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"Medical" diagnosis? Isn't PT diagnosis good enough?
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"Medical" diagnosis? Isn't PT diagnosis good ... - April 9, 2005 8:16:00 AM
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Diane
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I am really curious about this.. my question about it wasn't answered to my satisfaction in the chiro demo thread. I have a few other questions by now:
1. I'd like a firm definition: can anyone post a link, a cut&paste, anything that acurately defines legally and exactly what constitutes a "medical diagnosis"? particularly in states that seem to use this to hamper PT efforts at obtaining direct access.
2. Is it possible to separate the word "diagnosis" from the modifier "medical" and discern which of the two words carries more weight? Here, the word "diagnosis" carries the legal weight. Other modifiers can be legally used by other professions.
3. Has this apparent roadblock been suitably challenged? Or is it just a vague statement that is used by vested interests to maintain a false perception to guide policy and prevent certain groups i.e., PT, from forward movement? Is it mere illusion, serving to maintain a false sense of apathy in PT ranks in the non-direct access states?
Look forward to input on this.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 3:21:00 PM
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Jon Newman
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Hi Diane,
Thanks for moving this topic out of the other.
I'll post our "direct access" clause in a seperate post. I don't have any legal definitions to help out here.
On a different note...
James Meadows states in his book Orthopedic Differential Diagnosis in Physical Therapy (1999), "In one or two of these jurisdiction in the United States, this same therapist who can see the patient without referral does not have the right to make a differential diagnosis. This is obviously a silly state of affairs. How can anybody of any discipline see patients as a primary care practioner without making a diagnosis? To get around this stupidity, the therapists use the terms physical therapy diagnosis or functional diagnosis....It is time to realize that making a diagnosis is common to all health care professionals involved in the treatment of patients, not just physicians, and is not in and of itself practicing medicine"(page xiv in the introduction).
Earlier, on the same page he argues, "Only a detailed examination of the patient, an in-depth analysis of the information generated from the examination, and the subsequent generation of a differential diagnosis will provide this information, which is so vital to efficient and effective treatment."
I think that would sum up many PT's sentiments. However, one trend that has been gaining momentum has been the classification or clincal prediction rule. In these scenarios, no differential diagnosis needs to been made. In fact the "differential diagnosis" has already been down played by those who believe that the pain is in the brain and is due to irritated nerves. That is, there is a trend to downplay the need to even make a "differential diagnosis". And in reality, except for those who claim to literally be fixing some connective tissue in the body sans scapel or pharmacology, aren't we essentially symptom managing while providing educational expertise/guidance on how to make things better? If we accept this as our role, which I think it largely is, then the whole making a diagnosis and practicing "medicine" argument becomes much weaker in my opinion. Although then we have to accept what one of our major roles really is which may be tough on the profession's ego.
I don't see a way around the medicalization of people's pain if we make a differential diagnosis. Perhaps it has to be but I'm not convinced yet. Look forward to other ideas.
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 4:14:00 PM
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Jon Newman
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Here's a link to WI regs.
Note the referral requirements and the duty to refer clause.
[URL=http://folio.legis.state.wi.us/cgi-bin/om_isapi.dll?clientID=51572242&infobase=code.nfo&jump=ch.%20pt%201]link[/URL]
jon
Apparently to view this you need to click on any of the hypertext numbers starting with 448. Then scroll down to 448.56(1). That should work. If it doesn't your not missing much.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 4:33:00 PM
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Diane
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Here's what I see:
[QUOTE]PT 6.01 Referrals.
PT 6.01(1)pdf icon
(1) In addition to the services excepted from written referral under s. 448.56, Stats., a written referral is not required to provide the following services, related to the work, home, leisure, recreational and educational environments:
PT 6.01(1)(a)pdf icon
(a) Conditioning.
PT 6.01(1)(b)pdf icon
(b) Injury prevention and application of biomechanics.
PT 6.01(1)(c)pdf icon
(c) Treatment of musculoskeletal injuries with the exception of acute fractures or soft tissue avulsions.
