GAO Releases Report on Self-Referral of Therapy Services

For some time now, we have anxiously awaited the Government Accountability Office (GAO) report on physician self-referral for physical therapy. Originally expected to be released last fall, the report is the fourth and final in a series of GAO reports examining medical self-referral. The three previously published GAO reports focused on self-referral for imaging services (October 2012 http://www.gao.gov/products/GAO-12-966), anatomic pathology tests and procedures (July 2013 http://www.gao.gov/products/gao-13-445), and prostate cancer-related intensity-modulated radiation therapy (IMRT) services (August 2013 http://www.gao.gov/products/gao-13-525). Each of the previously released reports found higher rates of referral and increased utilization by physicians who had a financial interest in the services provided. This most recent report on physical therapy services, however, is less conclusive.

WHAT THE GAO FOUND

The GAO report on self-referral for physical therapy, which was released to the public on 6/2/14, analyzed Medicare Part B claims data from 2004 through 2010 and examined the number of PT services referred, the number of beneficiaries referred, and the number of PT services provided per beneficiary. Among the findings of the report:

• The number of self-referred PT services per 1,000 Medicare fee-for-service beneficiaries during the time frame was generally flat, while non-self-referred PT services grew by about 41%. Similarly, the growth rate in expenditures associated with non-self-referred PT services over this time period was also higher than for self-referred services.
• In 2004, approximately 4% of all Medicare FFS beneficiaries received PT services; this increased to approximately 6% in 2010. However, from 2004 through 2010, the number of beneficiaries that received self-referred PT services increased only 12%, while the number of beneficiaries that received non-self-referred PT services increased nearly 44%.
• Expenditures for self-referred services increased from $389 million to $428 million, an increase of about 10%. In contrast, expenditures for non-self-referred services increased from $1.2 billion in 2004 to $1.9 billion in 2010, an increase of about 57%. The larger increase in non-self-referred expenditures from 2004 to 2010 reflects the disproportionate increase in the number of beneficiaries receiving non-self-referred PT services over this period as well as more rapid growth in the number of 15-minute units billed for non-self-referred PT services.
• Self-referring family practice and internal medicine providers in urban areas, on average, generally referred more PT services than their non-self-referring counterparts. In contrast, self-referring orthopedic surgeons, on average, generally referred fewer PT services than non-self-referring orthopedic surgeons.
• Self-referring providers in all three specialties that GAO examined generally referred more beneficiaries for PT services, on average, but for fewer PT services per beneficiary compared with non-self-referring providers. The average number of beneficiaries referred by self-referring family practice providers in urban areas was approximately 43 to 87% higher than for their non-self-referring counterparts, depending on Medicare practice size. In contrast, beneficiaries referred by self-referring family practice providers in urban areas received 12 to 28% fewer PT services, on average, depending on practice size, compared with their non-self-referring counterparts.
• In the year a provider began to self-refer, PT service referrals increased at a higher rate relative to non-self-referring providers of the same specialty. The percentage increase in average PT service referrals between 2008 and 2010 ranged from approximately 7% for orthopedic surgeons to 33% for family practice providers. In contrast, the percentage increase in the average number of PT service referrals for non-self-referring providers during this time was lower, ranging from approximately 4% for orthopedic surgeons to 14% for family practice providers.
• While the percentage of modalities performed by the self-referring family practice and internal medicine providers was higher, the percentage of manual therapy services was also higher for these groups as compared to the non-self-referring providers, who had a higher percentage of therapeutic exercise services. The distribution of therapy services between self-referring and non-self-referring orthopedic surgery providers was almost equal, with most of the measured services showing less than a percentage point difference.

RESPONSE

Sen. Chuck Grassley (R-IA), who along with Rep. Sander Levin (D-MI) and Rep. Henry A. Waxman (D-CA), requested the GAO reports on self-referral, released a statement on his website that stated, “Unlike the previous reviews, GAO did not find a direct correlation between self-referral and billing per patient. Although GAO found that self-referred physical therapy services increased 10 percent between 2004 and 2010, self-referred services decreased as a total percentage of physical therapy expenditures during that period. While there may not be a direct link between self-referrals and cost, there does appear to be a relationship between self-referring providers and the overall number of individuals referred for physical therapy. GAO found that self-referring providers refer more individual patients for physical therapy than non-self-referring providers. This could mean that providers are unnecessarily referring patients for physical therapy when they have a financial interest.”

In its response to the report, the American Academy of Family Physicians (AAFP) stated that health insurers have encouraged providers to use imaging procedures, surgery for back pain, and medications that manage pain (such as opioids) less frequently. According to the AAFP, some providers may be choosing to use less imaging and treat fewer patients with surgery or opioids and instead manage these patients by referring them for PT services.  Recent studies may, in fact, support the fact that physicians who are more knowledgeable about the benefits of therapy may be more likely to utilize therapy services. A study in the April 2012 issue of Spine titled “Management patterns in acute low back pain: the role of physical therapy” (Gellhorn, et al) concluded that there was a lower risk of subsequent medical service usage among patients who received physical therapy intervention after an episode of acute low back pain relative to those who received physical therapy at a later time. Also, a study in the December 2012 issue of Spine titled “Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs” (Fritz, et al) concluded that physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care (including surgery, injections, advanced imaging, physician visits, and opioid use) compared with delayed physical therapy. Furthermore, the study states, delaying the initiation of physical therapy may increase the risk for additional health care consumption and costs.

The APTA’s response to the report pointed out that the results may be clouded by the inclusion of all outpatient services delivered in institutional settings, such as hospitals and skilled nursing facilities (SNFs), in its data of services provided by non-self-referrers as those facilities are more likely than a self-referring private practice to treat patients who may have more complex conditions which require more extensive care. The APTA also stated that the report’s research data lack relevant factors such as the severity of a patient’s condition, impairments, and comorbidities and that the research failed to capture the quality of care provided and that data on the frequency of visits and total expenditures are irrelevant without knowing patient severity and outcomes. These are all valid points but, interestingly enough, severity of condition, comorbidities, and lack of quality measures or outcome data are seldom mentioned by proponents of the removal of the IOASE when quoting older studies which date back to the early ’90s.

Regarding the rise in frequency of referrals by physicians when they have a financial interest, the president of the Private Practice Section of the American Physical Therapy Association, Tom DiAngelis, stated this demonstrates “the perverse incentive of physician ownership of PT practices”. In its online blog, the newly formed Physical Therapy Business Alliance, an organization which represents private practice physical therapy businesses, stated, “Even more to the point, the GAO Study suggested that their ‘so-called’ self-referred PT group had a relatively stable pattern of referrals between 2004 and 2010. It is common knowledge that many POPTS have not been accepting Medicare patients because they are the most costly to treat as a result of lower payment per hour and exhaustive, burdensome Medicare regulations/paperwork. Besides the mere compliance risk exposure that exists for their practice when they treat Medicare patients, these beneficiaries also tend to have greater co-morbidities and disability than younger patients. Many physicians owning physical therapy clinics are eager to “cherry pick” patients with private, well-paying insurance plans or more readily responding patient conditions.”  These would seem to be rather sweeping comments that attempt to broad-brush physician practices that provide therapy services.

Ultimately, without patient and outcomes data, both sides of the IOASE will use various pieces of this report to support their position. This fourth and final GAO report, though, does not appear to provide the proverbial nail in the coffin that opponents of the IOASE had been anticipating.