BILL ANALYSIS
AB 1444
Page 1
Date of Hearing: January 15, 2008
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Mike Eng, Chair
AB 1444 (Emmerson) - As Amended: April 9, 2007
SUBJECT : Physical therapists: scope of practice.
SUMMARY : Permits patients direct access to a physical
therapist without first obtaining a physician referral.
Specifically, this bill :
1)Provides that the practice of physical therapy includes the
examination, evaluation, and testing of a person with
mechanical, physiological, and developmental movement-related
impairments, functional limitations, and disabilities or other
health and movement-related conditions in order to develop a
plan of therapeutic intervention and to initiate treatment.
2)Permits a physical therapist to initiate treatment of
conditions that fall within a physical therapist's scope of
practice.
3)Requires a physical therapist to refer his or her patient to a
licensed physician, osteopath, dentist, podiatrist, or
chiropractor if the patient demonstrates signs or symptoms or
a condition that requires services or treatment beyond a
physical therapist's scope of practice.
EXISTING LAW :
1)Establishes the Physical Therapy Board of California (Board)
within the Department of Consumer Affairs for the purpose of
licensing and regulating physical therapists.
2)Defines "physical therapy" as the art and science of physical
or corrective rehabilitation or of physical or corrective
treatment of any bodily or mental condition of any person by
the use of the physical, chemical, and other properties of
heat, light, water, electricity, sound, massage, and active,
passive, and resistive exercise, and shall include physical
therapy evaluation, treatment planning, instruction and
consultative services.
3)Specifies that physical therapists are explicitly prohibited
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from diagnosing diseases or other medical conditions.
FISCAL EFFECT : Unknown
COMMENTS :
Direct access to physical therapists in California . Because the
Business and Professions Code does not explicitly prohibit
direct access to physical therapists, California law on this
issue is ambiguous. A May 1965 Attorney General (AG) Opinion
determined that while a physical therapist may not diagnose a
patient's ailment, it is acceptable for a physical therapist to
treat an ailment diagnosed by another medical health care
professional: "The statute could not be more clear that a
licensed physical therapist is not authorized to diagnose, and
we perceive no conflicts, ambiguities, or uncertainties in
limiting the practice of licensed physical therapists to
treating ailments diagnosed by those found to be qualified and
authorized by law to diagnose." Since 1965, the scope of
practice of physical therapists as defined in the Business and
Professions Code has not dramatically changed. The implication
of the 1965 AG Opinion is that a physical therapist must have a
diagnosis from an authorized health care professional prior to
treating a patient. A guideline published by the Practice
Issues Committee of the Board regarding the issue of direct
access to physical therapists states, however, that "physical
therapists are not required to have a referral from a physician
in order to provide treatment," but goes on to state that "a
physical therapist may practice without a physician's referral,
provided that a diagnosis is obtained from a diagnostician."
Direct access to physical therapists in the federal Medicare
program . Prior to June 2005, patients in the Medicare program
needed to obtain a referral from a physician before seeing a
physical therapist. A study mandated by the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173) examined the issue of patient direct access
to physical therapists. The study, conducted by the Medicare
Payment Advisory Commission (MedPac), concluded that, "Several
compelling reasons argue for retaining Medicare's current
requirements that physicians refer beneficiaries to PT services
and oversee their care. These requirements are in place so that
beneficiary health care needs are correctly diagnosed, referred
for treatment, and followed up. Given many beneficiaries'
multiple and chronic health problems, the requirements encourage
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coordination of the medical care beneficiaries receive."
Changes to the Center for Medicare and Medicaid Services' (CMS)
"Pub 100-02 Medicare Benefit Policy" took effect in June of 2005
that permit reimbursement for outpatient physical therapy
treatment under Medicare without a physician referral. Under
this policy, a "plan of care" must be completed by either a
physician, non-physician practitioner (e.g., nurse practitioner
or physician assistant), or a physical therapist. If a physical
therapist writes the "plan of care" he or she must obtain
certification (i.e., a signature from a physician or
non-physician practitioner) of that plan from a physician or
non-physician practitioner within 30 days of the initiation of
treatment. It is not necessary for a physician or non-physician
to actually see the patient in person for a "plan of care" to be
certified. Re-certification of the plan of care by a physician
or non-physician practitioner is required for every 30-day
interval that a physical therapist continues to treat the
patient.
Purpose of this bill . According to the sponsor, the California
Physical Therapy Association (CPTA), this bill "is a cost
effective measure that will allow consumers to get the care they
need without having to needlessly burden a physician with an
unnecessary visit." CPTA contends that this bill will bring
California into alignment with 43 other states that allow
patients direct access to physical therapists in some form and
with the federal Medicare system. CPTA asserts that the
experience of these other states and the Medicare system
demonstrates that there is not an increase in the risk of harm
to patients when they have direct access to physical therapists;
this assertion is supported by the fact that there is not an
increase in insurance claims.
The author contacted the largest national provider of
professional liability insurance to physical therapists,
Healthcare Providers Service Organization (HPSO), to inquire
about how this bill might impact insurance claims. HPSO
responded that it does not see this bill having any impact on
premiums because its experience in other states that permit
direct access to physical therapists does not indicate that
such access leads to increased claims: "Based upon our review
of claims, we do not view the ability to treat patients without
referral (either as a result of state legislation or CMS
regulation) as a risk requiring specific screening at this time
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because we can not make a direct correlation between direct
access and increased claims activity. This is demonstrated by
the fact that our program does not have a premium differential
for physical therapists in direct access states versus
non-direct access states."