PT 6.01(2)pdf icon
(2) A physical therapist providing physical therapy services pursuant to a referral under s. 448.56 (1), Stats., shall communicate with the referring physician, chiropractor, dentist or podiatrist as necessary to ensure continuity of care.
PT 6.01(3)pdf icon
(3) A physical therapist providing physical therapy services to a patient shall refer the patient to a physician, chiropractor, dentist, podiatrist or other health care practitioner under s. 448.56 (1m), Stats., to receive required health care services which are beyond the scope of practice of physical therapy.[/QUOTE]Emphasis mine.
1. So, this sounds like one can practice PT without referral... as long as its not in a PT clinic? Am I missing something?
2. This seems irritatingly and unnecessarily restrictive to me. Who wrote that thing?
Here is 448.56:
[QUOTE]448.56(1)pdf icon
(1) Written referral. Except as provided in this subsection and s. 448.52, a person may practice physical therapy only upon the written referral of a physician, chiropractor, dentist or podiatrist. Written referral is not required if a physical therapist provides services in schools to children with disabilities, as defined in s. 115.76 (5), pursuant to rules promulgated by the department of public instruction; provides services as part of a home health care agency; provides services to a patient in a nursing home pursuant to the patient's plan of care; provides services related to athletic activities, conditioning or injury prevention; or provides services to an individual for a previously diagnosed medical condition after informing the individual's physician, chiropractor, dentist or podiatrist who made the diagnosis. The affiliated credentialing board may promulgate rules establishing additional services that are excepted from the written referral requirements of this subsection.[/QUOTE]Emphasis mine. Maybe PTs are not as restricted as you think. Maybe all that needs to happen is to point out the illogic of not allowing direct access to PT in a clinic, a geographical space under control of a PT, while permitting direct access, i.e., PT assessment/treatment without referral in all these diverse settings and circumstances.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 4:53:00 PM
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Jon Newman
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Hi Diane,
I don't know who gets the awful job of translating what was intended to the form it ends up in. I think it's fine to treat in the PT clinic without referral--it just reads funny, just mind the semicolons.
On the topic of diagnosis, our practice act defines it this way:
""Diagnosis" means a judgment that is made after examining the neuromusculoskeletal system or evaluating or studying its symptoms and that utilizes the techniques and science of physical therapy for the purpose of establishing a plan of therapeutic intervention, but does not include a chiropractic or medical diagnosis."
The direct access "problem" in WI is not the diagnosis part but rather that insurance won't pay for treatment without referral despite its legality and status as otherwise reimbursable. Why do people suppose that is?
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:01:00 PM
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nari
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What is a PT clinic? Is it private or public?
The text sounds as though PTs do have more access than they are aware of. But perhaps the doctors are not aware of this?
Re medical diagnoses: they can be useful, we sometimes agree with them. but in the end it doesn't matter much. We treat as seen fit. Most medical diagnoses are so vague they are irrelevant.
In the health centre where I work (public) we refer to each other electronically, but purely as a courtesy, and for admin to know a referral has been made for records.
I am surprised to hear that in the USA chiros refer to PTs. I did not know that, and it doesn't occur here. Any referral is by word of mouth.
Can PTs refer to chiropractors?
jon, I agree with you; a medical diagnosis for PT purposes is becoming less and less significant.
It is part of the concept of treating a process and not a leg or a wrist in straight anatomical terms. Accepting and teaching that pain is only output and that level of output can be modulated to some degree by us, is significant.
Nari
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:15:00 PM
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Jon Newman
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Hi Nari,
WI, of course, is a highly advanced state. Other states don't have the wording we have. Some are better, some are worse. I believe a PT clinic could refer to a private or public office used specifically for PT treatment (as opposed to a patient's home, a school room or an industrial on-site job).
