let me explain..
- The proximity to a physician could be advantageous for communication and conferring on cases. PT having fill authority as to who is seen and for how long (how many visits). Hmmmm? Controls referrals. Can assure that productivity will remain high. May require higher volume of patient visits per day. PT may be supervising non licenses support personnel who have their own case load – being billed as PT The Federal Trade Commission (FTC) has held that an APTA component restrained competition and acted in violation of certain federal antitrust laws when it attempted to restrict physical therapists from being employed by physicians by declaring that such employment arrangements were unethical and illegal. The action was taken by the Federal Trade Commission in 1988 against the APTA’s Iowa Chapter. The FTC on 11/04/1988 issued a Complaint and Order against the Chapter, following publication of its intent to do so in the Federal Register (FR) of 08/30/1988. See 53 FR 33144, 08/30/1988, notice of proposed consent agreement; 53 FR 52679, 12/29/1988, notice of consent order. The notice of proposed consent order stated that the Chapter “communicated to members that employment by physicians was unethical and would subject the physical therapist to disciplinary action,” and the order provided in part: It is ordered that respondent shall cease and desist, directly or through any corporate or other device, from restricting, impeding, regulating, declaring unethical or illegal, interfering with, or advising against any physical therapist: Accepting or continuing any employment or other contractual arrangement with any physician, or other health care provider because such physician or health care provider employs or seeks to employ, or has a contractual arrangement with, or seeks to enter into a contractual arrangement with any physical therapist… Extracted from briefing paper to the 2007 APTA House of delegates by Jack Bennett ESQ
- Section 13401.5 of the Corporations Code dictates which professionals can own shares in other prof corporations, as long as the sum of shares owned by “other” professionals does not exceed 49%. So a PT can own up to 49% of a medical corp and likewise, an MD can own up to 49% of a PT corporation. There are 10 other healthcare professional designations which can have ownership in a PT corp – including: (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Licensed acupuncturists. (4) Naturopathic doctors. (5) Licensed occupational therapists. (6) Licensed speech-language therapists. (7) Licensed audiologists. (8) Registered nurses. (9) Licensed psychologists. (10) Licensed physician assistants. This all came into effect on Jan 1st 2014. (actual language – leave below for reference but no need to read) The following licensed persons may be shareholders, officers, directors, or professional employees of the professional corporations designated in this section so long as the sum of all shares owned by those licensed persons does not exceed 49 percent of the total number of shares of the professional corporation so designated herein, and so long as the number of those licensed persons owning shares in the professional corporation so designated herein does not exceed the number of persons licensed by the governmental agency regulating the designated professional corporation. This section does not limit employment by a professional corporation designated in this section of only those licensed professionals listed under each subdivision. Any person duly licensed under Division 2 (commencing with Section 500) of the Business and Professions Code, the Chiropractic Act, or the Osteopathic Act may be employed to render professional services by a professional corporation designated in this section. (a) Medical corporation. (1) Licensed doctors of podiatric medicine. (2) Licensed psychologists. (3) Registered nurses. (4) Licensed optometrists. (5) Licensed marriage and family therapists. (6) Licensed clinical social workers. (7) Licensed physician assistants. (8) Licensed chiropractors. (9) Licensed acupuncturists. (10) Naturopathic doctors. (11) Licensed professional clinical counselors. (12) Licensed physical therapists. (b) Podiatric medical corporation. (1) Licensed physicians and surgeons. (2) Licensed psychologists. (3) Registered nurses. (4) Licensed optometrists. (5) Licensed chiropractors. (6) Licensed acupuncturists. (7) Naturopathic doctors. (8) Licensed physical therapists. (c) Psychological corporation. (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Registered nurses. (4) Licensed optometrists. (5) Licensed marriage and family therapists. (6) Licensed clinical social workers. (7) Licensed chiropractors. (8) Licensed acupuncturists. (9) Naturopathic doctors. (10) Licensed professional clinical counselors. (d) Speech-language pathology corporation. (1) Licensed audiologists. (e) Audiology corporation. (1) Licensed