PHYSICAL THERAPY
House Bill 4712 (H-1) as reported from committee
Sponsor: Rep. Kathy Crawford
Committee: Health Policy
Complete to 10-7-15
BRIEF SUMMARY: The bill would allow chiropractors to prescribe physical therapy services for their patients.
FISCAL IMPACT: House Bill 4712 would not have a significant fiscal impact on the state or local units of government.
THE APPARENT PROBLEM:
The Michigan Public Health Code does not authorize physical therapists to accept a prescription written by a chiropractor. While chiropractors can and often do 'refer' patients for physical therapy, chiropractors cannot write prescriptions requiring that these services be provided to their patients.
Although one of five 'diagnosing providers' under the code, licensed chiropractors argue they, alone, do not have parity with their doctor-level colleagues (that is, medical doctors, osteopathic doctors, dentists, and podiatrists), when it comes to writing prescriptions for their patients to obtain physical therapy services.
Historically, chiropractors' scope of practice has reflected their education and training, generally considered in relation to a physician's education and training. While a physician's scope of practice is unlimited (diagnoses, surgeries, prescriptions), and a dentist's or podiatrist's practice is unlimited with regard to their respective anatomical regions, in contrast a chiropractor has a limited scope of practice—limited diagnoses, no surgery and no prescribing. Further, physical therapists, themselves, oppose the chiropractors' desire to write prescriptions for physical therapy, because simple 'referrals' are already customary. And finally, health care insurers, attempting to control costs, do not favor reimbursing for unnecessary services.
Nonetheless, chiropractors argue that the physical therapy prescription ban poses a barrier to health care that their patients and they must overcome. To eliminate this barrier to health care, legislation has been introduced to require physical therapists to accept prescriptions from chiropractors ordered physical therapy treatments for their patients.
THE CONTENT OF THE BILL:
House Bill 4712 would amend the Public Health Code to allow chiropractors to prescribe physical therapy services for their patients.
Now under the Public Health Code, generally, a physical therapist cannot engage in treatment of a patient unless that patient has a prescription written by a dentist, a doctor of medicine, a doctor of osteopathy, or a podiatrist. House Bill 4712 would retain this provision, and extend it, to allow a physical therapist to engage in treatment of a patient with a prescription written by a chiropractor. However, the bill offers two caveats.
First, the bill would allow a physical therapist to engage in treatment with a prescription written by a chiropractor, only if ordering that prescription would be in compliance with the health care professional's scope of practice. Second, regarding prescriptions ordered by chiropractors, the bill specifies that a physical therapist would not be required to accept any prescription that was more specific than to treat and evaluate the stated diagnosis.
Currently under the law, in two instances, the code does allow a physical therapist to engage in treatment without a prescription from any of these health care professionals: (1) for 21 days or 10 treatments (whichever occurs first), and (2) when a patient is seeking physical therapy services to prevent injury or promote fitness. House Bill 4712 would retain both of these provisions.
MCL 333.17820
ARGUMENTS:
For:
Proponents of the bill—the Michigan Association of Chiropractors—argue for 1) parity, and 2) greater access to health care for their patients.
Those who favor the bill note that "currently under Michigan's Public Health Code, after 21 days or ten treatments, physical therapists are limited to treating patients only with a prescription from an allopathic physician, osteopathic physician, podiatrist, or dentist." They say: "Despite the fact that chiropractic physicians are one of the five provider groups defined as diagnosing physicians under Michigan law, the physical therapy scope of practice does not allow PTs to accept a prescription for PT services from a chiropractic physician." Proponents argue this prohibition in the Public Health Code is antiquated, and denies them parity with other doctor-level providers of health care.
Further, those who favor the bill say the current prohibition creates a costly barrier to care. As a result of the barrier to care, "a chiropractic physician wishing to send a patient for physical therapy must instead send the patent to an MD, DO, podiatrist, or dentist to get a prescription for PT services. This creates unnecessary costs for the insurer and the patient, due to an additional office visit and resulting delays in care."
Against:
Opponents of this bill pose two key arguments: patients already have access to a physical therapist's care; and, the limited chiropractic scope of practice does not allow prescribing of any kind.
First, those who oppose the bill, including the Physical Therapy Association, argue that "although House Bill 4712 purports to remedy a consumer access to physical therapy problem, there is, in fact, no problem to be solved." Opponents explain that Public Act 260 of 2014 has improved consumer access to physical therapy by allowing consumers to seek evaluation and treatment by a physical therapist without a prescription from an MD, DO, DDS, or DPM for up to 10 visits or 21 days, whichever occurs first. Consequently, a chiropractor is already currently able to refer a patient to a physical therapist for evaluation and treatment."
Second, those in opposition observe that, currently, the Public Health Code grants authority to write prescriptions for physical therapy only to a medical doctor, a doctor of osteopathy, a dentist, or a podiatrist. Why? Because only doctors have an unlimited scope of practice, while only dentists and podiatrists have an unlimited scope of practice with regard to the respective anatomic region that they treat. What does an unlimited scope of practice mean to the patient? Among other things, it means they can be assured that their health care practitioner is able to competently diagnose bio-medical illnesses, prescribe medications, and perform surgeries.
Chiropractors have a limited scope of practice, in keeping with their education and training, which allows them to provide conservative treatment options. The Public Health Code currently does not allow chiropractors to prescribe any health service. To do so would expand the chiropractic scope of practice which currently is limited to "diagnosis of human conditions and disorders of the human musculoskeletal and nervous systems as they relate to subluxations, misalignments, and joint dysfunctions. These diagnoses shall be for the purpose of detecting and correcting those conditions and disorders or offering advice to seek treatment from other health professionals in order to restore and maintain health." So, chiropractors can "refer" their patients to other health care providers, but they are not equipped to "prescribe" services for their patients.
POSITIONS:
The Michigan Association of Chiropractic supports the bill. (10-6-15)
The Michigan Physical Therapy Association opposes the bill. (10-6-15)
Michigan Association of Health Plans opposes the bill. (10-6-15)
The Michigan State Medical Society opposes the bill. (10-6-15)
Michigan Speech and Hearing Language Association opposes the bill. (10-6-15)
The Michigan Orthopedic Society opposes the bill. (10-6-15)
The Detroit Chamber of Commerce opposes the bill. (10-6-15)
Blue Cross Blue Shield of Michigan (BCBSM) opposes the bill. (10-6-15)
The Economic Alliance for Michigan opposes the bill. (10-6-15)
Ford Motor Company opposes the bill. (10-6-15)
The Michigan Manufacturers Association opposes the bill. (10-6-15)
Legislative Analyst: J. Hunault
Fiscal Analyst: Paul Holland
■ This analysis was prepared by nonpartisan House Fiscal Agency staff for use by House members in their deliberations, and does not constitute an official statement of legislative intent.