MINUTES OF THE MEETING PUBLIC HEALTH, WELFARE & SAFETY COMMITTEE

MONTANA STATE SENATE

January 16, 1987

The meeting of the Senate Public Health, Welfare and Safety Com­mittee was called to order by Chairman Dorothy Eck on January 16, 1987, at 1 P.M. in Room 410 of the State Capitol.

ROLL CALL: All members of the committee were present.

CONSIDERATION OF SENATE BILL NO. 31; SEN. JUDY JACOBSON, spon­sor of the bill, District #36, stated that the purpose of the bill is to allow patients to have direct medical access to phys­ical therapists without having to have a medical doctor's re­ferral. Consumers now have direct access to practitioners in other health-related professions, such as occupational therap­ists, chiropractors, nutritionists, spor"ts trainers, etc. Physical therapists believe that the medical referral system is outdated and that consumers should have direct access to them, as well. Patients would still need a doctor's referral to get Medicare-Medicaid payments. Physical therapists have concur:r"ed in amendments to the bill.

PROPONENTS: MARY MISTAL, physical therapist from Billings, gave a historical perspective on the development of the physical ther­apy profession. It had its modern beginnings in WW I, when doc­tors referred \vounded soldiers for rehabilitation through phys­ical therapy. Physical therapists first trained in hospitals, in the 1940's established certificate programs, expanded the care offered during vm II and the Korean War, and then developed degree programs. Technological advances and research have allow­ed for a tremendous expansio~ of services; and Physical Ther­apy education has four to six-year programs with degrees to the Ph. D. level, with specific training to meet the needs of various age groups. P.T.'s operate in hospitals, clinics, and nursing homes; eleven states have direct patient access to phys. thera-pists. Exhibit #1.

RICHARD GAJDOSIK, Associate Professor of Physical Therapy at the Univ. of MT, testified on several key aspects of a physical ther­apy student's education: students are taught procedures to eval­uate needs, to recognize signs of normal and abnormal symptoms and to understand the limitations of physical therapy, and to work in cooperation with other members of the health field. The program seeks to have well-qualified students; and they produce conpetent, independent-thinking therapists. Exhibit #2.

CLAY EDI'lARDS, physical therapist, testified that the practice of physical therapy will not change dramatically; 90% will still be seen by a physician. But people in several categories will bene­fit: handicapped school children who get slowed in the school system through the referral to physician system, people with chronic pain, who must always get a doctor's referral, business

Public Health, Welfare and Safety Committee January 16, 1987 Page 2

people who attend seminars on avoiding injury at work and ask informational questions ( are physical therapists breaking the law now by conducting these seminars), and the public in general. Society is generally trying to become more physically fit. Any­one can open up shop and advise on physical fitness, nutrition, etc., except for P.T.'s, who must have a doctor's referral. The referral system has outlived its usefulness. Exhibit # 3.

GARY LUSIN, President, Montana Chapter of Physical Therapists, emphasized that physical therapists have continued to meet the needs of people through the years. People often don't need to see a physician and treatment is provided by a physical therapist. The public is recognizing the benefits of physical therapy in providing long-term solutions to health problems and learning to manage their problems themselves. Physical therapists offer cost-effective care and will continue to use the team approach. They know the limits of their profession, plus the scope of treatment will not change in Montana. They request direct pa­tient access to their profession. Exhibit #4.

P. SCHLESINGER, M.D., Great Falls, stated that patients need more direct access to physical therapists and that should not hurt the relationship with doctors. They have direct access to other practitioners with less extensive training. Physical therapists are the most qualified to educate the pub- ~ lic on preventive care and direct access would increase their opportunities to educate. Liability costs should not be affect-ed because of the excellent record of care in the past. Exhibit #5.

AIMEE V. HACHIGRAA, M.D., orthopedic surgeon, testified that she has had only two weeks of training in rehabilitation in her for­mal education and the rest by osmosis while a physical therapist has had over four years of education in that specific field. A person in need of rehabilitation has time with a therapist every day and only one session with a doctor. The initial cost of seeing a doctor could run $150 plus x-rays and paperwork, while the initial cost of seeing a physical therapist would be $40 plus x-rays. Physical therapists can be covered by major medical insurance companies. Montanans often cannot afford to see doctors because of a lack of insurance coverage, while they can more easily afford to see a P.T. This may be a turf question.

W.C. SMITH, Helena podiatrist, stated that he had worked for several years with physical therapists and found that they are competent and correct in their diagnoses.

CHADENE BURKHARTSMEYER, consumer of P.T.'s, has found them to be competent in assessment of her condition and have provided her with an excellent prevention program. Public should have direct access.

DEBBIE OLSON, patient, has had to have a doctor's referral twice when she could have gone directly to the therapist.

Public Health, Welfare and Safety Committee January 16, 1987 Page 3

JERRY LINDORF, physician, stated that he wants to see a qualified monitoring group for physical therapists and would like to see the addition a physician and a member of the public to the lic­ensing board. of A physician would recognize any problems arising between doctors and physical therapists, and any actions that are grounds for discipline or malpractive would be reported to the board.

MABEL GASKILL, patient, would like to have direct access to a P.T.

STANLEY ROSENBERG, President of Rosenberg Assoc. working with Re­habilitation hospitals, has a chronic problem requiring physical therapy. He has found that qualified physical therapists have correctly treated him and he has found a doctor's referral un­necessary and expensive. He feels that the physical therapist would refer him to a doctor, if necessary. Exhibit # 6.

JUDY BIRCH, OPI, stated that sometimes needs to see a therapist while doing extensive auto traveling (she) for work. Her doctor in Great Falls is too far away to have call for referral.

CRIS VALINKETZ, Developmentally Disabled of Montana, stated that she has had to have unnecessary prescriptions from doctors for children needing physical therapy.

MONA JAMISON, LOBBYIST, :'Montana Association of Physical Therapists, stated that: Physical therapists have a strong educational back­ground, including academic and clinical training with emphasis~on diagnostic skills. They are practicing now within the scope of their profession. Benefits: People know quite well which health care practitioner they need. The bill should have no impact on insurance rates. The bill will not change the freedom of choice statutes, which require~ that health coverage go directly to P.T's. The association supports the amendments, which will help E:"'T~_' s :..con­tinue their ties with the medical profession, but feels that the referral process is outdated. Exhibit # 7.

