BILL ANALYSIS
AB 721
Page 1
Date of Hearing: April 21, 2009
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Mary Hayashi, Chair
AB 721 (Nava) - As Amended: April 13, 2009
SUBJECT : Physical therapists: direct access to services.
SUMMARY : Allows an individual to initiate physical therapy
treatment directly from a licensed physical therapists (PT)
without a referral, as specified. Specifically, this bill :
1)Permits an individual to initiate physical therapy treatment
directly from a licensed PT, provided that the treatment is
within the scope of practice of a physical therapist and all
the following conditions are met:
a) If 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, the PT shall refer
the patient to a licensed physician and surgeon, dentist,
podiatrist, or chiropractor;
b) The PT shall disclose any financial interest he or she
has in treating the patient; and,
c) With the patient's written authorization, the PT shall
notify the patient's physician and surgeon that the PT is
treating the patient.
2)States that this shall not be construed to expand or modify
the scope of practice for PTs.
3)Specifies that it does not require a health care service plan
or insurer to provide coverage for direct access to treatment
by a PT.
4)Makes Legislative findings and declarations.
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.
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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
from diagnosing diseases or other medical conditions.
FISCAL EFFECT : Unknown
COMMENTS :
Purpose of this bill . According to the author's office,
"Currently, patients must incur additional co-pays in order to
receive referrals for evaluation and treatment from a PT.
Additionally, patients often experience delays in treatment when
waiting for referrals, which can result in higher costs to
consumers and insurance companies, along with decreased
functional outcomes. California's current medical referral
system for physical therapy is inefficient, costly, and
unnecessary."
Background . Currently, an individual is referred for physical
therapy treatment following a diagnosis from a licensed
physician and surgeon, dentist, podiatrist, or chiropractor.
PTs are statutorily prohibited from determining diagnoses, and
this bill emphasizes that it shall not be construed to expand or
modify the PT scope of practice. However, this bill authorizes
PTs to initiate treatment of an individual without a referral,
which presents a logical inconsistency.
Although the Business and Professions Code does not explicitly
prohibit direct access, a binding May 1965 Attorney General (AG)
opinion determined that a physical therapist may only treat a
patient's ailment that has been diagnosed by another medical
health care professional. The AG stated:
We note, preliminarily, that the practice of medicine
is composed of at least three consistent part:
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diagnosis, prescription, and treatment [citations
omitted]. Licensed physical therapists are
authorized, by section 2660, to practice on phase of
healing art, namely treatment, but are specifically
not authorized to diagnose. The third question
presented asks in effect, whether it is possible to
treat an abnormal condition without a prior
determination of the nature and character of the
abnormality. The answer is clearly in the negative.
This bill would allow a PT to treat a patient without a
diagnosis of the problem. Business & Professions Code 2038
defines diagnosis as:
?[an] undertaking by any method, device, or procedure
whatsoever, and whether gratuitous or not, to
ascertain or establish whether a person is suffering
from any physical or mental disorder. Such terms
shall also include the taking of a person's blood
pressure and the use of mechanical devices or machines
for the purpose of making a diagnosis and representing
to such person any conclusion regarding his or her
physical or mental condition.
It is unclear how a PT would treat an individual without
determining the nature of a person's problem. In addition to a
PT's statutory inability to diagnose, PTs are also prohibited by
law from using X-rays to determine the underlying cause of pain
or discomfort.
A review of other state statutes indicates that 16 other states
permit unlimited direct access to PTs. Six states, including
California, do not permit any level of direct access, and the
remainders of the states have variations of "limited direct
access." These variations include statutory and regulatory
directives relating to duration of treatment, PT education
levels, and physician contact.
The federal Medicare program requires input from a physician for
PT treatment. The Medicare Payment Advisory Commission,
concluded as a result of a 2003 study 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
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treatment, and followed up. Given many beneficiaries' multiple
and chronic health problems, the requirements encourage
coordination of the medical care beneficiaries receive."
Arguments in support . According to the California Physical
Therapy Association, "Physical therapist education and training
requirements have changed dramatically in the last 43 years and
justifies clarification and recognition by the Legislature that
the profession is qualified to treat patients' symptoms without
a formal diagnosis of a disease. The minimum educational
standard to become a physical therapist in California today is a
Master's Degree, and approximately 90% of physical therapy
programs now end in a Doctoral Degree. In addition, physical
therapists must pass a state and national licensing exam and
complete continuing education courses. Thus, physical
therapists are very well trained to provide treatment for
musculocskeletal conditions and impairments."
Arguments in opposition . The California Medical Association
writes, "This bill will unnecessarily expose patients to risk as
physical therapists begin treatments without the advantage of
proper laboratory or radiological testing, or lack of
understanding of an underlying medical condition. The Medicare
Payment Advisory Commission (MedPAC), in its December 2004
report, strongly admonished that Congress should not allow
Medicare beneficiaries direct access to physical therapy
services, citing that the current system does not in any way
impair the beneficiaries' access to physical therapy services?.
"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."
Previous legislation . AB 1444 (Emmerson) of 2008 was a similar
bill that died in the Assembly.
REGISTERED SUPPORT / OPPOSITION :
Support
California Physical Therapy Association
Congress of California Seniors
AB 721
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State of California, California Senior Legislature
85 individual consumers of physical therapy services
80 physical therapy students
53 physical therapists
Opposition
California Orthopaedic Association
California Chiropractic Association
California Medical Association
Medical Board of California
Analysis Prepared by : Sarah Huchel / B. & P. / (916) 319-3301