speech-language pathologists. (f) Nursing corporation. (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Licensed psychologists. (4) Licensed optometrists. (5) Licensed marriage and family therapists. (6) Licensed clinical social workers. (7) Licensed physician assistants. (8) Licensed chiropractors. (9) Licensed acupuncturists. (10) Naturopathic doctors. (11) Licensed professional clinical counselors. (g) Marriage and family therapist corporation. (1) Licensed physicians and surgeons. (2) Licensed psychologists. (3) Licensed clinical social workers. (4) Registered nurses. (5) Licensed chiropractors. (6) Licensed acupuncturists. (7) Naturopathic doctors. (8) Licensed professional clinical counselors. (h) Licensed clinical social worker corporation. (1) Licensed physicians and surgeons. (2) Licensed psychologists. (3) Licensed marriage and family therapists. (4) Registered nurses. (5) Licensed chiropractors. (6) Licensed acupuncturists. (7) Naturopathic doctors. (8) Licensed professional clinical counselors. (i) Physician assistants corporation. (1) Licensed physicians and surgeons. (2) Registered nurses. (3) Licensed acupuncturists. (4) Naturopathic doctors. (j) Optometric corporation. (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Licensed psychologists. (4) Registered nurses. (5) Licensed chiropractors. (6) Licensed acupuncturists. (7) Naturopathic doctors. (k) Chiropractic corporation. (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Licensed psychologists. (4) Registered nurses. (5) Licensed optometrists. (6) Licensed marriage and family therapists. (7) Licensed clinical social workers. (8) Licensed acupuncturists. (9) Naturopathic doctors. (10) Licensed professional clinical counselors. (l) Acupuncture corporation. (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Licensed psychologists. (4) Registered nurses. (5) Licensed optometrists. (6) Licensed marriage and family therapists. (7) Licensed clinical social workers. (8) Licensed physician assistants. (9) Licensed chiropractors. (10) Naturopathic doctors. (11) Licensed professional clinical counselors. (m) Naturopathic doctor corporation. (1) Licensed physicians and surgeons. (2) Licensed psychologists. (3) Registered nurses. (4) Licensed physician assistants. (5) Licensed chiropractors. (6) Licensed acupuncturists. (7) Licensed physical therapists. (8) Licensed doctors of podiatric medicine. (9) Licensed marriage and family therapists. (10) Licensed clinical social workers. (11) Licensed optometrists. (12) Licensed professional clinical counselors. (n) Dental corporation. (1) Licensed physicians and surgeons. (2) Dental assistants. (3) Registered dental assistants. (4) Registered dental assistants in extended functions. (5) Registered dental hygienists. (6) Registered dental hygienists in extended functions. (7) Registered dental hygienists in alternative practice. (o) Professional clinical counselor corporation. (1) Licensed physicians and surgeons. (2) Licensed psychologists. (3) Licensed clinical social workers. (4) Licensed marriage and family therapists. (5) Registered nurses. (6) Licensed chiropractors. (7) Licensed acupuncturists. (8) Naturopathic doctors. (p) Physical therapy corporation. (1) Licensed physicians and surgeons. (2) Licensed doctors of podiatric medicine. (3) Licensed acupuncturists. (4) Naturopathic doctors. (5) Licensed occupational therapists. (6) Licensed speech-language therapists. (7) Licensed audiologists. (8) Registered nurses. (9) Licensed psychologists. (10) Licensed physician assistants.
- Relative to physical therapy, what do we mean by “potential conflict of interest”? And we say “potential” yet the data and research on self referral patterns shows these problems are “real” not just potential. The most common forms of inappropriate professional behaviors are as noted: Physicians refer patients that don’t really need PT (you can give a personal example of something you may have seen. I always use the one of a friend who called me to say his Ortho was referring him for 12 PT visits to be done prior to a menisectomy. As soon as I heard this I knew he probably owned the clinic he was referring my friend to; which he did) Or, PT’s feel internal pressure to just see everyone referred for as long as they are referred and authorized, whether appropriate or not. In the end, in many cases, the best interests of the client may be compromised or the payer obligated to pay for services not clinically indicated. All of these are likely violations of APTA’s “Code of Ethics”
- So the legislature, in their infinite wisdom, set up disclosures intended to reveal financial interest to unsuspecting consumers (patients). These rules apply to any health professional referring a patient to another practitioner employed by the referral source. The degree to which these rules are adhered to is uncertain, yet we know there is virtually no investigation, auditing or enforcement.
