BILL ANALYSIS �
AB 1000
Page 1
ASSEMBLY THIRD READING
AB 1000 (Wieckowski and Maienschein)
As Amended May 8, 2013
Majority vote
BUSINESS & PROFESSIONS 12-0 APPROPRIATIONS 16-0
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|Ayes:|Gordon, Jones, Bocanegra, |Ayes:|Gatto, Harkey, Bigelow, |
| |Campos, Dickinson, | |Bocanegra, Bradford, Ian |
| |Eggman, Hagman, Holden, | |Calderon, Campos, |
| |Maienschein, Mullin, | |Donnelly, Eggman, Hall, |
| |Skinner, Ting | |Ammiano, Linder, Pan, |
| | | |Quirk, Wagner, Weber |
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SUMMARY : This bill allows patients to access physical therapy
services without a referral for 45 calendar days or 12 visits,
whichever comes first, after which the patient must receive an
in-person examination from a physician and surgeon or podiatrist,
who also must sign off on the physical therapist's plan of care;
expands the types of licensed professionals permitted to work for a
professional corporation, and permits a licensed physical therapist
(PT) to be a shareholder, officer, or director of a medical and
podiatric professional corporation, as specified. Specifically,
this bill :
1)Requires a physician and surgeon, podiatrist, or other referring
practitioner who refers a patient to receive services by a PT
employed by a professional corporation to comply with existing law
regarding financial arrangements for referrals, and requires the
referring practitioner to provide notice to the patient, orally
and in writing, in a least 14-point type and signed by the patient
of the following:
a) That the patient may seek physical therapy treatment
services from a physical therapy provider of his or her choice
who may not necessarily be employed by the medical or podiatry
corporation; and,
b) If the patient chooses to be treated by an employed PT, any
financial interest the referring practitioner has in the
corporation.
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2)Permits a person to initiate physical therapy treatment directly
from a licensed PT if the treatment is within the PT's scope of
practice and all of the following conditions are met:
a) If, at any time, the PT has reason to believe that the
patient has signs or symptoms of a condition that requires
treatment beyond the scope of practice of a PT, or the patient
is not progressing toward documented treatment goals as
demonstrated by objective, measurable or functional
improvement, the PT shall refer the patient to a physician and
surgeon, dentist, podiatrist, or chiropractor, as appropriate;
b) The PT shall comply with laws relating to his or her title,
as specified, and shall disclose to the patient any financial
interest he or she has in treating the patient and, if working
in a physical therapy corporation, shall comply with existing
law regarding financial arrangements for referrals, as
specified;
c) With the patient's written authorization, the PT shall
notify the patient's physician and surgeon, if any, that the PT
is treating the patient; and,
d) The PT shall not continue treating the patient beyond 45
calendar days or 12 visits, whichever occurs first, without
receiving, from a physician and surgeon or a podiatrist, and
acting within his or her scope of practice, a dated signature
on the PT's plan of care indicating approval. Approval of the
PT's plan of care shall include an in-person patient
examination and evaluation of the patient's condition and, if
indicated, testing by the physician and surgeon or podiatrist.
3)States that the 45 calendar day or 12 visit conditions do not
apply to a PT when he or she is only providing wellness physical
therapy services to a patient, as specified.
4)Clarifies that this bill does not expand or modify the scope of
practice for PTs, including the prohibition on a physical
therapist diagnosing a disease.
5)States that this bill does not require a health care service plan
or insurer to provide coverage for services rendered to a patient
who directly accessed the services of a PT.
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6)Requires a PT to provide the following notice orally and in
writing, in at least 14-point type and signed by the patient, to a
person initiating physical therapy treatment services directly but
before providing those services:
"Direct Physical Therapy Treatment Services
"You are receiving direct physical therapy treatment services from
an individual who is a physical therapist licensed by the Physical
Therapy Board of California.