OPPONENTS: LEE HUDSON, Chiropractor, Great Falls, Board of Direc­tors, Montana Chiropractic Association, stated that the Chiroprac-' tic Association does not feel that physical therapists have suff­icient education to become portal of entry/primary health care pro­viders, especially when their education is compared with that of chiropractors. See comparisons of training in Exhibit # 8.

GARY BLOM, President, Montana Chiropractic Association, stated that physical therapists are lacking in diagnostic and evaluation skills, particularly the use of X-ray. Many patients might be suffering from fractures or cancer that a p.t. would not detect. Therefore, it would be in the best interests of the public to approve this legislation. Exhibit # 9.

Public Health, Welfare and Safety Committee January 16, 1987 Page 4

BONNIE TIPPY', Montana Chiropractic physical therapists' training will level. She questioned whether the

diagnosis. Exhibit # 10.

Association, stated that the be upgraded to the Master's public should be into self-

KEN HASSLER, MT. Health Underwriters Association, stated that medical care is defined as that prescribed by a physician; if medical care is not prescribed by a doctor, physical therapy claims could be denied. Exhibit #11.

BOB ROBINSON, Workers compensation, stated that this bill does not address the MCA section, 33-22-11, on compensation.

DISCUSSION ON SB 31: Sen. Willia~s: Would passage allow a physical therapist to write a person off? Sen. Jacobson: No.

Sen. Himsl: Testimony has not addressed the amendments, which substantially change the bill. Sen. Jacobson: The amendments do not change the bill, but merely add to it.

Sen. Himsl: This strikes 37 and places it under Section 2. Karen Renne: This puts the new section 2 in front of Section 1, which will become Section 3 if the amendments are added.

Sen. Meyer: What costs are involved? Mona Jamison: The board is already set up under Title 2, and there is sufficient funding to cover the costs of two additional members.

Sen Jacobson: To close, the Montana Medical Association is com­fortable with the situation. The bill is fair and reasonable and the public is protected by having direct access. I urge a do pass.

Chairman Dorothy Eck then opened the hearing on Senate Bill #6 by calling on the bill's sponsor, Sen. Lybeck, District # 4. Sen. Lybeck stated that only 19% of Americans have completed organ donor cards, although many more people would probably like to donate organs. This bill would allow survivors to do­nate a deceased's· 'organs, if the family was confortable with that choice. Hospitals will draw up porper protocol procedures. to deal with these sensitive situations.

The meeting adjourned at 3:00 P.M.

ROLL CALL

Public Health, Welfare and Safety COMMITTEE

50th LEGISLJ\'rrVE SESSION ._- 1987 Da te /-4(- J'.P - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

ABSENT EXCUSED

Dorothy Eck

Bill Norman x Bob Williams 'v ------------------------------------~------~--------+--------------~------------~

Darryl Meyer

Eleanor Vaughn

Tom Rasmussen

Judy Jacobson

Harry H. "Doc" McLane

Matt Himsl -~

Tom Hager

_________________ . ____________ . __ L-______________ ~ ________ . ____ L_ ______ ~

Each day attach to minutes.

v DA'l'E.L~_.~_=-J.4!t .. COMMIT'rEB ON~~ tt/+ ,/~

( ~ VISITORS' R~GISTER ··-·-------------r---· -._ .... _._ .. _-_.---.. -- '---

NAME . HEPRESEN'l'ING BILL # ~--...",..~

;/ 4---_ ... _. -_ .. -+--

_~W~4-<~~~~~~ __ +----L..L¥~LC!.·J z1?Lt'>J~'~~:~'5~2..!....L-!LL-t-_V_----:;-/-+-_

P. \'. _; ___ --+-_-+--V--r--l--

~ il-<Lhnd! /

't} ~~~~,4?-_~--=;.L.J--V--~-'f ( If V

~

. S/)b

)/1 / J

'\-, VISI'l'ORS' HEGISTER --- -------------{---

NAME HEPRESENTING L __ -_ -----------it-------

----------ose BILL #

_~~ PS}:s __________ 5!}3L ,/

~-~IbJL~-~,O~ I U_1~' - -~c;t~cxjJ/X'r,"'5-.-- -/ -+--

._~ ,. , . . liAJ~. tiLl ~_,,----tl( -t-'--'--'-"---'-""-I--I---l-'~-I---J.Jl1/+ - M-AJ.-~----__t_£-=-,,.L...f-_4_--~-~-.­

IT, SB 31

!..-------------------+----------

--------------+--~---

--_ .. _-----------

--------------+-

------ --------- ----4-

,------------ --- -----------1-- ---

----------------t------------------ ------t------+--

----------------------+---

------------+----

-------------ir------l-------Jf----

------f-----4---

----------

(Plcclsc leilvP pro[JarC'd slatcmcnt with Sccrctarv)

SENATE HeAL! Ii Ix VV.:.Lrllt(i:. ~

FV.!.l::~lT CO __ -'-1----- I

MONTANA CH)A:PTER-L-(~ .Y/ ~ e~LL. 5i2-J~...,! OF THE

AMERICAN PHYSICAL THERAPY ASSOCIATION

AN HISTORICAL PERSPECTIVE OF PHYSICAL THERAPY

Physcial therapy emerged as a medical discipline following World War I. A formal program for physical rehabilitation was needed but none existed. As a result of a study of European programs for physical rehabilitation, the Division of Special Hospitals and Physical Reconstruction was established in August, 1917. Physicians developed Reconstruction Aides from physical educators and nurses to assist in rehabilitating the surviving patients with war-related injuries and disabilities from World War I.

In the early 1920's, the Reconstruction Aides organized to become the American Physiotherapy Association. These early physiotherapists, as they were known, were trained in hospitals for short periods of time to meet the needs of our country.

By the 1930's, the American Medical Association with the American Physio­therapy Association developed educational programs for physiotherapy in medical schools. As the success and reputation of physiotherapy grew, so too did its body of knowledge culminating by 1940 in certificate programs fOD individuals holding bachelor degrees in physical education or nursing.