- If only all required disclosures were really so transparent. In this particular situation, it’s not unrealistic to think that the unsuspecting consumer who so blindly adheres and does as told by a physician simply because they are a “doctor”, would still take the drug no questions asked! Let’s take a look at how our Code of Ethics applies to some Conflict of Interest situations.
- Plan of care: If not you – who’s making plan of care decisions for your patients? Sound and professional judgments! Regardless of where you work or who you work for! What does this mean? It means several things. Most importantly, and relative to potential conflicts of interests and referral for profit, it all boils down to whether clinical decision making is being done with the patients best interest in mind and not clouded by potential financial gain. Is the patient appropriate for PT? Does the patient really need PT? Once initiating a plan of care, who develops and then upholds appropriate discharge goals? Clinical decisions being made with anything but the patient’s best interest in mind is nothing short of greed and/or unethical behavior. And, the majority of over-utilization ethics violations brought against PT are for clinicians working for someone else. So again I ask: For who and for what are you willing to risk your license?
- Principle 7: Different language but similar intent. Protection of the consumer from poor judgment. Note 7F specifically speaks of “refraining from employment arrangements, or other arrangements, that prevent physical therapists from fulfilling professional obligations to patients/clients”. As already mentioned, these employment arrangements are not illegal, yet our COE’s make a precautionary statement of our “obligations”. Who is making decision regarding patient care? Continuation of care? Referring out to another provide when needed? Because here’s the deal, over-utilization doesn’t just hurt the patient’s or insurance company’s pocket book – it hurts all of us as well.
- We are not alone. MD’s have similar language in the their code of ethics. Yet - clearly there are physicians who don’t feel this particular verse pertains to them – or, they simply know there is very little auditing, investigation and enforcement. Which is true, complaints to the medical board are filed and a physician would have to do something “really” bad to get the attention of the medical board before they would send an investigator out.
- Much of what we just discussed hinged around the concept of over-utilization. Let’s take a look at the trickle down effects of over-utilization and how it adversely affects the entire profession.
- Consider how unsubstantiated and clinically inappropriate treatment hurts the profession as a whole. All healthcare providers and being highly scrutinized and held accountable to substantiate the service they are providing; this goes part and parcel with evidenced based practice which you’re all familiar with. When payers don’t get any bang for their buck, they simply put much tighter controls on that particular service, reduce what they pay for that service and/or eliminate it as covered benefit. If/when this occurs in the PT world, it drives down the bottom line of private practices and PT Depts, which has a profound effect on salaries and hiring. These are very real scenarios. In 2004 the entire California work comp code was modified and the end result was that physical therapy (as well as a few other services) were capped at a set number of visits for the life of the injury; with some exceptions. Prior to 2004 there was very little utilization review and a ton of over utilization. While I could point the finger at corporate and physician owned clinics for being the primary abuses – which would be mostly accurate – the bottom line is that the profession did not clean itself up and the regulators stepped in. Now, 11 years later, the reigns have been loosened a bit, but there is still much more reporting and paper work required to substantiate the service being requested. And, wouldn’t you know, many physicians got out of the work comp and PT business.
- What about when you see someone or another practice engaging in unethical behavior? Reporting them is not the easiest thing to do as none of us like to be seen as snitches or whistleblowers; however, it is our ethical duty and it really is easy. In reality, your most likely first action – prior to formally filing a complaint – is to have a conversation with the appropriate individual about the legal and/or ethical violations you’ve observed. Tough stuff when your job is potentially on the line and/or working with friends and close professional colleagues. One word of caution: make sure you have your facts in order before casting assertions of wrong doing.
