Are they all bad?
Physician Owned Physical Therapy Clinics
- Thread starter fozzy40
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I know the APTA is highly opposed to POPTS. I don't know if we can generalize that ALL physicians who own PT clinics have this 'referral for profit' mentality, but because there has been a growing number of them, we have to take a stand against all of them to uphold our ethical and legal standards as a profession.
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Fundamentally, all POPT clinics are bad because it is a conflict of interest. I find it highly doubtful that many if any physician owned PT clinics were started out of desire to produce better and more collaborated patient care.
I worked in one as a contract PT for about 4 months full time. The one I was at had definite pluses including greater array of and more interesting diagnoses, documentation readily available, and patient's were more likely to be compliant. However, the vast majority of the patient's were post op (non spine) which in my experience leads to a patient being more gung ho about rehab. AND, overall the patient diagnoses and POC were more cut and dry (RCR, achilles repair, scopes, total replacements of hip/knee/shoulder. The PT clinic manager had a good relationship with the physician's, they didn't interfere with us, and she didn't interfere with me.
To me it all comes down to the particular clinic and how it is run. Many non POPT clinics should be classified as POPT if you ask me based on fear of referral authority and lack of respect/understanding of PT autonomy.
IMO, business driven clinics inherently are flawed and therefore will produce poorer care than a clinic that is clinically and scientifically driven. POPT clinics are business driven.
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There really is no difference between a POPT clinic and business driven PT clinic BESIDES the fact that POPT clinics can self refer all day long when they may not have otherwise. In a POPT and business driven PT clinic there is too much pressure on the PT to pick up patient's, prolong the POC, and bill inappropriately.
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You're a PM&R physician and you don't want to believe physician's owning a PT clinic is inappropriate despite what anyone says.
I'd imagine there's no significant difference for the therapists. What I think Fiveoboy was trying to state is that the same way you can't have a doctor prescribing drugs and referring patients to his/her own pharmacy is the same reason why you can't have a doctor prescribing and referring patients to his/her own rehab clinic; There's a conflict of interest. Why should one be illegal and not the other?
As for the difference in a PT running a "mill" with dollar signs in his/her eyes compared to a doctor doing the same well, there isn't a major difference. However, there is a slight difference that plays a major role; a PT doesn't self-prescribe. Again, let's take the example of a pharmacist: Do pharmacists have dollar signs in their eyes too? Yes. Are they running a business for profit? Yes. Do they self prescribe or do doctors have to prescribe their medications to patients? Bottom line is there isn't a conflict of interest going on; unless there's a kickback system set in play between the pharmacist or the physician in which case we'd have a huge problem. That problem is even bigger when the physician doesn't even need a kickback system when he/she can just self prescribe. How much would prescription drug use increase? It's bad enough the way things are now; imagine how it would be with no regulation at all.
There are studies out there that show doctors who have their own rehab clinics prescribe PT at least twice as much.
Hope that made sense.
As for the difference in a PT running a "mill" with dollar signs in his/her eyes compared to a doctor doing the same well, there isn't a major difference. However, there is a slight difference that plays a major role; a PT doesn't self-prescribe. Again, let's take the example of a pharmacist: Do pharmacists have dollar signs in their eyes too? Yes. Are they running a business for profit? Yes. Do they self prescribe or do doctors have to prescribe their medications to patients? Bottom line is there isn't a conflict of interest going on; unless there's a kickback system set in play between the pharmacist or the physician in which case we'd have a huge problem. That problem is even bigger when the physician doesn't even need a kickback system when he/she can just self prescribe. How much would prescription drug use increase? It's bad enough the way things are now; imagine how it would be with no regulation at all.
There are studies out there that show doctors who have their own rehab clinics prescribe PT at least twice as much.
Hope that made sense.
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PT's probably on average make more money working in a POPT clinic, same goes for a chiropractor owned PT clinic. Why? not sure, perhaps it has something to do with greater caseload and there is a definite subgroup of PT's who flat out refuse to work in these so it is harder to hire.