I I I

During the 1940's and 50's, an Americanized designation to physical therapy from physiotherapy was made. Three significant forces (World War II, the Korean Conflict, and the polio epidemic) during this time spurred the ~ growth of the profession. Many victims of these travesties were kept alive with physical rehabilitation becoming an integral part of their existence.

In the late 50's and early 60's, physical therapy education evolved into baccalaureate degree programs, with an increasing number of states believing it appropriate to license the practitioners of physical therapy.

By the mid-60's, public policy recognized the physical therapy profession through inclusion in the Medicare and Medicaid legislation. The physical problems of the senior citizens increased with the aging of the general population, necessitating an expansion of expertise in physical therapy.

From the mid-60's to the present, the expansion of skill, professionalism and knowledge through specialized research in physical therapy has continued. Greater amounts of work have been produced for physical therapists as the technology in medicine improves and extends lives. This has been evident in the polio epidemic survivors, in military conflict as in Vietnam, and most recently in total joint replacements and other innovative reconstruction",,­procedures in the senior population. ~

By 1969, all fifty states licensed physical therapists. One year certificate programs have been phased out and replaced with four and six year degree granting university programs accredited by the American Physical Therapy Association. Advanced degrees at the Master's and Doctoral levels are held by many therapists. Specialization in the areas of orthopedics, pediatrics, cardiopulmonary, sports physical therapy, and clinical electrophysiology is currently taking place with board certifies specialists being named I annually as the strict criteria is met.

Presently, physical therapists in Montana practice in tation centers, schOOl systems, private offices, industry, Our knowledge and expertise includes rehabilitative skills methods promoting health and wellness.

hospi tals, rehabili - ""'/'1 and nursing homes. and preventive

I

Page Two AN HISTORICAL PERSPECTIVE OF PHYSICAL THERAPY

SEN,Jc iii..I\UH 01 ,,_ ... r .. lt~

EXHIJli i:). _LI---­DATE ,1- /C- - J ,7 BILL NO. .$' {3 3 I -

Direct patient access to physical therapy is the logical step in allowing consumer choice in today's health care market. Eleven states and the u.S. Army have recognized this and have made physical therapy services directly accessible to the public.

We look for your support for direct patient access (SB 31) to continue the advancing growth of the physical therapy profession in Montana.

Respectfully submitted

YlKVVj llJt ,jf.J1, >1 Mafy Mistal, P.T. Vice-President of the Montana Chapter of the American Physical Therapy Association

Richard L. Gajdosik, Associate Professor Physical Therapy Program University of Montana

St.i'L.iE HcALfH 61 ~~":"Lr.'J{c

['" :": L

L:, / - /C- - J,'? 5B . .7~ '"

As a representative of the Professional Physical Therapy Program at the University of Montana, I would like to speak in support of Senate Bill 31. I have been on the faculty at the University of Montana for 10 years. I helped plan and implement the Program at the University. The Program was first accredited by the American Physical Therapy Association in 1981, and is currently fully accredited.

Because we seek to prepare physical therapists to deliver services primarily in a rural setting, we select mature, highly qualified students. Their average age is 27 years, their average GPA is 3.5, and they score in the top 10% on the national professional licensing examination.

Our goal is to produce independent thinking, competent practitioners. In order to achieve this goal we prepare students to evaluate neurological, musculoskeletal, and related cardiovascular and respiratory functions of patients, and to determine the appropriate physical therapy procedures to maintain or restore strength, range of motion, and improve functional levels. The students complete coursework in . anatomy, physiology, neuroanatomy, pathology, physical therapy sciences, and medical sciences. They learn the signs and symptoms of both normal and abnormal functions of the body, and they learn to identify and quantify measurable data on patients. We teach the students to perform physical therapy evaluations by first collecting subjective and objective information. After assessing this information they develop a plan of treatment. They are instructed to recognize the limits of our scope of practice, and they learn to consult with other members of the health team when questions arise or when signs and symptoms are not consistent with those of expected movement dysfunctions. Through this educa­tion physical therapists are capable of autonomous practice in close cooperation with all members in the medical field.

The increasing number of scientific research publications documented in our professional journals demonstrates that we have accepted responsibility for generating our own body of knowledge. The newest physical therapy procedures would be implemented more effectively by allowing the patient direct access to physical therapists.

The quality of the student entering our program, as well as other programs, and the direction they receive in our curriculum produce competen~, independent thinking practi­tioners who work well in the medical community. I urge you to allow the public direct access to the expertise of physical therapists by supporting Senate Bill 31.

~ January 10, 1987

R~: Senate Bill # 31 Clay Edwards, Fhysical Therapist

MONTANA CHAPTER OFTHE

AMERICAN PHYSICAL THERAPY ASSOCIATION

SENATE HEALTH & WELFARE EXHlBlT NO, _--'-' 7~ __ _

DATE / -=-_/L - f L • BILL't> . . _.S&J.-'-

TC: :,~ada:::l ChairIT.an and members of the Ser;.ate :Fublic Health CO!!lrr:i ttee

... I Y:2.nt to briefly explain to you what I believe the p2.sSage of this Jill ~ill do to the practice of physical therapy and what portion of t~e ~ublic ~ill Bost benefit froE the pa2sage of this legislation.

ill During the t'l'JO and one-half years that our state association has been drafting this legislation it has been, and still is, my personal

. belief tl::.at the prEctice of physical therapy will not change d:~2...-::2.t-lilt icall:T .... ii th the passage of this bill. Vie viill continue to see cC-SC';.b

of our p2.tients by rr:.eEns of physicicm referral. Vie will continue to ; !l2.Ve the very close working relatio~.ship we have 2.lvI2.;:,TS had with Ii. :physicians.

The ne::1cers of the public that will be dranatically and po si ti vel: r

...... c~ffected fall into several g:.:oups. There v!ill be a major imrrove:::-:ent ~ treatment for handicapped s~hool children. Fhysical ther2.~ists are the only mambers of that tr2atment team that need a physici~s

i referral. I personally have now waited 3~ ~onths for a surgic2.l .. re-y;ort and doctors referral from a childrens hospital so I car.:.

legally and safely cow~ence treatment for a student.

~ Another group that v!ill benefit by cost and time savings by going cirectly to a physical therapist are those patients with chronic physical problems. Patients with arthritis, nonoperable neck a.."'ld back L. rain, nonacute strokes and many other chronic disabilities will ce able to gGt immediate treatment. In reality, many of these patie::ts non go directly to the physical therapist 2.nd the referral is only a

~ telephone call to the doctor from the therapist.

