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Toni Talks about PT Today

Supervised Exercise or Extended Therapy?

Published December 8, 2010 5:49 PM by Toni Patt

During our monthly staff meeting, one of our sister facilities presented an in-service describing recent changes in a post-therapy program for patients. The program had relocated to a new location and expanded services. Before the move, it was held after-hours in the gym of another inpatient rehabilitation facility. Graduated patients could come and exercise under the supervision of an exercise physiologist in a wheelchair-friendly environment.

That isn't the case anymore. The new location is an outpatient facility, which also has a wheelchair-accessible gym. It also has a robotic gait trainer, body weight-support system and functional e-stim set up. Members of the program now have access to that equipment for supervised exercise. I have a problem with that. As far as I know, those modalities are considered skilled and require the presence of a therapist. I don't see how the program can claim it isn't providing therapy with this equipment.

First, I have no problem with exercise using the wheelchair-accessible equipment with the exercise physiology. That's no more skilled than if I went to a gym and hired a personal trainer. I have a big problem with claiming use of a robotic gait trainer isn't skilled. The in-service presenter told us to refer anyone who we felt would benefit from use of that equipment. A prescription isn't needed but the person will need to attend some outpatient therapy to be fitted for the equipment and determine the settings. After that the therapy, oops, exercise will be supervised by someone other than a PT or PTA.

Excuse me. That facility can't have it both ways. Either the equipment is a skilled service or it isn't. They want to bill the insurance companies for putting patients on the equipment because that requires the involvement of a licensed therapist. Then, suddenly post-discharge the equipment is no longer skilled and can be operated by a non-licensed person. And this is offered at a cost that can be paid for out-of-pocket. Which is it?

The logic behind this is obvious. Their patients are plateauing on the equipment or the insurance stopped paying. The patients can't afford to self-pay for the therapy but want to continue using the equipment. They can afford the lower-cost exercise program but first they need outpatient therapy to set it up. Once again, I say which is it, skilled or not? This is particularly amusing to me given that the evidence isn't showing robotic gait trainers to be any more effective than body weight-support systems.

This is taking us down the slippery slope toward fraud. I can hear the argument. Those patients need to continue their therapy, can still make improvements, will lose whatever improvements have been made, etc. Those are probably all true to some degree. Sure, the facility can agree to take less to provide the service but doing so is a form of fraud because everyone else is then being overcharged. Imagine an insurance company discovering this. Their first reaction would be to deny further payments for the equipment, claiming it is no longer skilled.

There is also the little problem I have with undermining our profession. The APTA is pushing for direct access by saying we're the only ones who can do what we do. That's apparently not so if non-therapists are able to provide robotic gait training and functional e-stim without a therapist present. This practice completely shoots the DPT down. Why do we need a doctoral-level degree to perform non-skilled services? Or maybe we do need a few DPTs to establish treatment parameters. The rest of the employees can be unskilled. I'm sure management would love an excuse to cost-cut a few PT salaries down to that of a technician.

I have an internal debate running on whether I should call the PT board and ask about this. It could be I'm completely wrong and it's just me overreacting. Or, I could be right to some degree. I'm not sure what the actual fallout from being right would be but I doubt I would enjoy it. If I'm right, would it be right to set in progress something that could ultimately shut it down? Of course, I could call and never get an answer. I just don't know.

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