"Under California law, you may continue to receive direct physical
therapy treatment services for a period of up to 45 calendar days
or 12 visits, whichever occurs first, after which time a physical
therapist may continue providing you with physical therapy
treatment only after receiving, from a person holding a physician
and surgeon's certificate issued by the Medical Board of
California or by the Osteopathic Medical Board of California, or
from a person holding a certificate to practice podiatric medicine
from the California Board of Podiatric Medicine and acting within
his or her scope of practice, a dated signature on the physical
therapist's plan of care indicating approval of the physical
therapist's plan of care and that an in-person patient examination
and evaluation was conducted by the physician and surgeon or
podiatrist.
"____________________________
Patient's Signature/Date"
7)States that violation of these provisions constitutes
unprofessional conduct.
8)States that existing law which provides for the types of licensees
a professional corporation may employ as shareholders, officers,
directors, or a professional employee, as specified, does not
limit employment by a professional corporation to only those
professions specifically designated.
9)Permits any person licensed under the Business and Professions
Code (BPC), the Chiropractic Act, or the Osteopathic Act to be
employed to render professional services by a professional
corporation, as specified.
10)Permits a licensed PT to be a shareholder, officer, or director
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of a medical and podiatric professional corporation, as specified.
11)Makes technical and conforming changes.
12)Makes legislative findings and declarations.
FISCAL EFFECT : According to the Assembly Appropriations Committee:
1)Potentially significant costs to the state as well as to other
employers and their insurers, including the State Compensation
Insurance Fund (SCIF), for worker's compensation claims. These
costs are difficult to project, but direct referral to PTs could
increase costs for worker's compensation for state employees well
in excess of $150,000. In addition, this bill specifies it does
not require direct access to PT to be covered by a health insurers
or plans. There are instances where an enrollee or insured
self-refers outside a health plan's gatekeeper system and,
depending on the circumstances, an enrollee could be reimbursed.
2)Potential minor, absorbable fee-supported special fund enforcement
costs to the Physical Therapy Board of California.
COMMENTS :
1)Purpose of this bill . This bill would allow consumers to have
direct access without physician referral to a PT for treatment for
up to 45 calendar days or 12 visits, whichever comes first. It
also authorizes the creation of a professional physical therapy
corporation, and generally permits any healing arts licensee to be
a shareholder, officer, director, or professional employee of an
authorized professional corporation. AB 1000 aims to represent
the reconciled interests of certain physician, orthopedic
physician, and physical therapist groups as they relate to direct
access to physical therapy and employment in professional
corporations. This bill is sponsored by the California Physical
Therapy Association.
2)The practice of physical therapy . The Act defines the practice of
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
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planning, instruction and consultative services." Physical
therapy also includes the promotion and maintenance of physical
fitness to enhance the bodily movement related health and
wellness. A PT may evaluate, plan treatment, instruct and
consult, but may not diagnose.
To obtain a California license, a PT applicant must complete an
accredited four-to-six-year college program which includes studies
in basic medical sciences and biology, as well as clinical
experience. The curriculum focuses on the evaluation and
treatment of the heart, lungs, muscles, bones, and the nervous
system. A PT applicant must pass both a national physical therapy
examination and a California examination on physical therapy laws
and regulations to be eligible for licensure.
There are currently 26,000 licensed PTs in California.
a) Access to physical therapy in California . A PT may work
with a patient directly to "promote and maintain physical
fitness," but a PT must have a doctor's diagnosis and referral
to "perform tissue penetration for the purpose of evaluating
neuromuscular performance," on a patient, which is essentially
the heart of physical therapy practice. This interpretation of
law is based on a 1965 Attorney General Opinion.
Medicare covers physical therapy services and requires that a
patient be under the care of a physician. Medicare also
requires that the services be furnished pursuant to a plan of
care, and that the plan be certified and recertified
periodically by a physician (usually every 30 days).
b) Direct access to physical therapy in other states.
According to the Federation of State Physical Therapy Boards
(FSPTB), there are 17 jurisdictions that have unlimited direct
access to physical therapy, 30 jurisdictions with limited
direct access and 6 jurisdictions that have no direct access.