Injury prevention is rapidly becoE2ing a major focus of business a.."'lc. L industry. Physical thera~ists are ideally educated to present low back - injury prevention seminars and are indeed doin8: so. These SeLlin3..rs

have the potential of reducing Vlorlanens compens2tion clai!:'~s and. paJ,,:::ents ; considerably. Am I cur;:'entl~~ breaking the 12.'[/ v!llen I present these II. prot;ra:ls? Possibly. I certainly 8..111 \-vhen the inevitable employee

remains to ask what they can tio for their chronic low back proble~. :,:y statements to him are now treatrr,ent and are illegal. I believe

~;: SC~Qtc 3ill ~ I]l::::v~/ ~C~ri2 .. I'Q2 --~,~'3 2

'~t:i~i,ll fL:.AUH & WELFARE

EXrL. i "J. .3 DATE /-/& - £ /' BILL NO. • 3> .8 ::1 I

r-h:'sical therapists are the most qualified persons in a community to :;;resent this information but "1,3 are about the only ones that car...r..ot lawfully do it.

The last group that I TIant to sinE,le out is the public in general. ~hero is now a major er:rph8,sis on wellness and health promotion in our society. Any physical education teac~1.er, aerobics instructor, YI'I~CA e~l~loyee, or anyone else C2.n open sho"9 and instrLl.ct and counsel ~eo}Jle on diet and exercise vii th almost no training. In most rural I;:o~ltana ci tie s and towns p the rl:/sical therapist or physician 8.re the nost qualified persons to yresent t~is infoTI~ation. The physici2n ~oes not have the ti~e and this anti~uated referral reQuire~ent prevents 2e from doin~ it.

I ur:Ie you to give this eill a e.o r:a.ss recor:L':lendation fron this CCill­

::;.i ttee. The refe1"1"2.1 recl~~ rement for pnysical ther2.py has outli vea "i t .... need an"::! is 110"1 ""'·re"'ro-·"'+in~ 1:000. r:1e rli ci"'e T'at"er t"''"'n T'.T'o"11ot i nc- it - ..:) ..... L~.L __... ~' " ___ v ---0 C -:.. .1... \....-- _ .... - - J.~ .l.!.e.. J.- - 1.... ..1.J. b ..... •

,

MONTANA CHAPTER OF THE

AMERICAN PHYSICAL THERAPY ASSOCIATION _ •. _ •• j~ "_,,L.111 01 V~ ... Lr/"ii\t

EXH,SlT [';0. --o/.,L-----DATE ___ -?:=/? - R L

To: Senate Public Health Committee ~ILb ~:0. 5I3-~ .. I. Re: Senate Bill 31, An Act Allowing Direct Patient Access to Physical

Therapy

Understanding the benefits to the public that Senate Bill 31 can provide by allowing the public direct access to physical therapy, to a large part requires the understanding of the profession of physical therapy. What is physical therapy and what do physical therapists do?

First of all physical therapy is an integral part of the medical system. This is certainly demonstrated by our history and development over the last 68 years. Through this, the philosophy which guides physical therapy care has arisen out of medical and physical therapy research.

Physical therapy is not a new profession but rather one that is 68 years old. Through those years and as the profession has expanded physical therapists have provided a safe quality care to millions of patients. Our history indicates clearly that we have effectively treated patients and this bill will not change that particular aspect of physical therapy care. In actual practice, physical therapy care, as provided by licensed physical therapists, is done totally under the careful hands and decision making of the treating physical therapist.

Physical therapy is a profession that is rapidly expanding. Utilization is also rapidly increasing. The public, as well as other health care providers are realizing that for many patients, with a variety of problems and conditions, physical therapy provides a long term solution to their problem.

Physical therapists have considerable expertise in recogn1z1ng and treat­ing limited bodily function resulting from musculoskeletal or neurological conditions. Physical therapy, and physical therapists, hold the philosophy of evaluating, treating, and educating patients to achieve optimum function as soon as possible. Perhaps most importantly physical therapists are able to expertly advise, and educate, individuals to understand their condition as well as how activities they do throughout the day working or recreating can effect the continued stress on the body that could result in prolonged injury. Physical therapy has an important preventive emphasis that in the long run can be very cost effective to consumers and third party payors.

- 2 -

SEN,,1t lb,LlH.lj ".Lt,,~ [XHi..;" "J - I _ ~ Z-DATE / - if BILL N~. :=> t3 3 '-

Physical therapy is a team oriented profession. We are very cognizant of the skills of other professionals and will continue to work closely with those professionals with the primary goal of quality, effective patient care. Certainly core to that team approach is continued and on­going consultation with the patient's physician.

Physical therapy is a profession made up of individuals that share the same internal and external problems and concerns as other professions. We have a vast majority of individuals that work hard to advance the pro­fession for better patient care and certainly in the present health care environment for cost effective care.

...

Senate Bill 31 allowing direct patient access to physical therapy will not change the scope of physical therapy practice in Montana. Physical therapists will continue to practice physical therapy only, a field that only physical therapists are best educated in. We know our profession well and we also know the boundaries that limit our profession. The long history of our referral and communication relationship will continue with physicians and other health care providers for quality patient care. For those individuals who choose to seek the services of a physical therapist initially to address their problems, Senate Bill 31 certainly provides ~ them that right which could result in early intervention and safe and effective outcomes.

Physical therapy is a profession that can be trusted. It is a profession that has provided considerable benefit to the public for years and it is a profession that the public should have direct access to. I urge you to support Senate Bill 31 that will allow direct patient access to physi­cal therapy.

