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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Regulations: Are They a Necessary ‘Evil’?

Published June 12, 2009 3:40 PM by Lisa Lombardo

BALTIMORE--Do we really need all of the regulations Medicare and the physician fee schedule places on the PT profession-or do the regulations just make practicing PT more cumbersome and confusing?

Likely a little bit of both, according to the panelists at the 2009 Rothstein Debate, "When Does Regulation Become Over-Regulation, and When Does Under-Regulation Invite Abuse?"

The debate was held June 12, with panelists Larry Benz, PT, DPT, MBA, ECS, OCS, and Stephen Levine, PT, DPT, MSHA.

"Medicare is very complex; what we want to discuss is the concept of regulations and how they apply to us as practitioners," said Anthony J. DeLitto, PT, PhD, FAPTA, moderator for the debate.

Taking the "over-regulation" side of the debate, Dr. Benz said rules and regs are needed, but they tend to creep, and thus the profession ends up with rules on top of more rules. "This tends to demoralize; go into any clinic and you can tell which therapists are treating Medicare patients versus those who aren't. The rules are well-intended but the consequences are rarely discussed. We acquiesce to a certain number that puts a cap on our earnings. Regulation causes many therapists to act immorally," Dr. Benz said.

But Dr. Levine, taking the supporting position on regulations, responded that in essence, regs get a bad reputation that does not always apply. "There are many misconceptions about regulations and why they exist. They provide for some standardization of rules. They are very complex and don't always make sense but the result of not having them can be severe." The profession needs standardization, he said, much like speed limits on roads. "Most PTs operate in a few settings where the rules are transparent. Health care fraud and waste costs millions of dollars every year, so regulations are necessary."

The panelists addressed questions on the cost of deregulation to the PT profession, and whether the APTA and state governing bodies also do enough to influence how regulations are written and applied-and if they should be involved at all.

"The problem is there are too many regulations," Dr. Benz opined. "The pendulum should begin to swing the other way. Only nuclear power control seems to have more than our profession." Dr. Benz said another problem is that bureaucrats to make the rules are "far removed from the therapists and their patients. Autonomy in PT should unshackle practitioners from added rules."

But Dr. Levine said an overabundance of too ambitious regulations "is a myth, a misperception. We can't have things both ways. What we are paid to do is based on one-to-one care of therapist to patient. We can't be paid as if we are doing the service and also are able to use care extenders for example." Through physician-fee regulations and coding on one-to-one care and incident-to examples, others end up determining how PTs get paid, he admitted. "It's like auto insurance. But we can still define how we want to practice; APTA has a position that only PTs and PTAs can provide services."

But regulations end up limiting the profession, Dr. Benz countered. "Physicians don't limit themselves (in payment) in this respect, but PT does," thanks in essence to over-regulation.

Both panelists agreed that the profession needs to better police itself in order to mitigate some rules and that most clinicians try to do the right thing regardless of how they are governed by regs. They also concurred that in some ways, the cost to the profession of not having at least some payment/fraud regulations would be much higher than the costs of implementing regulations and teaching therapists to follow them.

The "Current Controversies: Rothstein Debate" was established annually in memory of Jules Rothstein, PT, PhD, FAPTA, Editor-in-Chief Emeritus of the Journal of Physical Therapy.


The issue isn't the amount of regulation, its the quality of the regulation and is it meeting its intended purpose?  

When I cannot charge a manual therapy and a therapeutic activity in the same session and no one can give me a good reason  why and gosh darn it, some people need a manual procedure and then need to do some type of activity to restore their function after....this is where regulation breaks down and misses its intended target.

When a comma leads to controversy over who gets which share of the intervention...this is where regulation breaks down and misses its intended target.

When I have to sit there with my patient one on one while they spend ten minutes on the bike because I cannot "double" my patients without severe reduction in payment...this is where regulation breaks down and misses its intended target.  I should be paid for my expertise and outcomes and not by how closely I watch someone exercise.

Christie ,, September 8, 2009 8:27 AM

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