Chiro's can refer to us but as insurance will have it, the patient first has to see their MD before seeing us if they want insurance to pay for it. So it's chiro, then MD then us. On the other hand, since insurance pays for chiro treatment without MD referral, if we send a patient to a chiro they can go directly. Of course the patient doesn't need us to send them, they can just go and still be reimbursed by insurance.
Just follow the dollar signs and you'll start to understand referral patterns. Chiros are the cat that slipped out of the bag and as I've said before, not too many people are interested in letting that happen again.
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:16:00 PM
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Diane
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THIS needs changed... certain bits in section 448.52:
[QUOTE]448.52 Applicability.
448.52(1m)pdf icon
(1m) A license is not required under this subchapter for any of the following, if the person does not claim to render physical therapy or physiotherapy services:
448.52(1m)(a)pdf icon
(a) Any person lawfully practicing within the scope of a license, permit, registration or certification granted by this state or the federal government.
448.52(1m)(b)pdf icon
(b) Any person assisting a physical therapist in practice under the direct, on-premises supervision of the physical therapist.
448.52(1m)(c)pdf icon
(c) A physical therapy student assisting a physical therapist in the practice of physical therapy or a physical therapist assistant student assisting a physical therapist in performing physical therapy procedures and related tasks, if the assistance is within the scope of the student's education or training.
448.52(1m)(d)pdf icon
(d) A physical therapist who is licensed to practice physical therapy in another state or country and is providing a consultation or demonstration with a physical therapist who is licensed under this subchapter.
448.52(2m)pdf icon
(2m) A license is not required under this subchapter for any of the following:
448.52(2m)(a)pdf icon
(a) Except as provided in par. (b), a chiropractor licensed under ch. 446 claiming to render physical therapy, if the physical therapy is provided by a physical therapist employed by the chiropractor.
448.52(2m)(b)pdf icon
(b) A chiropractor licensed under ch. 446 claiming to render physical therapy modality services.[/QUOTE]....
Argh. Here we have this part that says a chiro doesn't need a PT license to have a PT "employee" who is providing PT (spelled s-l-a-v-e), or if the chiro is providing modalities that are PT modalities. Why do references to chiros even EXIST in an act that governs PTs?
[QUOTE](1) The affiliated credentialing board shall grant a license as a physical therapist to a person who does all of the following:
448.53(1)(a)pdf icon
(a) Submits an application for the license to the department on a form provided by the department.
448.53(1)(b)pdf icon
(b) Pays the fee specified in s. 440.05 (1).
448.53(1)(c)pdf icon
(c) Subject to ss. 111.321, 111.322 and 111.335, submits evidence satisfactory to the affiliated credentialing board that the applicant does not have an arrest or conviction record.
448.53(1)(d)pdf icon
(d) Submits evidence satisfactory to the affiliated credentialing board that the applicant is a graduate of a school of physical therapy approved by the affiliated credentialing board, unless the affiliated credentialing board waives this requirement under sub. (3).
448.53(1)(e)pdf icon
(e) Passes an examination under s. 448.54.
448.53(1)(f)pdf icon
(f) If the person was educated at a physical therapy school that is not in the United States, the person satisfies any additional requirements for demonstrating competence to practice physical therapy that the affiliated credentialing board may establish by rule.
448.53(2)pdf icon
(2) The affiliated credentialing board may promulgate rules providing for various classes of temporary licenses to practice physical therapy.
448.53(3)pdf icon
(3) The affiliated credentialing board may waive the requirement under sub. (1) (d) for an applicant who establishes, to the satisfaction of the affiliated credentialing board, all of the following:
448.53(3)(a)pdf icon
(a) That he or she is a graduate of a physical therapy school.
448.53(3)(b)pdf icon
(b) That he or she is licensed as a physical therapist by another licensing jurisdiction in the United States.
448.53(3)(c)pdf icon
(c) That the jurisdiction in which he or she is licensed required the licensee to be a graduate of a school approved by the licensing jurisdiction or of a school that the licensing jurisdiction evaluated for education equivalency.