Respectfully,

~'o/~:J~ Gary Lusin

(

ASSOCIATES

,. ~ o "II

"' 1/1 1/1

o % • r-

% 1/1

DONALD F. LANG i PI<ESSfN'ATE HEALTH & WELFARE ~

n

EXHIBIT NO.~ ; - 0

October 29, 198~ATE ____ 1--=I-~ -e..tf > ~ PIlL ".' S~.J/ ___ ~

Mr. Kenneth Davis Director of the

Department of Practice American Physical

Therapy Association 1111 North Fairfax Street Alexandria, Virginia 22314

Dear Ken:

Re: Practice Without Referral

Our firm as a major administrator of Professional Liability insurance for physical therapists has been monitoring claims in those jurisdictions where practice without referral is allowed. Specifically, Arizona, California, Maryland, Massachusetts, Nebraska, Nevada, North Carolina, Utah and West Virginia. It is my understanding that California and Nebraska are jurisdic­tions in which the therapist has been able to practice without referral for a considerable period of time. As of this writing, we have no firm evidence that practice without a referral has had a negative impact on Professional Liability claims.

It would be normal, from an underwriter's approach, to expect that when the therapist is practicing independent of the physician, claim experience might be less favorable than that where a physician is involved. Again, we do not find this to be the case at the present time. I can only suggest to you that the professional therapist utilizes every viable tool available in order to provide the patient with the best care possible. I would also suggest that in those areas where practice without referral has been allowed, the truth of the matter is that the therapist counsels with the physician in cases where there would be any questions whatever as to what might be proper in the handling of that patient. The less p~ofessional therapist is going to be more subject to losses w1th or without the restriction of requiring physician referral.

IoCAIN OFFICE ms ""CM'GA" AVENUE. CMICAGO. Ill. 6()60.1. {J'21'27·'",. AO""N'SHUTIVE OHICE. 2'3! WIS':0",5'''' AVENUE. WASMINGTON. 0 C .2OOC7

-9-~,,- RMPAP,' 4C4W!i3P04A'J4.$ ==_4 1Q4J! .C,..... .$A is e&Q!&. le. sa ....... ".4; a 4. ;; ·r ."l ...... _ .• -

-< o ~ II>

.'

, .... ( ( .. ,,; _ " ... _, ,lit ... '-"-

EXHil:li l Nu. s::_ DATE /-1( ~1,7 BIll NO. :2 f3:5 I

Dear Ken: October 29, 1985

The number of incidents in the entire physical therapy area has been steadily increasing, as have been the dollar values of judgments in malpractice actions. These two fac­tors in addition to others have had a negative affect on the pricing of Professional Liability coverage for physical therapists, but again that affect seems tp be across-the-board and not a function of practicing with or without a referral. It i£ cur intent to continue to monitor our therapy program. Should we notice any significant change in those areas where practice without referral is allowed, you may be assured that ~e will contact your office.

ely.

- ;~-Dona1(;. Lang

DFL/cc

-10-

, \

'S£NATE HEJlLTH & WELFARE

"J< J'.,.- ""1 U ~BlT NO. ~ . \.,..1: &.0..,-1 II\' I ,~,DJlr0:" +"1-:=-J L

&"",\\,- 'k.L r..{';'1.t"u "\ '\ \ It ~ >

~> ~ CL~ ~ t~O'Tl'\ I ! $.8 .s/ NAME IS STANLEY ROSENBERG. I AM PRESIDENT OF ROSENBERG AND

P -w-k I p,;hF l6(: ~ ..., ~;-~.1~ .. ASSOCIATES, A PUBLIC HEALTH CONSULTING FIRM. I rIP± ~AVE WORKED IN lIV~

A REHAB. HOSPITAL FOR TWO YEARS AS A PATIENT AND STAFF

.. EDUCATOR. IN THAT FACILITY, I WORKED IN CLOSE RELATIONS~i'At..t.. SJ'/.JF/~ lt1c 1.,"/111'1 ~ ~ PHYSICAL THERAPISTS AS WELL AS OCCUPATIONAL THERAPISTS. I

HAVE ALSO BEEN A CONSULTANT TO NURSING HOMES AND HAVE BEEN

~ ASSOCIATED WITH LONG TERM CARE FACILITIES SINCE THE INCEPTION

OF THE LONG TERM CARE IMPROVEMENT PROGRAM INITIATED DURING THE

NIXON ADMINISTRATION. THE PROGRAM WAS CANCELLED DURING THE

CARTER ADMINISTRATION. I SPEAK NOW AS A CONSUMER OF PHYSICAL .. THERAPY SERVICES FOR MANY YEARS BECAUSE OF A CHRONIC LOW BACK

~ PROBLEM. MY EXPERIENCE BOTH AS A CONSUMER AND AS SOMEONE WHO

HAS WORKED IN HOSPTALS AND LONG TERM CARE FACILITIES, I FEEL,

~OVIDE ME WITH SOME CREDIBILITY.

& I BELIEVE PHYSICAL THERAPISTS WHO HAVE GRADUATED FROM .. ACCREDITED SCHOOLS HAVE THE KNOWLEDGE REQUIRED TO PRESCRIBE THE

"it .. NEED FOR AND TREAT PATIENTS WHO BENEFIT FROM PHYSICAL

THERAPY. PHYSICAL THERAPISTS ARE TOUGHT TO RECOGNIZE WHAT THEY

.. CAN AND SHOULD NOT TREAT AND WITH THE EXCEPTION OF ORDERS ,eo I

RECEIVED FROM A PHYSIATRIST,' A PHYSICIAN WHO SPECIALIZES 11/

DISEASES OF THE MUSCLES, RECEIVE ORDERS OR PRESCRIPTIONS WHICH

i. USUALLY SAY, "PROVIDE P.T AS NECESSARY." OR ,"P.T AS INDICA'I'ED"

THE PHYSICAL THERAPIST THEN BA~ CHOOSE$THE MODALITY OF

-TREATMENT, I.E. HEAT, ICE, ELECTRIC STIMULATION, DEEP HEAT 01' Vl-~tI.feVF"

,', USING ULTRA SOUND, ciR STRETCHING EXERCISES. "IN SHORT, THE t.

n~YSICAL THERAPIST IS TOLD BY THE REFERRING PHYSICIAN, DO WHAT ..,., YOU THINK IS NECESSARY. YOU DECIDE WHAT IS NEEDED AND DO IT~ .. THE NEED TO SEEK A PHYSICIAN'S REFERRAL IS UNNECESSARY

• , ',JI

.~M·l"t· ",,,Uti 6t WeLFARE .":>'-11 t\ llll-'

EXHiBIT !~O. --?C6=L---­DATE I "./~ - ,I Z Bill NO. ..9 B 3 (

SINCE NOTHING IS ACTUALLY PROVIDED THE PATIENT EXCEPT THE

ADDITIONAL COST OF REFERRAL. AND, IT IS JUST THAT, AN ~ ~\\.svnl(t' ~ (JJ/

ADDITIONAL COST TO THE PATIENT. IF, THE P.T. FEELS A FURTHER

EXAMINATION IS NECESSARY, OR MEDICATION IS INDICATED, SUCH AS A

MUSCLE RELAXANT, THEY WILL AND DO REFER THE PATIENT TO THE

PHYSICIAN.

