BILL ANALYSIS �
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|Hearing Date:May 2, 2011 |Bill No:SB |
| |924 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 924Author:Walters
As Amended:March 30, 2011 Fiscal: Yes
SUBJECT: Physical therapists: direct access to services.
SUMMARY: Allows patients to initiate physical therapy treatment
directly from a licensed physical therapist, provided the treatment is
within the scope of practice of a physical therapist.
Existing law:
1) Establishes the Physical Therapy Act, which is enforced by the
Physical Therapy Board of California (PT Board), to license and
regulate the practice of 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. Indicates that
the practice of physical therapy includes the promotion and
maintenance of physical fitness to enhance the bodily movement
related health and wellness of individuals through the use of
physical therapy interventions. Specifies that the use of roentgen
rays and radioactive materials, for diagnostic and therapeutic
purposes, and the use of electricity for surgical purposes,
including cauterization, are not authorized under the term
"physical therapy." Indicates that a physical therapy license does
not authorize the diagnosis of disease.
3) Provides that an applicant for a physical therapy license must be a
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graduate of a professional degree program of an accredited
postsecondary institution/s approved by the PT Board, and must
complete academic coursework and clinical internship in physical
therapy.
4) Provides that the words "diagnose" or "diagnosis" include any
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. Machines or
mechanical devices for measuring or ascertaining height or weight
are excluded from this section.
This bill:
1)Allows patients to initiate physical therapy treatment directly from
a licensed physical therapist provided that the treatment is within
the scope of practice of physical therapists, as specified, and all
of the following conditions are met:
a) If, at any time, the physical therapist has reason to believe
that the patient has signs or symptoms of a condition that
requires treatment beyond the scope of practice of a physical
therapist, the physical therapist shall refer the patient to 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 to a person licensed to practice
dentistry, podiatric medicine, or chiropractic.
b) The physical therapist shall disclose to the patient any
financial interest he or she has in treating the patient.
c) With the patient's written authorization, the physical
therapist shall notify the patient's physician and surgeon, if
any, that the physical therapist is treating the patient.
2)Provides that the conditions specified in Item #1 (a) to (c) above,
does not apply to a physical therapist when providing evaluation or
wellness physical therapy services to a patient, as specified.
3)States that this bill shall be not construed to expand or modify the
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scope of practice for physical therapists, as specified, including
the prohibition on a physical therapist diagnosing a disease.
4)Provides that this bill shall not be construed to require a health
care service plan or insurer to provide coverage for direct access
to treatment by a physical therapist.
5)Finds and declares that an individual's access to early intervention
to physical therapy treatment may decrease the duration of a
disability, reduce pain, and lead to a quicker recovery.
FISCAL EFFECT: Unknown. This bill has been keyed "fiscal" by
Legislative Counsel.
COMMENTS:
1. Purpose. The California Physical Therapy Association (CPTA) is the
Sponsor of the measure. According to CPTA, this bill "is needed to
streamline health care delivery and to increase consumer choice and
access to needed care. In 36 other states, including the
surrounding states of Arizona, Hawaii, Nevada and Oregon, patients
have the ability to go to a physical therapist directly for
treatment. Physical therapists in these states take the same
licensing exam and are trained by colleges and universities
adhering to the same national educational standards, which include
teaching for independent practice. Additionally, CPTA indicates
that Medicare pays for the direct treatment by physical therapists
before a formal diagnosis is determined by a physician."
CPTA further argues, that "Californians should be afforded the same
opportunity to save costs and have reduced waiting times before
receiving physical therapy treatment. Physical therapy education
and training requirements have changed dramatically in the last 46
years. The minimum educational standard to become a physical
therapist in California today is a Master's Degree. In 2015, all
physical therapy programs will end in a Doctoral Degree and a
Doctorate will be the new educational standard. In addition,
physical therapists must pass a state and national licensing
program and complete continuing education courses. Thus, physical
therapists are very well trained to provide treatment for
musculoskeletal conditions and impairments, and students educated
and trained at California colleges and universities may take their
degree, pass the same national exam as is given in other states,
and provide direct treatment to patients in neighboring states but
not California."