448.53(3)(d)pdf icon
(d) That he or she has actively practiced physical therapy, under the license issued by the other licensing jurisdiction in the United States, for at least 3 years immediately preceding the date of his or her application.[/QUOTE]So, a person can get a PT license if they agree to all of the above. I don't see anything in there about agreeing to work "under referral only."
More questions:
1. Does the PT profession in this particular state have an organization that acts as a liason to the government of the state? In BC our college takes on that role. Its job is to protect the public by disciplining wayward PTs who violate our code and rules and ethics etc. It governs our direct access and has the authority to pull charts and yank licenses for violations.
2. Does anyone have a copy or a link to the Physical Therapy Act as written by your own similar organization?
3. If you have such a body in place, maybe all that needs to happen, is to mandate it to straighten out a couple bits of wording and allow PTs to treat without referrals in their own clinics. That particular rstriction is ludicrous.
I'll look some more to see what the deal is with diagnoses, or maybe someone who knows this act better can pull that part for me.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:25:00 PM
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Diane
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Another question: Can PTs go ahead and work for cash? I see no impediment to this, other than financial insecurity. Why couldn't a PT keep their "day job", working part time under referral for pay, and start a private solo cash practice in their own establishment (i.e., humble treatment room somewhere)? I see no law against that, at least not so far.
By the way, thanks for posting the link Jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:33:00 PM
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Jon Newman
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Hi Diane,
In WI, it is the WI PT association that plays politics and works out the intent of the practice act. This is actually updated and revised.
The chiro thing doesn't bug me. If a chiro owns a practice and hires PT's to perform PT then they should be able to advertise. That PT is no more a slave then some other PT practice owners. My buddy in PA worked for a real gem (PT) and it took him years to get out. In retrospect, after reading Barrett's recommended "The sociopath next door", my buddy worked for a sociopath or at least someone who skirts close to the definition.
The other chiro thing just states that chiros doing ultra sound and estim (virtually all of them around here) can claim to provide physical therapy modalities but not physical therapy.
We can treat in our own clinics if the patient is willing to private pay. The patient is unlikely to get reimbursed by the insurance company. Therefore, rather than spend out of pocket money, they go through the process of seeing the MD for their sprained ankle first.
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:47:00 PM
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Diane
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So it's more about the scary idea of financial insecurity. There's no law against taking off the ball and chain.
Well, the gradual move over to a cash practice while going part time (but not giving up) your day job is the way to proceed then. At some point you can let go of the insurance "job."
There are numerous people who don't mind paying cash. They are the ones who currently fill the treatment facilities of the CAM people.
Lots of them actually do have treatable stuff, would be glad to see a PT, and DON'T want to be medicalized first. They would eventually find their way to a good competent PT. HINT: Market yourself to massage therapists; they are often tired of massaging someone for years who hasn't progressed and will be happy to move someone over. Market to hairdressers and barbers; they talk to people all the time, or rather people talk to them all the time. I get many referrals from them.
It doesn't take much time at all for word to spread. Painstakingly and ethically build your reputation and you will end up being the one who EVERYONE sends all their hard cases to; even other PTs will come and pay out of pocket for good treatment, even if they don't send you any patients. Who cares? There are more than enough patients to go around.
It would take some time, maybe a year or so, to build a practice, but you definitely could build one outside the insurance system; it's already been done, by lots of PTs. I hope some more of the success stories will appear.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 5:56:00 PM
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Jon Newman
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Hi Diane,
I think financial insecurity is what limits many PT's from going out on their own. However, many practices actively seek to prevent that sort of thing by requiring PT's to sign a non-compete clause that would not only disallow the PT from doing as you suggest but also prevents them from working for anyone else in the area for a specified period of time.
In my rural area, 95% of the MD's are employed by one corporation and, to the best of my understanding, their referral habits are tracked. Private pay would be the necessary way to go around my neck of the woods I think.