- For many of you, the answer to all of these questions may very will be “I Don’t No”. Yet, it is your professional responsibility to understand how your time is being accounted for and how your services are being billed. In the case of Medicare, and likely some of the other large payers, the services are billed with your NPI number and not only should you care, you have a right to know.
- Though I can not proclaim to fully understand how all practices, hospital, rehab facilities or private practices operate, in many cases the treating clinician completes a charge slip – or in this era of electronic health records and automation – does the treatment documentation and charges at the same time; yet, the actual codes and/or dollar amounts are not transparent. It is not uncommon for a treating clinician to have no clue how much their services were being billed. You should know and your supervisor, billing department, practice owner (whoever you report to) should be very willing to share the info with you. If they refuse, show them the COE’s. If still not cooperative, you should look for a new place to practice. Let’s talk a bit about the supervision of physical therapist assistants and support personnel
- If you think back to our earlier list of the “top 8 disciplinary actions” against California PT’s, right there after negligence and sexual misconduct is “lack of supervision of support personnel”. Here is the list again – (go forward one slide and then back again to this one). My hunch, is that this form of violation is more prevalent and that most cases go unreported. Again, it’s really hard to bring assertion of unlawful practice against your current employer. Those not comfortable practicing in such setting would likely leave rather than forcing change. Which is an excellent start – and I admire the person not willing to risk their license for someone else; yet, it leaves behind a practice operating in violation of the law. And this portion of our COE’s is a great example of how the lines blur quickly when discerning law from ethics. These principles are written inferring a knowledge of the law and, more specifically, the supervision and delegation limitations content areas of the PT practice act. The word “appropriate” in Prin. 3E is the synonymous with saying “in accordance with the law”.
- If you think back to our earlier list of the “top 8 disciplinary actions” against California PT’s, right there after negligence and sexual misconduct is “lack of supervision of support personnel”. Here is the list again – (go forward one slide and then back again to this one). My hunch, is that this form of violation is more prevalent and that most cases go unreported. Again, it’s really hard to bring assertion of unlawful practice against your current employer. Those not comfortable practicing in such setting would likely leave rather than forcing change. Which is an excellent start – and I admire the person not willing to risk their license for someone else; yet, it leaves behind a practice operating in violation of the law. And this portion of our COE’s is a great example of how the lines blur quickly when discerning law from ethics. These principles are written inferring a knowledge of the law and, more specifically, the supervision and delegation limitations content areas of the PT practice act. The word “appropriate” in Prin. 3E is the synonymous with saying “in accordance with the law”.
- Here are the top 8 reasons California PT Licensiates experienced disciplinary action. (In order of frequency or not?) The most common infraction is failure to report a change of address; which results in a citation not disciplinary action; the main difference being one (citation) may result in a fine, the other (disciplinary action) affects your licensure – temporarily or permanently depending upon the severity. Unprofessional conduct (patient neglect/safety) – need examples Sexual Misconduct: - No, you may not have a sexual relationship with your patient! This could mean any sexual relationship such as inappropriate speech or touching, gestures, etc. Therapists also need to be reminded of patient misperceptions of treatment; there are cultural, age or gender differences where it is inappropriate to touch. These may be common-sense things, but it happens! Don’t forget to get informed consent if the appropriate treatment requires touching sensitive areas. Lack of supervision or misappropriate use of support personnel Documentation – this includes content and legibility Unprof conduct – illegal practice of medicine/dx of disease. Fairly self explanatory and it does happen. If suspicious of disease or feel the patient needs a new/different medication, communicate with the referring physician or suggest the patient consult with an MD, but do not use disease terminology. Same with dry needling – as much as you may believe in its clinical utility, Calif PT’s can not do anything which punctures the skin unless specifically licensed to do needle electromyography Failure to document wellness services ??? DUI – self explanatory.What is the punishment?