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2. Background. The Physical Therapy Act (PT 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
planning, instruction and consultative services. Furthermore, the
practice of physical therapy includes the promotion and maintenance
of physical fitness to enhance the bodily movement related health
and wellness of individuals through the use of physical therapy
interventions. However, the use of roentgen rays and radioactive
materials, for diagnostic and therapeutic purposes, and the use of
electricity for surgical purposes, including cauterization, are not
authorized under the term "physical therapy." The PT Act provides
that a physical therapy license does not authorize the diagnosis of
disease. Additionally, the PT Act indicates that a physical
therapist, upon specified authorization of a physician and surgeon,
may perform tissue penetration for the purpose of evaluating
neuromuscular performance as part of the practice of physical
therapy, provided that the physical therapist is certified by the
PT Board to perform the tissue penetration and evaluation and the
physical therapist does not develop or make diagnostic or
prognostic interpretations of data produced. To obtain licensure,
a physical therapy applicant must be a graduate of a professional
degree program of an accredited postsecondary institution/s
approved by the PT Board, and must complete academic coursework and
clinical internship in physical therapy.
To access physical therapy treatment, an initial diagnosis for a
medical condition must be made by a physician and surgeon or
another practitioner who is authorized to diagnose. This current
state of the law was echoed by a 1965 Attorney General Opinion
which reviewed the validity of a statute that allowed a physical
therapist to conduct specified methods of treatment but prohibits
him/her from making a diagnosis. The issue was whether this
statute was invalid because it was indefinite and uncertain. In
upholding the statute, the AG Opinion indicated that the practice
of medicine consists of three parts: diagnosis, prescription, and
treatment. The AG opinion pointed out that although it is
impossible to treat a bodily or mental condition without first
ascertaining the condition, this does not imply that the one
rendering the treatment must also have performed the diagnosis.
However, the AG opinion was clear that a licensed physical
therapist is not authorized to diagnose, and that the AG perceived
no conflicts, ambiguities, or uncertainties in limiting the
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practice of licensed physical therapists to treating ailments
diagnosed by those found to be qualified and authorized by law to
diagnose. Therefore, a licensed physical therapist may only treat
an ailment basing his treatment upon a physician's diagnosis.
The federal Medicare Program covers physical therapy services but
limits how much is covered for medically-necessary outpatient
physical therapy. The outpatient therapy limits for 2011, is
$1,870 for physical therapy and speech language pathology combined.
There are certain exceptions to these limits if the services are
medically necessary. Medicare coverage for physical therapy
requires that a patient must be under the care of a physician, the
services must be furnished under a plan of care, and the plan of
care must be certified/recertified periodically by a physician
(usually every 30 days).
3. Other States that Provide Direct Physical Therapy Access. Unlike
California, there are some states that allow for patients to
directly access physical therapy treatment. According to the
Federation of State Physical Therapy Boards (FSPTB), an
organization of state physical therapy licensing authorities or
boards, 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. For
example, California's neighboring states of Nevada and Arizona have
unlimited direct access. On the other hand, the FSPTB indicates
that Washington is a "limited" jurisdiction, where a consultation
and periodic review by an authorized health care practitioner is
not required for treatment of neuromuscular or musculoskeletal
conditions, but requires that referrals must be made if there is
reasonable cause to believe symptoms or conditions are present
which require services beyond the scope of the physical therapist's
practice, or for which physical therapy is contraindicated.
Additionally, there are states that require notification to
physicians and surgeons while providing direct access. For
example, Kansas allows for physical therapists to evaluate and
treat a patient for no more than 30 consecutive calendar days
without a referral under specified conditions. New Jersey requires
a physical therapist to refer any individual who has failed to
demonstrate reasonable progress within 30 days of the date of
initial treatment to a licensed health care professional.
4. Other Primary Health Care Practitioners in California. This bill
allows a consumer to directly access physical therapy services
without the referral or diagnosis of a physician. Essentially, the
physical therapist becomes the first contact for a consumer for
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specific health care services. This practice is not unique for
certain health care practitioners . Aside from physicians and
surgeons, naturopathic doctors, dentists, optometrists,
chiropractors, osteopathic physicians and surgeons, and
acupuncturists are primary care practitioners in California.
5. Related Legislation. AB 783 (Hayashi), pending on the Assembly
Floor, would add licensed physical therapists and occupational
therapists to the list of healing arts practitioners who may be
shareholders, officers, directors or professional employees of a
medical corporation, podiatric medical corporation, or chiropractic
corporation, as specified.
AB 721 (Nava) of 2009, is substantially similar to the provision of
this bill. AB 721 failed passage in the Assembly Business &
Professions Committee.
