Phase out the Doctors; make room for PT’s
In several of my previous articles, I have discussed the efficacies and common sense reasons why physical therapists should be granted the increased autonomy referred to as, Direct Access. In most instances direct access refers to outpatient physical therapy in diagnosing and developing plans of care (POC) for orthopedic injuries or dysfunctions. However, one area that I think is in need of increased autonomy is home health.
Home health in many ways already affords the healthcare practitioners some form of autonomy. Nurses, speech therapists, occupational therapists, and physical therapists are able to enter a patient’s home and develop a POC with relatively minimal interference or red tape with a primary care physician (PCP)/referring doctor’s office or insurance provider. By signing off on the proper forms and acknowledging the physician referral, home care can start and continue for several certification periods. Physicians stay relatively out of the way and allow the aforementioned health providers to deliver what they deem to be proper and effective care for all types of patients.
This all seems well and good, but recently Medicare, in an effort to save money and cut back on waste, has increased the need for physicians to be active in developing and giving affirmations on patient POC’s. The result may allow Medicare to save some dollars, but at what cost. If certain criteria are not met or a PCP is lax in saying on top of the forms and certifications needed to continue care, many patients’ home care episodes are cut short, and adequate and safe care is near impossible to be delivered.
PCP’s are a vital and necessary asset for patients to go through in acquiring the care and referrals they need, but there is a limit and time for that care to be handed on to more qualified individuals. However, there is the common belief that MD’s/DO’s/PCP’s know everything there is to know about the healthcare field. In many ways this is true, a PCP was designed to be the gateway to all other specialists and modalities in an effort to save time and money on delivering care to patients. This is a dated and costly system, where now the doctors are the main beneficiaries of the PCP system, and this especially evident on home care rehabilitation. The average med student receives one semester’s class in rehabilitation science, and unless they choose to pursue rehabilitation as a specialty, they are done after that semester.
In what way is a PCP qualified to make decisions above a physical therapist is regard to rehabilitation decisions? These include placing orders and prescribing equipment needed in home and out of the home. This equipment includes durable medical equipment (DME) like hospital beds, shower chairs, commodes, chair lifts, etc.; assistive devices like crutches, canes, wheel chairs, etc.; bracing like orthotics and knee and ankle braces etc. All of the previously mentioned equipment requires a physicians referral and, in some cases, letters or medical necessity. These letters can be done by therapists as well in some instances, but none of the prescriptions can be written by a therapist, and yet, the PCP often has no indication of what the patient needs, they are just filling out a form because the therapist ordered it from the DME company. So, why I ask, must the therapist wait for a PCP to send the order, when it is the therapist who makes the decision on what the patient needs or does not need to function safely in his or her home environment.
Add into the mix the fact that the year is 2011, and I have yet to speak with or meet a PCP that still makes regular house calls. So even if the PCP knew the difference between a tub bench and a backless shower chair, has he/she been inside and seen the patients’ home? The answer is no, and, in fact, until recently PCPs would refer patients to homecare PT because the patient asked for it even when the patient did not qualify for home care. Medicare has tried to fix this with new requirements this year, but I still get patients regularly that are Medicare primary and are by no means homebound. These patients should be sent to an outpatient clinic that is geared to a higher-level patient. There are extenuating circumstances, but, again, my point is that we, the home care specialists and therapists are better suited to make the determination than PCPs are, but Medicare requires PCPs referral and visits in spite of this.
If Medicare truly wanted to stop waste in health care and save money, they would put the responsibility in the hands of the professionals that deserve it. Physical therapy programs are now, nationally, a Doctor of Physical Therapy program; we have established ourselves as willing and capable, now it is Medicare’s, and other insurances’, jobs to hold us accountable and give us the autonomy we deserve.
No one can replace what a PCP and other referring MD’s offer to patients nor does any therapist want to replace them. If a patient is demonstrating signs that require physician notification or guidance like a cardiac patient, then we are willing and able to notify a physician immediately. This happens daily in home care to where I am calling all sorts of specialists to insure that the patient I am seeing currently is as safe and stable as possible when I am finished and leave the patient’s home. What I am asking for is simply allow the therapists to be the autonomous primary care physicians for home care rehabilitation making the call on what should be prescribed, and we do not need a PCP looking over our shoulders to do it. This will make for fast, efficient, and cost effective delivery of patient care.