CPTA argues that direct access is needed because our health care
system is in crisis due to access problems and high costs. In
addition, CPTA maintains that this bill will "improve access to
rehabilitation services for injured workers, frail seniors and
young athletes engaged in sports. Allowing consumers the
ability to see a physical therapist directly instead of waiting
for a physician's appointment and having to pay a co-payment,
that may cost as much as $40 a visit, is a common sense approach
that will make health care more efficient and less costly for
patients and our health care delivery systems."
Additionally, CPTA maintains "physical therapists are extremely
qualified to initiate treatment, receiving a post-baccalaureate
level education?accredited schools of physical therapy in the
U.S. have required physical therapy students to undergo the
rigorous education and training necessary to allow them to
perform medical screening, identify movement impairments, and
treat patients without physician referral. However, physical
therapists that hold those credentials are restricted from using
those skills unless they move out of California to practice or a
direct access law in this state is passed."
The Physical Therapy Board of California (Board) supports this
bill stating that it has received minimal consumer complaints
regarding this issue and that none have resulted in discipline
due to patient harm. The Board maintains that this bill will
benefit the consumer by removing an obstacle to receiving health
care and by reducing the cost of health care.
Opposition . The California Orthopaedic Association (COA)
opposes this bill arguing that it will expand the scope of
practice of a physical therapist to treat nearly any medical
condition. COA contends that it is not a simple matter to
differentiate musculoskeletal problems from non-musculoskeletal
problems and that such a distinction often cannot be made by a
visual inspection of a patient. Furthermore, to separate and
diagnose musculoskeletal problems from other medical conditions,
x-rays, MRI scans, and/or blood tests are often required and
physical therapists do not have the ability to order or
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interpret these tests. COA maintains that under this bill,
"many diagnoses will be missed and many patients undertreated if
physical therapists are allowed to begin treatment before a
physician and surgeon, with broader overall training, examines
the patient." In addition, COA asserts that a "physical
therapist does not have adequate training to support this
expanded scope of practice" and will not be aware of missed
diagnoses because he or she does not know what he or she does
not know. Finally, COA refutes the sponsor's contention that
patients needing the services of a physical therapist do not
receive a referral in a timely manner and claims that the 2004
study by MedPac supports this claim.
The California Chiropractic Association (CCA) opposes this bill
arguing that it would expand physical therapist's scope of
practice by allowing them to evaluate and treat patients without
a diagnosis or a referral from a physician, and puts patients at
risk. CCA contends that health care providers must receive
comprehensive training in order to be able to diagnose
conditions and ensure patient safety: "physical therapists do
not study the physiologic functioning of the entire human body
adequately to be able to diagnose potentially life-threatening
conditions."
The California Medical Association opposes this bill asserting,
"Physical therapists serve an important role in healthcare, but
their training and education does not authorize them to make
diagnoses or evaluate the patient's entire medical condition.
Physical therapists are trained to treat, not diagnose, and
should not be allowed to function as the first point of contact
where initial diagnosis is necessary?Patients, especially the
elderly, may have precipitant medical issues and improper
treatment due to missed diagnoses could add to the gravity of
health problems or undetected medical conditions."
Related legislation . AB 2868 (Bogh), Chapter 222, Statutes of
2006, permitted physical therapists to use the title "doctor" in
written or verbal communications if the physical therapist has
received a doctoral degree in physical therapy.
REGISTERED SUPPORT / OPPOSITION :
Support
California Physical Therapy Association (sponsor)
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Alhambra Valley Physical Therapy
Attachi Physical Therapy
Back on Track
Bak Physical Therapy
California Senior Legislature
Cameron Park Physical Therapy Center
Casa Colina Hospital for Rehabilitation
Clear Lake Physical Therapy, Inc.
Dagostino Physical Therapy
El Dorado Physical Therapy & Associates
Foothill Physical Therapy
Fortanasce & Associates Physical Therapy/Sports Medicine Center
Hayashida & Associates Physical Therapy
Hoeck Physical therapy, Inc.
Impact Rehabilitations Center
Kaufman Physical Therapy
Levas Physical & Occupational Therapy
Optimal Performance Physical Therapy and Injury Prevention
Peak Physical Therapy
Petaluma Orthopaedic and Sports Therapy
Physical Therapy Board of California
Progressive Physical Therapy
PTPN
Redwood City Physical Therapy
Saint Francis Memorial Hospital Center for Sports Medicine
San Francisco Sport and Spine Physical Therapy
Santa Barbara Cottage Hospital
Sierra Orthopaedic & Atheltic Rehabilitation
Sports Area Physical Therapy
Thompson & Rodrigues Physical Therapy Associate, Inc.
Westwood Physical Therapy
Wilshire Linden Physical Therapy
Numerous individuals
Opposition
Alvarado Orthopedic Medical Group, Inc.
Arrowhead Orthopaedics
California Academy of Eye Physicians & Surgeons
California Academy of Family Physicians
California Chiropractic Association
California Medical Association
California Orthopaedic Association
California Society of Industrial Medicine and Surgery
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California Society of Physical Medicine and Rehabilitation
Foothill Orthopaedic Medical Clinic
Kerlan-Jobe Orthopaedic Clinic
Los Alamitos Orthopaedic and Sports Physical Therapy
Monterey Peninsula Orthopaedic and Sports Medicine Institute
Orange County Orthopaedics & Sports Medical Group, Inc.
Orange Orthopedic Medical Group, Inc.
Orthopaedic Medical Group
Osteopathic Physicians & Surgeons of California
Sacramento Knee & Sports Medicine
San Diego Sports Medicine & Orthopaedic Center
Spondylos Medical Group, Inc.
Torrey Pines Orthopaedic Medical Group
Numerous individuals
Analysis Prepared by : Rebecca May / B. & P. / (916) 319-3301