IN MY OPINION, THE NEED FOR A MEDICAL REFERRAL FOR PHYSICAL

THERAPY IS ANTIQUATED PRACTICE AND SHOULD BE DISCARDED.

W h (I -I m d {U.."" ,~", IJ .~ e I S- i D ha ". e +lw p.T. ell ~ '/ YJoJ e... ct-.-re4 e ~ l.-L h t? I"l ;-'11 d I (-'i ~ leI ()

to p

eop

le w

ho

are

...

•

livi

ng i

n a

nu

rsin

g h

ome,

p

erso

nal

car

e h

om

e or

re

tire

men

t ce

nte

r •

rela

tive

s an

d f

rien

ds

of

resi

den

ts

• re

pre

sen

tati

ves

of

com

mu

nit

y g

roup

s or

p

ub

lic

agen

cies

•

emp

loy

ees

and

ad

min

istr

ato

rs

of

care

fac

ilit

ies

r

Wh

o to

con

tact

for

O

mb

ud

sma

n s

ervi

ces:

Sta

te O

mb

ud

sma

n

P.o

. B

ox 2

32

C

apit

ol S

tati

on

Hel

ena,

Mo

nta

na

5962

0

Tol

lfre

e P

ho

ne

Nu

mb

er

1-8

00

-33

2-2

27

2

All

con

tact

s ar

e k

ept

in c

onfi

den

ce.

Loc

al O

mb

ud

sma

n

Cal

l y

ou

r lo

cal

Are

a A

genc

y o

n A

ging

or

yo

ur

Co

un

ty

Cou

ncil

on

Agi

ng

4,00

0 co

pie

s o

f th

is p

ub

lic d

ocu

me

nt

wer

e p

ub

· lis

he

d a

t an

est

ima

ted

co

st o

f 7q

; pe

r co

py,

for

a to

tal c

ost

of $

280.

00,

wh

ich

incl

ud

es

$280

.00

for

pri

nti

ng

and

$.0

0 fo

r dis

trib

uti

on

.

Mon

tan

a's

Lon

g-te

rm C

are

Om

bu

dsm

an

Pro

gram

.~

Om

bu

ds-

,

l wh

at?

J 7-r~

Thi

s pr

ojec

t w

as f

un

ded

by a

gra

nt

from

th

e A

dmin

istr

atio

n o

n A

ging

W

ashi

ngto

n, D

C

_hel

p r

esol

ve p

rob

lem

s ..

. to

th

e co

nce

rns

of

peop

le w

ho

as

soci

ated

wit

h l

ong-

term

car

e li

ve i

n l

ong-

term

car

e fa

cili

ties

. su

ch a

s A

n o

mb

ud

sman

can

help~·

• ex

erci

sing

res

iden

t ri

ghts

re

side

nts

no

t o

nly

un

der

stan

d '

•

qual

ity

of c

are

and

lif

e b

ut

exer

cise

th

eir

righ

ts t

o w

ith

in f

acil

itie

s r-

good

car

e. O

mb

ud

smen

are·

• ad

min

istr

ativ

e de

cisi

ons

imp

arti

al I?e

dia~

ors

:whe

n an

d p

olic

ies

they

loo

k In

to s

Itua

tIon

s of

r-

. sta

te a

nd

loc

al

con

cern

to

resi

dent

s. I

f g

rou

nd

s fo

r co

mpl

aint

are

fo

und,

om

bu

dsm

en m

ove

into

'-'

acti

on.

Th

ey m

ay s

uppl

y in

form

atio

n, s

ugge

st s

olut

ions

,­

and

pre

ss f

or a

ctio

n o

r ch

ange

o

n b

ehal

f o

f re

side

nts.

-- -

. .

serv

Ice

agen

CIe

s •

Med

icai

d, M

edic

are

and

oth

er l

ong-

term

ca

re p

rogr

ams

• ab

use,

neg

lect

or

expl

oita

tion

of

resi

dent

s

pro

vid

e se

rvic

es.

. .

• in

form

atio

n ab

ou

t lo

ng­

term

car

e -

serv

ices

, ca

re i

ssue

s an

d

pla

cem

ent

opti

ons

• re

ferr

als

to a

ging

se

rVIc

es p

rogr

ams

• as

sist

ance

for

lon

g-te

rm

care

sta

ff t

o h

elp

th

em

mee

t th

e n

eed

s an

d

conc

erns

of

resi

dent

s •

educ

atio

n to

en

han

ce

publ

ic a

war

enes

s an

d

use

of t

he

long

-ter

m

care

sys

tem

•

advo

cacy

for

nee

ded

le

gisl

atio

n an

d p

olic

ies

• p

rom

ote

th

e d

evel

op

men

t o

f co

nsu

mer

gro

up

s

Family Practice

Norman A. Fox. M.D. DIPLOMATE. AMERICAN

BOARD OF FAMILY PRACTICE

John S. Patterson. M.D. DIPLOMATE. AMERICAN

BOARD OF FAMILY PRACTICE

Robert J. Flaherty. M.D. DIPLOMATE. AMERICAN

BOARD OF FAMILY PRACTICE

Leonard R. Ramsey. M.D. DIPLOMATE. AMERICAN

BOARD OF FAMILY PRACTICE

11tedica! ~JJociateJ, 7'. e. A Professional Corporation

SEVEN EAST BEAll. BOZEMAN. MONTANA 59715 PHONE: 406-587-5123

SENATE HEALTH & WElfHlE tXtIHm NO -+-?--­DATE L~M - t;7 BIll NO... (.,f 8 ?>I.