- As we discussed earlier, the Calif Bus and Professions code now authorizes health professionals to be shareholders of another practitioner’s corporation as long as they meet the requirements of the law. Today’s presentation is not intended to go through all the nuances of the law; however, from an ethical perspective, you should know not only who “with” but who you work “for”. Being party to an illegal business arrangement is trouble for those in violation of state and federal laws. Working for a practice illegally formed and/or operated certainly is not recommended if not also being complicit in breaking the law. How this pertains to our code of ethics is pretty straight forward: (next slide0
- As we discussed earlier, the Calif Bus and Professions code now authorizes health professionals to be shareholders of another practitioner’s corporation as long as they meet the requirements of the law. Today’s presentation is not intended to go through all the nuances of the law; however, from an ethical perspective, you should know not only who “with” but who you work “for”. Being party to an illegal business arrangement is trouble for those in violation of state and federal laws. Working for a practice illegally formed and/or operated certainly is not recommended if not also being complicit in breaking the law. How this pertains to our code of ethics is pretty straight forward: (next slide0
- This pretty much sums it up. If you break the law you have definitely violated the Code of Ethics. Probably not a big surprise here. A great way to check, even if you think you know, is to go to the Secretary of State website and do a search.
- I don’t believe these situations exists to the degree that they once did; but, that’s just from my own perspective. The bottom line is that any lease or rent agreement which greatly hinges on the volume of business referred to the lessee (tenant) from the lessor. This is a very difficult thing for an employee to know and even more difficult thing to prove. Nevertheless, it is highly illegal and, therefore, unethical and this too gets back to Principle #5 from the prior slide. If breaking the law you are in violation of your Code!
- So we’ve spoken a bit about referral for profit and ethical concerns surrounding various practice types, but what about the big boys. Kaiser, Sutter, Dignity Health? Why do we get so up in arms and perturbed about PT’s working for and generating income for MD’s while thousands of PT and PTA’s are employed by large health systems providing multi-disciplinary services? The primary reason is that most are organized as HMO’s, not medical groups, and therefore are not referring for profit. The rather large corporate structure, salary structured and income/patient volume related incentives to providers are so inter-mingled and broad, that a single practitioner can not significantly affect their personal financial gain by referral patterns. That said, the ethical obligations are no different. Up North there is a rather large medical system called John Muir Medical System. They are entirely physician owned, and have a history of making inappropriate PT referrals to their clinics. Earlier I mentioned my friend referred for those 12 rpre-op visits before menisectomy; a John Muir orthopedist. It’s Maddening. And, as far as I’m concerned, what bothers me more than the ortho’s greed, is knowing there are PT’s working their adhering this type of practice pattern.
- So let’s talk a bit about Consumer direct access to Physical therapy services in California. Bus and Prof code 2620.1 was amended and, effective Jan 1st 2014, “A person may initiate physical therapy treatment directly from a PT….” This form of DA is labeled “limited” because there are restrictions. Understand what we are talking about here is the law, yet also remember that in many ways legal and ethical practice are synonymous. How many of you have seen a change in the way consumers access your services since this law went into effect? Direct access is now legal in nearly all states and our particular flavor is actually less restricted than many other states; yet there are restrictions – or conditions as referred to by the Legislature. While CPTA’s belief that arbitrary caps or restrictions on treatment are not warranted or necessary, we accepted the limits of 12 visits or 45 calendar days. These limits are relatively generous compared to what other states have been granted and we are confident that with time, our record of safety, efficacy and consumer protection will lead to unrestricted direct access. Just last year, Oregon had all restrictions removed from their direct practice provisions. This happened over 20 years in three separate phases.
- So, while achieving DA was great, the legislature, as they tend to do with most things, imposes restrictions that dampen the mood. Let’s look at the limitations on consumer direct access in PT.
- Here are the conditions: Within our scope of practice. This has always been the case and is incumbent on every PT regardless or work setting, employment arrangement or whether working by referral or direct access. Similar language to COE’s principle 3C. Disclosure of financial interest in treating the patient. This one is a bit onerous. Regardless of how a patient arrives at your practice, there is a good chance that you are going to treat the patient and “someone” is going to financially benefit. I believe the impetus for this particular “condition” is to counter the requirement that physicians must disclose their financial interest when referring a patient to a clinic they have ownership and/or a financial interest in. Notification to patient’s primary care physician if they have one.