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 9, 2005 8:52:00 PM
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Diane
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Jon,
Sorry,I don't quite get what you mean:
[QUOTE]many practices actively seek to prevent that sort of thing by requiring PT's to sign a non-compete clause that would not only disallow the PT from doing as you suggest but also prevents them from working for anyone else in the area for a specified period of time.[/QUOTE]1. PTs who wanted to set up a cash practice wouldn't be competing for the same (insurance) patients.
2. PTs who wanted to set up a cash practice would be working for themselves, not "for anyone else" or any other competing existing clinic, same area or not.
3. What constitutes an "area"? This bothers me, smacks of monopoly. Aren't there laws that forbid that?
4. If there was a problem and fair competition was somehow squashed by a clause in a contract, couldn't the PT who wants a cash practice just go and set up in a different "area"?
5. Sure seems cut-throat. Don't take a job in the first place where you have to sign away your right to practice autonomously.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 10, 2005 2:42:00 AM
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SJBird55
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Diane, the noncompete clause generally means that the person cannont practice whatever they are licensed to practice within a designated mile radius. Noncompete clauses generally never mention the payer mix.
In our little area, there are two large hospitals. One of them 3 years ago or so closed their family practice. The physicians had noncompete clauses - they couldn't practice for 3or 4 years within a certain mile radius (I believe it was 20-30 miles?). It was ridiculously stupid because the physicians wouldn't be "competing" with the hospital at all, seeing that the hospital yanked their services out of the area... but that's what happened. Yes, they could have fought it... but their attorneys advised not to - the physicians would have won the case, but the time to win would take as long as the clause was in effect AND the money spent would have been outrageous.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 10, 2005 5:00:00 AM
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Diane
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Wow. SJ, who insisted on the non-compete clauses? Was it the hospitals or the insurance companies? (I'm a bit dense about insurance companies in the US, other than they sound big and terrible. Actually they sound greedy and dictatorial as well, if they were/are behind it.)
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 10, 2005 5:02:00 AM
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Jon Newman
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Hi Diane,
As SJ pointed out, non-compete means you can't practice as it is spelled out in the contract. Sometimes you can't practice any PT within some geographic radius that would essentially require you to move or drive excessively far.
Here, there is one hospital at the center of about a 60 mile diameter circle--the "area" that I'm referring to. In that circle, there is only one PT private practice. The rest(2 other clinics) are owned by the same Corp. One could argue that a monopoly exists but no one is stopping anyone from setting up another practice. It's just that, as you've noted, financial insecurity is a strong disincentive since most of those MD's inside that radius work for the same Corp. I doubt that it is written in their policy and procedure manual not to refer out to other places. However, consumers usually listen to the MD's as to where to go next. The power of suggestion. Something that might eventually be lessened with reimbursed direct access.
Also, when you have a variety of offices that will charge your insurance and one that can't, the value sensitive customer (ie the vast majority of customers) will go to those other places.
I agree with your sentiments about "do not compete". Try to get out of them or try to modify them or simply avoid working someplace with them.
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 10, 2005 6:31:00 AM
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Diane
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Sounds like health care by insurance dictate, rather than by geographic/organic common sense.
Jon, [QUOTE]Something that might eventually be lessened with reimbursed direct access.[/QUOTE]Any idea how to proceed?
Here is what is in the inside of my head, jumbling around: Is it worth spending valuable energy fighting to remain part of a corporate "system" that locks PT into clauses? That dictates your income? How many people you need to see per hour to make a living? That funnels its own customers at you, instead of letting the right sort of patient population find you themselves? That ties you into a subservient relationship with a group of equally ball&chained MDs? That dictates geographical areas where you can and cannot work?
On the plus side, it seems that there is no restriction on any PT who wants to work for cash. I (so far) found nothing in that legislation that really restricts anyone, any PT, from direct access if they want it. OK, such a PT will not get any slice of insurance probably. But why would anyone want to, when it sounds like a full time job on top of treating patients, just to extract fair payment from these "corporations"?
I recall reading somewhere that a lot of US individuals don't have medical coverage anyway. That doesn't necessarily mean they have no disposable income.