January 9, 1987

Senate Public Health Committee CapItol BuIlding Helena, MT 59604

Dear Committee Members:

Pediatrics

Paul H. Visscher. M.D. DIPLOMATE. AMERICAN BOARD OF PEDIATRICS

Eric Livers. M.D. DIPLOMATE. AMERICAN BOARD OF PEDIATRICS

James R. Feist. M.D. DIPLOMATE. AMERICAN BOARD OF PEDIATRICS

Todd D. Pearson. M.D. DIPLOMATE. AMERICAN BOARD OF PEDIATRICS

A bIll before the LegIslature would allow the publIc greater access to the servIces of Physical Therapists. Currently, the publIc has free access to the rudImentary physical therapy offered by ChIropractors, who lack training In tradItIonal medical discIplInes. PhysIcal TherapIsts, on the other hand, are traIned In and familiar wIth tradItIonal medical concepts of physIcal therapy and could provide much more appropriate treatment for patients. If the case can be made for the public's free access to Chiropractic care, then there Is no question that the public can clearly benefit from freer access to the care of registered Physical Therapists.

Sincerely,

Robert J. Flaherty, M.D.

RJF:sw

KENNETH V. EDEN, M.D.

:~;', ... oIl-filiH & WtlJAR£

fXiUBIT NO, 7 DA1E-_,_/-/t -~:/

INTERNAL MEDICINE - GASTROENTEROLOGY HILL.. .£ B 3 .{ ... -

MEDICAL ARTS BLOCK III N. LAST CHANCE GULCH. SUITE G

IlELENA. MONTANA 51J60 1

Members of Public Health Co~ittee State Senate Helena, MT 59601'

Dear Senators:

January 9, 1987

'.,i

TELEPHONE (406) 442·1994

I would lik e to express my support for Senate Bill 31 r~gardi~g free acce&~ of patients to the care provided by Monta~~ phy~i~al therapi~ts.

11 my own practice many patients are referred by n:e fo!' evaluation by a physic.<'I.l therapist, and! have found them as a group to be well trained, con~cient{ous and to render their services in a very professional ~nner.

In reality, many patients self refer to a physical. therapists and then request authorization retrospectively. In almost all cases, I do this.

I think the present law in unrealistic and discriminates unfairly against physical therapists since patients have free aCC~2S to others in the h~\lth care field such as ,chlropractors, 'acupuncturists, optometrists, naturopath:;" wld etc. Aruong these groups, I think the physical therapia,s are perhaps the mose .:i.ilr;l'!ly to refer patients whose problems are outside their area of expertise.

I think the risk of physical therapists failing to recognize a problem that is beyond their area of expertise is a real one but certainly no more so than it is for physicians or any othel."health professional. I think one must rely on pro­fessional integretity of which physical therapists as a group have demonstrated an ample amount.

Sincere'ly yours,

K~nn£th V. Eden, }1.D.

KVE/dr

•

ORTHOPEDIC ASSOCIATES OF BOZEMAN, P.S.C. 206 NORTH GRAND

BOZEMAN, MONTANA 59715 PHONE 587-5546

SENATE HEALTH & WELFARE EXHmlT NO .. --,.7'---__ _ DATE. J ~ l~ - 8- 7 Bill NO._S {5..:3 /

E. LEE BLACKWOOD, M.D. FRANK W. HUMBERGER, M.D. BERNARD M. VARBERG, M.D.

January 15, 1987

Legislators of the 50th Session State of Montana Capitol Building Helena, MT 59620

Dear Sirs:

After reviewing Senate Bill No. 31, an Act allowing direct patient access to physical therapy and amending Section 37-11-104, M.e.A., I wish to state that I am in favor of this bill allowing physical therapists to evaluate and initiate treatment of patients without the direct prescription of services by a physician. I feel that physical therapists in general are much better trained than chiropractors who have direct access to patient evaluation and care. It has been my experience that they use good judgment in their evaluation and treatment plans and are prompt in referral if they

~ are concerned or have a problem. I feel good in giving my unqualified support for this bill and would encourage its passage.

Sincerely,

Frank W. Humberger,

FWH/mj

, ..

Testimony - Senate Bill 31 ...,::i'. d: dLr1Lni 6t Wc.Lff\RE

CH .... , i .:0 _' g= Submitted by: Dr. LeE Hudson

Great Falls, Montana DATL_ /-?~ )} L

08U.l NO. = rf? ? I , F"

January 16! 1987

Senators of this committee; good afternoon. My name is Dr. Lee Hudson. I am a Board Eligible Chiropractic Orthopedist and a member of the Board of Directors for the Montana Chiropractic Association. I practice in Great falls.

I would like to make it clear that we do not want to attempt to prohibit anyone from practicing the profession which they are trained for. Trl8 question at hand today is not whether the Physical Therapy profession is a worthy profession. It has a proven place in the health care community. The qUEstion we must ask today is whether the Physical Tnerapy profession has the education and training, most importantly in diagnosis, tc become a portal of entry/primary health care provider. For the first and most important step in treating the human body is making a proper diagnosis. Only after a proper ciagnosis has been made, can a treatment plan be formulated.

I have researched the similarities and differences in ed~cation oetween my profession (Chiropractic), and the Physical Therapy profession. I have not included the Medical profession in my research, however, Medicine and Chiropractic have comparable educational requirements. ~

I have obtained course curriculums from two major Physical Tnersoy programs, (Utah and Washington), and the curriculum of my Alma Mater (Northwestern College of Chiropractic).

1. 80th Chiropractic and Physical Therapy require a minimum of two years pre-professional training.

2. Cniropractic pro~ession training is a four year program. Physical Therapy professional training is 8 two year program.

3. The Physical Inerapy programs researched ~ere comprised of between 880 and 1,110 total hours of education. The Chiropractic program researched was comprised of 4,411 total hours of education. This is 4 times the total class hours.

-1-

--;. . ' ...

Last but probably most importantly;

. ~t:.LFAKt '"E. '\ . uri ~ ~t\, r\ I t to"

EX"I;I1;;.;l J £ /' .".

OA1 ~~ (2 -< I.~ B\LLNO,~

4. Chiropractic education includes 1,260 classroom hours which are directly related to diagnosis. The Physical Therapy programs researched contain between 120 and 180 hours of courses which can be related to evaluation or diagnosis.

I would also like to point out that the edusation of a Physical Therapist contains 0 hours in x-ray diagnosis; a very valuable tool.