Disadvantages: working for a flawed system with questionable ethics to start with, greater caseload, unsupportive of the advancement of the PT profession (who wants to work for a profession that has no respect for your own and support it monetarily?), pressured to see patient's too long or when not actually needed.
Advantages: more money, interesting diagnoses, better caseload outcomes overall IF working for a non spine Ortho owned practice seeing many post op versus seeing greater amount of chronic pain, better availability of documentation. This is not to say that on a case by case basis POPT clinics have better outcomes.
A PM&R owned practice would be a nightmare for a PT if you ask me, unless you want to see chronic pain patient's all day long.
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Thanks for all of the replies. I do see the conflict of interest for sure. However, I've also seen patients who were sent for physical therapy for 3-4 months at a time with no improvement and/or very small/questionable goals. So when I see that I'm not sure what to make of those clinics. Are these therapists maximizing visits? Is there pressure from administration? Is this not also unethical?
It's funny because I'm on the job search right now and seeing practices with in-house physical therapy is a concern/turn-off for me. There are good and bad therapists all over the place and I don't want to feel obligated to refer to the in-house therapists if I don't feel like they are doing a good job.
Just another side of the coin...
It's funny because I'm on the job search right now and seeing practices with in-house physical therapy is a concern/turn-off for me. There are good and bad therapists all over the place and I don't want to feel obligated to refer to the in-house therapists if I don't feel like they are doing a good job.
Just another side of the coin...
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YW. Overall the system as it is today makes it VERY difficult for PT's to provide the best care possible in the most economical manner. Hard to reason through exactly why that is. I was in a clinic not to long ago where a PTA was basically running the show, and the management hired PT's contract/PRN/travel to come and do evals/sign off on continuing/do progress notes. There was one gentleman I saw who was in the 60's in terms of visits (s/p MVA x 3 within a short period of time) without substantial benefit. I D/C'd him the first time I saw him and the "clinic manager" flipped out because the patient was an "MVA." She was fired after I complained about how inappropriate it was. The president of this company (who is a PT) had all kinds of stickies all over the place with unbelievably unethical remarks like "all patient's to be charged 7-8 units on evals." I've been in SNF's where the "rehab manager" has told me to try to evaluate a patient that in my opinion was not nearly appropriate because the "doctor wanted her to get PT." This was after attempting numerous times on the severely debilitated, demented patient s/p hip ORIF with a Max A PLOF. There is a lot of pressure to pick up patients and prolong the POC. And if you don't, you're implied/labeled as a bad PT, can definitely lose your job or have your hours cut. I could give examples all day long that implicates the business/politics versus the PT's.
What it comes down to IMO is the lack of power/authority of the actual clinicians to control these issues. Right now it is controlled by big businesses/physicians that can essentially do whatever the hell they want.
If I were you I would take a lot of time finding businesses/PT's that practice in an ethical and competent manner and send all your patient's to them. As you know, a friendly smile and a nice personality of a marketing person means nothing. Finding a group of PT's with further training post grad would be a good start. Jesspt is in the Chicago area as far as I know...
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I agree with what you are saying. However, I think all providers (physicians included) are losing control of some of these issues that you listed which affects all of our bottom lines. Perhaps that maybe why some there are these POPTs popping up to help make ends meet. At the end of the day, practicing ethically with patient centered care should be at the forefront. However, we are all trying to practice with our given restraints in our imperfect (but better than none at all) system. It's not an excuse to practice as such but as you've stated it's a problem not limited to physicians.
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Of course those therapists and facilities are acting in an unethical fashion. Physicians don't own the rights to unethical behavior. But, the way the system is set up, allowing for them to be involved in referral for profit scenarios, they certainly seem to have the potential for the most financial gain.