- Our practice act now stipulates that at 45 calendar days or 12 visits, whichever comes first, the PT is obligated to refer the patient to his/her physician for an exam and signed plan of care. This only applies to patients that directly access PT without a prior diagnosis. For instance, if you have seen a patient previously for a chronic condition (such as spinal stenosis), if they return to your office and your clinical findings suggest that the patient’s current symptoms are related to the stenosis, you are exempt from the day/visits restrictions. That said, Medicare still requires a signed plan-of-care from a medical doctor within 30 days of commencing. With Medicare, the patient is not required to physically “see” the doctor, however, State law supersedes Federal law in the case of professional practice privileges and, therefore, even the Medicare beneficiary must actually see their doctor after 45 days if accessing PT directly. If a patient sees there doctor anytime prior to 45 days, treatment does not need to be interrupted.
- Our practice act now stipulates that at 45 calendar days or 12 visits, whichever comes first, the PT is obligated to refer the patient to his/her physician for an exam and signed plan of care. This only applies to patients that directly access PT without a prior diagnosis. For instance, if you have seen a patient previously for a chronic condition (such as spinal stenosis), if they return to your office and your clinical findings suggest that the patient’s current symptoms are related to the stenosis, you are exempt from the day/visits restrictions. That said, Medicare still requires a signed plan-of-care from a medical doctor within 30 days of commencing. With Medicare, the patient is not required to physically “see” the doctor, however, State law supersedes Federal law in the case of professional practice privileges and, therefore, even the Medicare beneficiary must actually see their doctor after 45 days if accessing PT directly. If a patient sees there doctor anytime prior to 45 days, treatment does not need to be interrupted.
- Here it is: this sample disclosure statement, available for download on the CPTA web site. Under the “practice” navigation tab, then to the “Consumer Direct Access Resources”. You can use this as a template in it’s original form or edited.
- This serves as a reminder that our practice rights and privileges are unrelated to payment. The laws and regulation which govern our license are separate and unrelated to the insurance industry, their internal policies and the State regulations which govern them. The CPTA Payment Policy Committee has been actively communicating with the largest payers; encouraging payment for direct access PT services. Currently Medicare, UHC, Cigna and Blue Shield cover DA PT as a covered benefit. What we have on our side is evidence-based data which shows that an “episode of care” for someone with a musculoskeletal injury is less expensive when the injured individual sees a PT first. The reason workers compensation carriers and state funded health plans were exempt, was to prevent the bill from carrying a perceived substantial cost to the State. Anything with a significant fiscal impact would likely have been defeated. Additionally, workers’ compensation and HMO’s require prior authorization for all services before they are provided.
- All PT services billed to any payer must be accompanied by an ICD-9 – and as of next week, Oct. 1st, an ICD-10 code. It should be noted that this classification scheme is not limited to disease; there are functional impairment codes, such as code V-49.1 which is Impaired function of the arm, involving movement. With a PT “plan of care” being directed at restoring function, the use of functional codes are exactly what PT’s should be using. Medicare has, for several years, required PT’s to append an ICD-9 code to describe the functional impairment – not the medical diagnosis – in order to be paid appropriately. With regard to ethical and legal practice, the PTBC has gone on record, affirming that a PT assigning a functional impairment code to a patient presenting without a medical referral and/or established diagnosis is not practicing unlawfully.
- All good things are accompanied by implied and specific responsibilities . The primary purpose of a license is to protect the consumers served by the professionals. The first, being that all PT’s take it upon themselves to determine if they are clinically competent and prepared to see individuals not previously screened by a medical doctor. Direct access PT is not a mandate. A PT not competent or prepared for this form of elevated practice should not being seeing patients directly. Another obligation is that all patients accessing PT services without a medical referral are presented the disclosure as previously discussed. Appropriate utilization. We discussed this and the ethical considerations earlier when looking at avoidable conflicts of interests. Without a recommended or specific frequency and duration or treatment – it’s up to us to make sure our services are not over utilized.
