New study of patients receiving physical therapy following total knee replacement raises new concerns over referral for profit
A new study concludes that patients who undergo total knee replacement (TKR) surgery and are referred to a physical therapist (PT) not affiliated with their surgeon’s practice have fewer visits and more individualized, one-on-one care. Conversely, the research showed that those who received physical therapy services from a clinic owned by their physician had twice as many visits and were provided a less-intensive approach.
The study, e-published ahead of print in the scientific journal Health Services Research, examined whether the course of physical therapy treatments received by patients who undergo TKR surgery differs depending on whether the orthopedic surgeon (OS) has a financial stake in physical therapy services, often called physician self-referral. The authors reviewed 3,771 TKR episodes. Of those, 709 (18.8%) met criteria as self-referring. Of the remaining 3,062 episodes deemed non-self-referring (NSR), 2,215 (72.3%) were cases in which the OS who performed the TKR did not have an ownership interest in physical therapy services. For the remaining 847 NSR episodes, the OS had an ownership interest in physical therapy services, but the patient received services elsewhere.
Key findings included:
- The duration of episodes of care provided by a physician-owned physical therapy practice were a week longer.
- TKR patients who were treated in a clinic owned by their OS received an average of 8.3 more (or twice as many) PT visits than those who were treated in a clinic in which their OS had no financial stake.
- When there is no financial incentive for the OS owner, the episodes of care were virtually identical to those received in a non-physician-owned clinic, making clear the link between financial profit and course of care.
- Patients who received care in a non-physician-owned clinic tended to receive more one-on-one care than those who were self-referred to their physician’s own physical therapy services. Patients who were self-referred for treatment received less intensive interventions and more group care, an approach that requires more visits and potentially extends recovery time.
“When there is referral-for-profit, and from this data as related to group therapy and an extended number of visits, it stands to reason there is increased risk that the patient’s individual needs are of secondary importance to revenue. This has long been the concern here at the American Physical Therapy Association (APTA), and it is why we have fought so hard, alongside our partners in the Alliance for Integrity in Medicare Coalition, against physician-owned physical therapy services (POPTS),” said APTA President Sharon Dunn, PT, PhD, OCS. “This study provides further evidence that when the bottom line takes precedence in health care the patient loses. A patient’s welfare and recovery should always be the primary focus of treatment.”
Beyond the clinical implications, authors believe their study adds more weight to the argument against the in-office ancillary services (IOAS) exception to the Stark laws – federal legislation that prohibits most self-referral practices in Medicare. IOAS allows physicians to self-refer for several “common sense” or same-day treatments; unfortunately, it also creates loopholes for services that are rarely provided on the same day, including physical therapy, anatomic pathology, advanced imaging, and radiation therapy. Authors write that most research on these exceptions has reached the same conclusion as their own study: “that self-referral results in increased use of services and higher health care expenditures.”
The study was funded by the Foundation for Physical Therapy and was authored by Jean M. Mitchell, PhD, James D. Reschovsky, PhD, and Elizabeth Anne Reicherter, PT, DPT, PhD. Reicherter, who is currently employed by APTA, was with the Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, when the study was conducted.