Kansas is an example of limited direct access, permitting PTs
to evaluate and treat patients for no more than 30 consecutive
calendar days without a referral to a physician or other
specified health care provider. This bill would make
California a limited direct access state, allowing patients to
visit a PT for 45 days or 12 visits, whichever comes first,
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before requiring an in-person examination by a physician. The
rationale for limited direct access is that any condition
serious enough that it cannot be resolved within 45 days or 12
visits warrants examination and possible diagnosis by a
physician to rule out more serious problems.
3)Professional corporations . A professional corporation is an
organization made up primarily of individuals of the same trade or
profession. The Moscone-Knox Professional Corporations Act of
1968 authorized the formation of professional corporations to
obtain certain benefits of the corporate form of doing business,
such as limited legal liability. At that time, only medical, law
and dental professional corporations were envisioned. There are
now 15 authorized healing arts professional corporations. Current
law specifies which healing arts licensees may be shareholders,
officers, directors or professional employees of professional
corporations controlled by a differing profession so long as the
sum of all shares owned by those differently licensed persons does
not exceed 49% of the total number of shares of the professional
corporation. For example, a professional medical corporation may
have up to 49% of its shares owned by any of 11 different healing
arts professions (such as registered nurses or acupuncturists) as
long as at least 51% of shares are owned by licensed physicians.
This bill would also authorize the creation of a PT corporation,
allow any person licensed under BPC, the Chiropractic Act, or the
Osteopathic Act to be employed to render professional services
under the 16 authorized types of professional corporations, and
permit a PT to be a shareholder, officer, or director of a medical
and podiatric professional corporation.
a) Medical corporations' employment of PTs . PTs are not
currently included in the list of healing arts professionals
authorized to be shareholders, officers, directors or
professional employees of medical corporations. Prior to 2010,
PTs worked in medical corporations under guidance from the
Physical Therapy Board that the professions designated in
statute were not exhaustive, and that therefore PTs could
practice within a professional medical corporation.
However, on September 29, 2010, Legislative Counsel issued a
written opinion that PTs could not work in a medical
corporation because they were not specifically included among
the permissible healing arts licensees under the Moscone-Knox
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Act. Legislative Counsel viewed medical corporations'
employment of PTs as related to the ban on the corporate
practice of medicine, which was intended to protect the public
from inappropriate corporate influence over professional health
care decision-making.
The opinion further indicated that since the Act provides that
it is unprofessional conduct to violate, attempt to violate,
aid, abet, or conspire to violate any provisions of the Act
itself, the Moscone-Knox Act, or any related regulations,
physical therapists employed by medical corporations could be
subject to discipline by PTB. In the same manner, since a
medical corporation is not authorized to employ PTs to provide
physical therapy services, a medical corporation doing so would
be unlawfully engaging in the practice of physical therapy.
On February 28, 2011, the Department of Consumer Affairs (DCA)
issued an opinion on the same issue and reached the same
conclusion as the Legislative Counsel.
SB 543 (Steinberg and Price) of 2012 enacted a stopgap measure
to temporarily allow continued employment of PTs by medical
corporations until a legislative fix could be attained. SB 543
prohibited PTB, until January 1, 2013, from disciplining any PT
for providing physical therapy services as a professional
employee of a medical corporation, podiatric medical
corporation or chiropractic corporation. However, no PTs have
been disciplined since January 1, 2013 for such a violation due
to lack of PTB resources.
b) Prohibitions on self-referral . California has banned
healing arts professionals from receiving compensation for
referring patients for health care services since the early
1990s. These provisions were enacted to ensure medical
professionals make judgments about rendering services
uninfluenced by their own financial interests, as well as to
protect consumers from fraud or unnecessary and excessive
health care expenses.
Current law permits the payment or receipt of consideration for
services other than the referral of patients as long as the
consideration is based on a percentage of gross revenue or
similar type of contractual arrangement and is commensurate
with the value of the services rendered. For example, a
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physician may own a medical corporation and employ a PT. The
physician may refer patients to that PT and receive payment for
the PT's services as an owner of a corporation, but the payment
must be based on the value of the PT's care, not for the
referral of the patient to the PT.
This bill reaffirms that all healthcare providers must adhere
to existing law barring compensation for referral, and requires
a referring provider to disclose any financial relationship he
or she may have in making a referral to a particular PT.
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301
FN: 0000867