- While this deviates a little from the topic of “ethics or law”, I would just like to share a few thoughts about the opportunities consumer DA brings to our profession. The PT profession has been on a continuous path of growth and expansion of practice privileges since it’s inception. The attainment of direct access, primary care provider status is the pinnacle. Many of you will never know practice in the role of a “technician” or subservient care giver obligated to follow a strict, prescriptive plan of care. When asked, people can generally tell you who their primary care giver is. Who their dentist is. Wouldn’t it be great if a few years from now most Californian’s know who their physical therapist is? Certainly, the idea of marketing and promoting one’s practice is not unique or a new concept. But now, for the first time, you can do so knowing that those who respond to your ad or promotion or call for action can be seen directly; no longer required to point them in the direction of their physician for a referral. The topic of marketing and practice promotion could be a whole day presentation in and of itself, but there are endless opportunities and many resources available to you. Until very recently, nearly all PT patients were referred. The opportunities to refer patients to our preferred medical specialists occurred occasionally; with direct access patients, those opportunities will become more plentiful. When this occurs, physicians, surgeons, physiatrist and podiatrists will begin to identify PT’s as peers on the same level as other primary care providers and a valuable relationship. Achieving direct access was a huge step in the evolution of PT practice in California. It is inevitable that time will allow for the loosening of onerous and burdensome restriction, or “conditions” as we just discussed. It’s simply a matter of California PT’s practicing in accordance with law and the legislature, over time, getting more comfortable with the idea of PT’s have unrestricted primary care status as musculoskeletal experts. Just a year ago, the last of any restrictions were lifted for PT’s in Oregon.
- Ethics and law – I believe practicing in an ethical and legal manner is pretty simple. Figuring out ways to effectively measure, assess and remediate unethical behavior is apparently not so simple. The word remediation means to solve or remedy a problem.
- People break rules for different reasons. The worst offended is the somebody who intentionally violates a rule or social/ethical standard. What’s done to solve or correct the problem – is referred to as remediation. The degree to which unethical behavior ruminates through the PT profession is poorly understood. The data presented earlier, gives a glimpse into those cases brought to the attention of the PTBC which were investigated and charges filed. Developing effective and fair methods to address ethics violations is difficult and challenging.
- It is broadly accepted that we don’t know the scope of ethics concerns in physical therapy; and this is not unique to PT. Medicine has similar concerns and a bit more research on the subject that nearly complete lack of study in PT.
- Studies of medical doctors show ethical decision making declines over the years. Is this because societal pressures change peoples ethical decision making skills? Or, do they begin modeling behavior after what they see in clinical rounds? It can become very difficult and confusing to determine who your role model should be. Ethical decision making is an evolutionary skill. From the very first things we do as a child and then evolves relative to our life experiences and education. Some people are not capable of differentiating between different behaviors. They can come in front of investigators and answer questions correctly or as instructed by their attorney, but they just don’t get it. Ideally, everyone would possess the skills to recognize a situation requiring ethical decision making and the resolve to make the right decision. Unfortunately everyone does not possess these skills and the academic community and licensing boards aren’t sure how to best teach these imperative skills.
- Where to go for learning: You can start with the APTA. They offer a 10 module professionalism series as well as a few different video’s. They can all be found under the “practice and patient care” tab off the home page. See here (next slide). Additionally, there are literally dozens of online PT and healthcare industry CE offerings, easily found by doing a simple search. The search terms “ethics and physical therapist” return a number of topline hits of very affordable courses. If you’re doing this as part of your biannual CE requirement for California licensure, please be sure to make sure it’s approved. Lastly, if you’re not sure if your decision making is in line with legal and ethical standards and requirements, or questioning the decisions, action, policies of others around you or delegating to you – call someone. Call the Chapter office. Call a professional colleague. You can ask questions withour implicating yourself or anyone else in wrong doing. It is much safer and wiser to inquire and seek clarification. Ignorance does not provide one punitive or consequence free actions.