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PT on the Run

Who's In the Driver's Seat?

Published February 14, 2014 11:15 AM by Michael Kelley

(Editor's Note: Throughout the month of February, ADVANCE bloggers Michael Kelley and Lisa Mueller will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #2 -- "What Drives the PT Profession?")

The PT profession has no doubt changed a lot since our humble beginnings. Even over the past 10-20 years, the education standards and demand for physical therapy have significantly increased. But what's driving these changes and what will continue to drive the evolution of our profession?

There are obviously many entities that guide our profession, but one in particular stands out in my mind: the insurance industry. I'll give you an example. A few weeks ago, my ADVANCE counterpart Lisa and I were talking about direct access. Lisa said, "Michael, every state in the country has direct access." To which I replied, "Lisa, that's just not true!" Naturally I did some research and according to our dear friends at the APTA, every state in the country does enjoy direct access.* (You'll notice the glaring asterisk at the end of that sentence).

You see, in every state practice act, there is some language that establishes some form of direct access. Here's the problem, the state practice act governs our profession as PTs. It does not have any enforceable action on the insurance industry. If an insurance company says you must have a doctor's prescription prior to going to see a PT or it won't pay for PT services, then a patient is obviously going to obtain one. Regardless of what our practice acts say, the insurance company gets to decide what it's going to pay for and what documentation and prior authorization are required to pay for it. So even when our state practice acts and educational institutions preach direct access, we're still at the mercy of the insurance industry.

As healthcare professionals, we're always striving to do what's in the best interest of our patients. But we do so realizing we're not the only players in the game. And unfortunately in this game, the players with the most influence also are the ones who control the most money. The future of the PT profession looks bright, but we need to keep advocating for our patients and profession not only to our congressmen and political leaders, but to the insurance industry as well.

For the time being though, it's my belief that the insurance industry is the biggest driver of our profession. They are the ones dictating who can be seen, how often we can see them, what we get paid for, and how much we get paid. Do I think this is the way things should be? Of course not, but this is the world we live in and until the stronghold the insurance industry has on the healthcare marketplace is broken, it seems we're going to have to continue to play by their rules.

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Your column is the harsh wake up call to Lisa's blue sky thinking. We need both. I agree with you that the insurance companies have most of the control, not only over our profession, but pretty much everything that occurs in health care.

I've worked for an insurance company. How many PTs were in influential positions? None. Positions of influence are occupied by doctors and nurses who have gone on to get MBAs and other degrees related to the business world. This is one area where I believe the APTA has fallen short. Supporting the DPT has provided us with some clinical clout, but it is not enough. The APTA needs to support PTs who want to be leaders in healthcare and insurance. This is how we will gain business clout and change the system from within. So many of us are brilliant business men and women who run hugely successful practices. The problem is; that doesn't translate into change in the larger healthcare picture. Here in the UK, physios are on commissioning boards, boards of health and public health authorities. These roles are definitely not as lucrative as private practice, but they have a huge impact on how the profession is seen on the whole and what role it plays in how healthcare develops. We already have direct access, direct reimbursement, and are about to gain prescribing rights here. If that can be accomplished in the bureaucracy that is the NHS, then it should definitely be able to happen back home. Cheers for a thought provoking discussion.

Dean Metz February 17, 2014 4:57 PM

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