AB 1444 (Emmerson) of 2008, would have revised the definition of
physical therapy and authorized a physical therapist to initiate
treatment of conditions within the scope of physical therapist, as
specified. AB 1444 was referred to the Assembly Business &
Professions Committee but the hearing for the bill was cancelled by
the Author.
6. Arguments in Support. The California Advocates for Nursing Home
Reform states that the current system of requiring medical referral
prior to access to physical therapy is burdensome and expensive for
consumers and results in delays in treatment, and that this bill
has incorporated a number of provisions to ensure the health and
safety of patients and does not extend the scope of practice of
physical therapists.
The California Senior Legislature indicates that this bill protects
and enhances the quality of life of aging Californians.
Adient Health Inc states that physical therapy is now at a Doctorate
level and physical therapists are trained to function in direct
access environment. Additionally, it states that for the physical
therapists it employs in other states that allow for direct access,
it has not experienced a single complaint or malpractice claim
based upon a patient seeking services directly.
7. Arguments in Opposition. The California Medical Association (CMA)
states that 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
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of an underlying medical condition. CMA states that "without a
proper diagnosis, there is not a definitive way to determine the
appropriate treatment. Without the ability to comprehensively
evaluate patients, physical therapists are not equipped to properly
diagnose and treat medical problems. Proponents of the bill claim
that 43 other states already have legislation in place to allow
patients to directly access physical therapy treatment. This claim
is very misleading. In reality there are several variations of
access to physical therapy in other states. These include
requirements for a previous diagnosis from a physician, limited
treatment periods before consulting a physician, and access to
evaluation by a physical therapist only and not treatment. The
type of access that this would provide is only available in two
other states." Lastly, CMA asserts that patients with specific
ailments should be properly assessed by the medical professionals
that are trained to give a complete evaluation and diagnosis.
The California Orthopaedic Association (Association) states that there
is no compelling argument as to why physical therapists should be
allowed to initiate a regimen of rehabilitation services on a
patient who has not been seen and evaluated by a physician. The
Association states that a physical therapist cannot order or
interpret X-rays, MRI scans, or blood tests, and consequently a
physical therapist's ability to assess a patient's condition is
severely limited, and the current system which requires physician
referral is not only safer but is more efficient.
The California Chiropractic Association states that physical
therapists do not study the physiologic functioning of the entire
human body adequately to diagnose potentially life-threatening
conditions, and are not trained to order or interpret diagnostic
tests, such as laboratory, X-ray and MRI, to complete diagnosis.
Physical therapists are not trained to recognize conditions in
which a referral is necessary which puts the patient at risk.
The California Association of Joint Powers Authorities states that
this bill will increase workers' compensation utilization review
costs for referrals, lead to higher litigation costs when disputes
arise over treatment, and has the potential to create serious
medical problems for the injured worker if their physician is not
directing all their care.
8. Policy Concerns.
a) Referral or notification to a treating physician. This bill
allows a consumer to directly access physical therapy treatment
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without a diagnosis from a physician and surgeon or any other
practitioner authorized to diagnose, provided that certain
conditions are met. Although the bill specifies that a physical
therapist must refer a patient to a physician and surgeon,
osteopathic doctor and surgeon, dentist, podiatrist or
chiropractor, if at any time the physical therapist has reason to
believe that the patient has signs or symptoms that requires
treatment beyond the scope of practice of a physical therapist,
this standard seems very broad and subjective. In order to
establish a more objective standard and to ensure consumer
protection, should physical therapists instead be required to
refer a patient to their treating health care practitioner within
a certain period of time; for example, 30 or 60 days, similar to
other states which allow direct access? Additionally, should a
physical therapist be required to notify the patient's treating
physician that a patient is under the care of a physical
therapist?
b) Anti-Kickback and Anti-referral statutes. The bill currently
requires a physical therapist to disclose to the patient any
financial interest in treating a patient. This subsection should
be amended to include provisions requiring a physical therapist
to comply with Section 650 of the Business and Professions Code
which embodies state and federal policy relating to the
prohibitions against receiving payments or some other form of
compensation for referring patients for health care services.
SUPPORT AND OPPOSITION:
Support:
California Physical Therapy Association (Sponsor)
California Advocates for Nursing Home Reform
California Senior Legislature
Numerous Individuals
Opposition:
California Association of Joint Powers Authorities
California Chiropractic Association
California Medical Association
California Orthopaedic Association
California Society of Anesthesiologists
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Consultant:Rosielyn Pulmano