One concern is incentive. If you have a guaranteed referral source, you have NO incentive to do greatwork (think radiology, but I am not sure about the self-referral laws there). The biggest concern from a PT standpoint ishaving non-PTs perform rehab at a cheaper cost. Believe it or not some POPTS employ ATCs, chiropractors or even thosewith an exercise science background to rehab post-op patients without thesupervision of a PT. Also, POPTS tend toburn through 4-5 patients an hour (not all but most) vs. a PT owned clinicwhich generally sees 2-3 an hour.
The bottom line is that patients get better care from anon-POPT setting. In your job search,the best way to ensure yourself great PTs in your area is work near a great PTschool. (USC, Pitt, Delaware, NYC, etc.)
Some may get on me and say it is only semantics, but I think a big one for the profession.
POPT = Physician owned Physical Therapy Service. But you said, 'Believe it or not some POPTS employ ATCs, chiropractors or even thosewith an exercise science background to rehab post-op patients without thesupervision of a PT.'
In most states, POPTS must employ PTs because physical therapists are the only ones to provide physical therapy/physiotherapy. These are protected terms in most states....So I totally get your point, but I think we need to keep hammering home the point that only licensed PTs can perform PT and therefore are the only ones employed at a POPTS.
OK, off soap box now
Thanks for pointing that out, sorry.
Fozzy, in some states, including Delaware, ATCs can function like a PTA (performing manuals etc.), but they do need a PT to sign off on their notes. I am 100% fine with this because they do great work and even provide insight that PTs sometimes don't have. They can't be operating alone as a PT though.
I am not going to start the whole chiro debate, but I see a lot of them advertise rehab.
Fozzy, in some states, including Delaware, ATCs can function like a PTA (performing manuals etc.), but they do need a PT to sign off on their notes. I am 100% fine with this because they do great work and even provide insight that PTs sometimes don't have. They can't be operating alone as a PT though.
I am not going to start the whole chiro debate, but I see a lot of them advertise rehab.
I 100% with that that as long as they are producing results I will refer to them no matter what. I do have a problem with practices that are advertising physical therapy or using "rehabilitation" as a synonym for PT when it clearly is not.
Couldn't agree more. It is a slap in the face to someone who spent 3-4 years at PT school studying rehab. I know that some chiros can get a certification in different states and advertise PT. I think this goes back to the stone age when PT was just begining and chiro was an established field.
In your job search I would advise against places with physician owned PT. I couldn't state that enough. Like you mentioned before you don't want to be stuck with someone who isn't up to par. I think it is important that PTs suffer for sub-par performance. I promise you that if you have a good working relationship with an independent PT they will do everything in their power to go the extra mile for your patients and keep you as a referral source.
Rehabilitation is not a protected term in most states. OTs, PM&R docs, SLPs, PTs, ATs, etc, etc provide rehabilitation. Physical therapy and physiotherapy and PT are protected (by law) terms in most states, so only licensed PTs (and PTAs) can state they are performing physical therapy/physiotherapy. A few years ago, several states' PT Association had initiatives for people to 'report' signs and other advertising that were illegally (in some cases) and improperly using Physical Therapy. In some states, using physical therapy for what you provide when you are not a Physical Therapist can carry a criminal penalty (although I imagine it is not prosecuted all that often...)
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I struggle with this topic as well. On the one hand, I'm always weary of POPTS because of the chance for unethical behavior...but it really just depends on the physician. I understand all the arguments, but all PT clinics suck up to the MDs to get referrals. Hell, I work in a non for profit catholic hospital and we are at the mercy of our staff MDs for referrals. You can't make a salary and pay off your student loans without seeing patients. That's the business. The key, if you do go down the POPTS route, is to find a doctor that stays out of it. If they truly stay out of it and give you autonomy, who cares where it comes from? How is that better than a large corporation? Overhead isn't free, and neither was school. That's capitalism...so long as it has a minimal effect of you plan of care.
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Where should I send your cookie?