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Physical therapists across the Southeast would like to see an exemption removed from the Stark Laws that allows physicians to offer physical therapy services in their offices. They say it interferes with patient choice and costs private practice therapists money.

"It's killing private practices," said Sylvia McCandless, president of the Mississippi Physical Therapy Association. "It prevents the patient from having a choice about where they go. The Stark act was developed in the '70s when dentists and doctors had therapists in their offices. Now, there's a big push for physicians to have in-office therapy. A lot of times, the consumer is not aware that their physician is making money off these services. One profession should not own another."

The American Physical Therapy Association has been fighting the In-Office Ancillary Services Exemption for years. The exemption allows physicians to own and refer to the services that they own.

"The current loopholes in the Stark regulations allowing physicians to employ/own PT have had a devastating effect on the PT profession, as well as restricting patient choice and increasing healthcare costs," said Justin Elliott, associate director, State Government Affairs, for the American Physical Therapy Association in Alexandria, Va. "Some physicians have used the loopholes to exploit PT for their own profit."

Physicians and their legal representatives argue that providing PT to their patients is a legitimate right.

"Physicians ought to be able to employ a physical therapist for rehabilitation services," said Steve Keene, general counsel for the North Carolina Medical Society in Raleigh. "We think it's good for patient care. We would oppose any law that prevents physicians from employing physical therapists."

The APTA issued a White Paper in 2007 that defines the issue:

"The term 'referral for profit,' in the context of physical therapy practice, describes a financial relationship in which a physician refers patients for physical therapy treatment and derives a financial benefit from the referral. In the most common referral-for-profit arrangements, physicians have an ownership interest in the physical therapy practice to which they refer, known as physician-owned physical therapy services, or POPTS.

"The American Physical Therapy Association has long held that POPTS present conflicts of interest for health care providers, diminishing patients' right to choose a physical therapist, and could subject patients to unnecessary inconvenience, expense and treatment. In a January 2005 position paper, APTA restated its longstanding opposition to POPTS and support for legislative and regulatory measures at the state and federal levels to ban the practice."

The APTA conducted a survey in February 2007 of members of its private practice section asking for feedback on their experience with POPTS. Letters and e-mails cited lots of patient choice and superfluous treatment issues, shoddy care and unqualified staff at POPTS establishments, as well as in overall loss of referrals for traditional private physical therapy clinics, according to the White Paper, which added that nearly 6 percent of the physical therapists who responded to a 2004 survey reported receiving threats of withheld referrals from physician-owned practices. More than 85 percent of the responding therapists said the threats were made to induce the sale of their practices to the physicians.

An in-office physical therapy service can add hundreds of thousands of dollars in annual revenue to a medical practice, and take business from private physical therapy practices, the APTA maintains.

"We are seeing abusive situations where physicians are using physical therapy to boost their profits, or where the patient really doesn't need the service," said Roshunda Drummond-Dye, associate director of federal regulatory affairs for the APTA. "We have been seeing a lot of abuse from a national standpoint."

Employees or patients have to report the abuse.

"We hear these types of situations all the time from physical therapists or patients," Drummond-Dye said. "(The federal government is) hearing from occupational therapists, people in medical imaging, pathology and other areas. It is a growing problem. We've put forth several proposals to the federal government to take out physical therapy from the Stark Laws In-Office Ancillary Services Exception."

McCandless, who has been in private practice in Jackson for 20 years, specializes in women's health and general PT.

"My business is probably down 30 percent" due to competition from doctors' in-house therapy services, she said. "I used to be the only private practice clinic on my street and now there are 15. I don't mind competition, but when they're owned by the physicians and they direct where to go, that is not fair competition. There may be a specialist that may be of more help to the patient than the one in the office."

One of the issues is that the Stark Laws have been diluted in recent years, and they are not being enforced, McCandless said.

"Medicare found that people were getting all kinds of therapy and it was costing them a fortune," McCandless said.

Stark Laws are named for U.S. Congressman Pete Stark, who sponsored the legislation in the Omnibus Budget Reconciliation Act of 1989 which barred self-referrals for clinical laboratory services under the Medicare program, effective Jan. 1, 1992. This provision is now known as "Stark I." The law included exceptions to the ban in order to accommodate legitimate business arrangements. The Omnibus Budget Reconciliation Act of 1993, known as "Stark II," expanded the restriction to a range of additional health services and applied it to both Medicare and Medicaid. Passage of "Stark II" raised concerns among some provider groups, including physical therapists.

One of the major issues, according to physical therapists, is that the Stark Laws are unenforceable.

"The Stark Laws are purely federal legislation and do not directly have an effect on any state activities," said Steve Forbush, president of the Arkansas Physical Therapy Association. "The state laws governing these activities are usually called 'Anti-Kickback' legislation or 'Prohibition of Fee Sharing'. It is a misnomer to call any state laws by the name 'Stark Laws'."

Tags:

American Physical Therapy Association, Mississippi Physical Therapy Association, Stark Law, Steve Keene, Sylvia McCandless

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