Scope-of-practice battles hit the Capitol

Two decades ago, podiatrists and orthopedic surgeons roiled the Capitol with a battle to define where the foot ends and the ankle begins. But the Capitol is annually the battleground for debates that might seem more appropriate at a medical conference.

This year, it’s Assemblywoman Mary Hayashi, D-Hayward, who is at the center of the action. She’s put forward a trio of bills that could change the scope of healthcare practices relating to physical therapists and athletic trainers.

Probably least controversial is her AB 25, a bill designed to mitigate the risks of concussions in high school sports. It would require additional training for high school coaches, require that there be people present at sporting events with proper trainer for spotting concussion symptoms, and set parameters calling for players to be held out of games when they have these symptoms.

Concussions in sports have been a huge issue in the press lately, with most of the attention going to football. There have been numerous stories in recent years of former National Football League players suffering from memory loss, mood swings, depression and other symptoms associated with repeated brain trauma. Last month, former Chicago Bears safety Dave Duerson shot himself to death in Florida after reportedly suffering symptoms for years. He pointed the gun at his chest after sending text messages to family members stating that he wanted his brain donated intact to the Boston University School of Medicine, which has been conducting a long-term study on the brains of former football players.

Hayashi’s AB 374, meanwhile, would license athletic trainers by setting up an Athletic Trainer Licensing Committee under the Medical Board of California. The California Athletic Trainers Association has been pushing for this type of legislation for years.

Mike West, president of the California Athletic Trainers Association (CATA) says the bill merely seeks to set standards for the profession, in order to protect young athletes.

“[Under current law] high schools can hire anybody they want to provide medical services to athletes,” West said. “If an athletic trainer in this state proves to be incompetent, there are no ramifications, no way of report him.”

But AB 374 is opposed by the California Physical Therapy Association (CPTA). The two professions have long had a rivalry. Physical therapists face a longer education path, and have long argued that licensing athletic trainers would allow lower skilled trainers to provide a lower quality of service.

But Hayashi’s most controversial bill appears to be one that proposes the fewest changes to the medical status quo. Her AB 783 would allow medical practices to employ physical therapists. The CPTA says this leads to higher costs and overtreatment.

“It’s just bad legislation for the consumer, the patient and the taxpayers,” said  James M. Syms, president of the CPTA. “It’s an avoidable conflict of interests. It’s self-referring for profit.”

The legislation is supported by the powerful California Medical Association (CMA). The group points out that medical groups have been employing physical therapists (PTs) for years. The CMA has argued that a majority of PTs work for doctors or medical groups already. According to the state Employment Development Department, 28 percent of PTs in California work for hospitals, while only four percent work directly for physicians. Thirty-eight percent work for “Other health practitioners.” 

The law is only necessary, they say, because of the decision by the California Physical Therapy Board last fall to stop certifying these arrangements, which have long existed in a legal gray area. The CMA says this battle is really within the physical therapy profession, between those in private practice and those working for medical groups — and that it would lead to major unemployment among PTs, at least in the short term.

“Claiming that physician-led coordinated patient care models are structured simply for profit is ludicrous,” said James Hinsdale, M.D, president of the CMA, in a statement. “The CA PPG claims of kickbacks are completely without merit as California has some of the most robust anti-kickback laws in the nation which would be unaffected by this bill.”

But Paul Gaspar, a board member with the CPTA, claimed that medical practices employing PTs is a violation of the Moscone-Knox Professional Corporation Act, which bars the undue influence or control of one profession over another.

He also pointed to a study conducted between 2002 and 2004 by the federal Office of the Inspector General, which found that 91 percent of physical therapy visits authorized by doctors under Medicaire did not meet “program requirements” showing they were valid and needed — something which cost the federal government $136 million over six months. Gaspar said that studies have shown that doctor referrals lead to more than twice as many office visits, and that there have been cases where doctors have sent patients repeatedly even after the PT said they didn’t need further treatment. 

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