In the neighbourhood where I live, here, there are many many self-employed people. (Granted, here these people still have provincial coverage for medical and hospitalization, so they don't worry about financial implications of life&death issues too much..)
They work for the movie industry, are contract workers, self-employed writers/ artists/ singers/ musicians/ actors/ dancers. Their incomes are variable. When they have money they don't mind spending it to feel good in their bodies.
People like this exist everywhere. They are the ones who are willing to take chances, pay cash willingly, tell their friends all about the new practitioner, ".. who is a PT, but is "different" because they are easy to get in to see; you pay cash, but s/he has a different way of working and spends time with you. The big difference is you don't have to see a doctor first to get in." Maybe their massage therapist has referred them. They are autonomous people who prefer to be around and receive help from other autonomous people, because they don't really like the "system" either. And they have plenty of discretionary income.
I gather restrictions on seniors visiting you outside the system might be a problem; is it true that any US citizen over 65 grows an immediate ball and chain whereby they must be treated within the system by law and not outside it? Can they go to spend money on massage therapists if they want? In the meantime, sounds like there would still be lots of PTs willing to work inside the system to take on this population. Meanwhile those PTs who went outside could help the profession evolve, and perhaps in time the rules would be changed, as seniors demanded the right to see whoever they wanted with their own discretionary income/means.
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 10, 2005 6:53:00 AM
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TLB
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Diane,
Non-compete clauses can not be enforced and won't hold up in a court of law. You cannot restrict someones right to make a living. I talked to some corportate PT guys (one of the big boys) who if I did some work for them wanted me to sign one. I refused and told them they don't hold water, they agreed but stated if anyone who signed it then broke the clause would be taken to court and appeal, appeal, appeal, esentially bleeding you dry. They have much deeper pockets. Now doesn't everyone want to go work in the corporate PT arena? I believe I'll pass.
Todd
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Todd
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 10, 2005 7:37:00 AM
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Jon Newman
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Hi Diane,
No easy answers for this. I'm not sure who influences insurance company decisions. Anything that allows them to shell out fewer dollars is likely the winning solution for them. Insurance companies fear that reimbursing direct access will likely increase their costs, as MD's often don't immediately send patients to PT. They will often first try pharmacology and time. This defers and sometimes eliminates the need to see a PT. So the incentive is strong for insurance companies to keep the status quo. A demonstration project theoretically will demonstrate which is more cost efficient and everyone involved knows what's at stake, except the consumer. Ultimately, I don't think it boils down to actually caring about the patient.
jon
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Re: "Medical" diagnosis? Isn't PT diagnosis g... - April 11, 2005 2:12:00 AM
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Sebastian Asselbergs
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Couple of remarks:
First the non-competition-clause. In the states, where private enterprise is so highly valued, there are restrictions on where a PT can open up shop (when s/he has worked in a nearby institution/clinic). Here in "social" Ontario, ANY PT can open up ANYWHERE. Believe me, they have even opened up right next door to hospitals and other clinics. And why not?
Diagnoses made by MDs and diagnoses made by PTs are rarely the same: this causes confusion and needless nitpicking in court rooms - with reviewing the historical "ownership" of the term by MDs, the value of the education by PTs yadayadayada - you know how lawyers can be....
Having two different diagnosis by two different practitioners IS a hot legal issue in the cases of settlements and lawsuits. We should be moving towards using the term as experts in our field, (as should doctors BTW - they, however, seem to believe they can put a diagnostic label on just about anything!).
With regards to changing the insurance industry's minds: get the proof that PT is cost effective and has long term benefits vs. drugs and surgery, and they would change their tune very quickly! Yes, it is the $ that guides almost all decisions. We should be the ones to prove that their money is better spend with PT. Just trying to have them "believe" our claims, is rather unworthy of a true profession.
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All Forums >> [RehabEdge Forum] >> Open Forum >> "Medical" diagnosis? Isn't PT diagnosis good enough? 