SENAi£ Htf\UH & Wi:.LfA

CAPITAL CHIROPRACTIC CENTER OOUBIT NO. 9-I

GAJN P BlOM, DC

1732 PROSPECT A \IE NUE DATE. J - It - cf Z HELENA, MONTANA 59601 - ~ B 3 I " Bill NO,~, 'c

PH!L!P ,Ii.. BLOM, DC, FICC (406) 449-74S8

January 14, 1987

'-;-he r~~)ntana Chiropractic Association believes that the physical therapists Oefl~]tely are not qualified to diagnose or evaluate. Their education does not teach this and therefore they do not have the qualificaitons.

t·1any pathologies can mimi c musculo-skeletal problems, therefore it is essential that a differential diagnosis be made. In addition to physical, neurological, and orthopedic testing, a radiographic examination should be utilized.

Physical therapists do not have the qualifications to perform or interpret ,\:-rays. Manycancers, fractures, and other abnormal i ties are found through use of x-ray. These are various contraindications to using physiological theraputics such as heat, massage, ultra-sound, and mobilization especially if certain disease processes are present. These contr6.indications of treatment must be pointed out through precise diagnosing. We believe that this legislation is not in the best interest of public health.

Chapter 26.

.... , . " :SENATE HEALTH' ~.WELFA~:~;f~~:f: db *' b' ..... , '1-1( .. ~---<~-""""'-EXHtBIT iio.. '/GJ';.'-.,' ................... •·

DATE )- /te' ct:Z BILL NO.~SL.....L8~3""-'-/_-

_.--.,

THE GE:\ERAL PHYSIOTHERAP\­SCB~IISSIO:\

I::\TRODLCTORY i. The ::\ew Zealand Society of Physiotherapists. in associatlon \.,.itn th,,~

:\ew Zeabnd ~lanipuJ;Hi\'e Therapis~s' Association and the ::\eW Ze2.i:l.nd Priv~te Physlotherapists' Association. was represented ;it almost a:l hearings of the Commlssion. The submission of the societySubmi;;~ion ~51. induding the material supplied ill connec:ion with it, W<l5 :"ost ;.:"eiul to us. The society also helped to provide experts from over!>eas.

2. :\Jthough the conclusions reached bv the ::\e\\ Zealand Society of PhYSIOtherapists and its associated gr~up-; were not in favour' of chlroorac:ic. we should like :0 record that the stand take:: was a const~uca\'c one. The physiothe~ .. pists 5a\",; themsel\'es ;~:; criLles oi chiroDractic. not enemies. It did seem, too. that some da\' all ~peci;.tlis[s in man~al therapy. whatever their background. might be abie to work together ;:1 further research. However, at present, physiotheraplsts are aligned wlth the '\1edicai Association in opposing the provision 01 health benefits for chiropractic patients.

3. It was nOteworthy that the group oi physiotherapists specialising in manual [he rap" were responsible for prep:lring the material for the submission. They also presented it and were therefore ~wa;.lable for c:-os~­examination. This · .... a~ valuable sillce, apart i;-~m ,be ch,·:Jpr2.Cl'_,r". ,::t" '~ere better informed on the use of manual therapy than :.my other gro:..li) who appeared. Although, in generaL they echoed the iT:edical oppositio:-t, they were more specific and were aiso prepareG to make sug~estio:1::; ~G~)'...:t integrating chiropractic into the heaith system. They aiso sa\\ '11:, ilt't'e ;, .. ,.

research into manual therapy.

EDCC,-\ TIO::\ OF PHYSIOTHERAPISTS 4 .. -\t this point some~h!ng needs La be ~aid about [he f:CUcZlr:on c!

physiotheraplsl3 and. irl panicuiar. of manip;Ji3,lj~'e !.herapists sine:: the\' maintain that thev ar{' capable of pro,'idinl:: .'ill the ~en:ices no\, !l, ... ir.:v periofmr"d h:. chi~opracto~s. .- .

5 .. :\ 3-\'ear full-limc.~ourseisoikr_(Od for thr! Dlplomaof Physl,::;tI1erapv. 't~:i1iird:Oi the,,;purs.c:;\,lf9().h9ur~,f~llu~JJ$.sP~ti(ii:!.4i;1~9ii.pr,acr;,~e.,.

\;~J~$~~:tt~~~t£M~~Ji~~{i~~\i~Sc~~~~~~1kli~ti~~}~~ ~ . ~6muCh.Jessdem3.riarng;;''lf'hcii",-;ai'5--·e-nler ·(r3.l·rli~:; ~~n 1979 and in s'ub5eq'uent'''~;''ea;s'' '~i1I"pr0h;lbi\' have a preregistratiuD YI:;).:- alte

~:;~~~:~~;,i~~~~;;;t~~:;;;;7J~1iIr~~]\~;';,;~t;nnh~~~ibh'g(a parar!Iecl.~caLHe IS taught the ba~lc SCle:lCeS as :t general background to ni';: rt)j~ within the framework pro\'ided by the rekrrin~ m(dic;l doctor. Ohviuusi· .. <)nce he is in pracuce, hospital or pri\·ate. tj~,.,,\t;j.1L.:;:.~~.d

~r:.fL~.e~:::::.$r2:v~·-4:~.·,~~,f8J.V~~iljt~~iof,!,ptJh!=p-'1rit;nt.;~Jljl~.J.hf\Y;hlk,.9~:~lS' ¥hy.slC?0e~aplSt',· ~s speaa!lm portanceipa!tlcularlY:~ln~,"m;-;:h,hSPlt~.i ~.ltlng:, HIS niam ~ethcxls ~f tre.1tmen.t are electro-therap:" tne~a.pe~uc mO"crIl~lll' ,'1 .. ",<:,1; .. ' ''''er-n:'' ' ___ 0._- ~~"~~P ~nrl ""'''bll'C~'',..,n

T ... ~ •. v.~~ .~4I-,t},.'1!0-,·.~_ L-:,~t",>":,~:,:,,,,:"" .... ~~, .. ; __ ~.:'-~·~~')..llooLb~~_~";·""w ... ~,:·:·.~ ... ·· .. ~:- .. ~"-'- .. 't,. procedure::;. r~~;t::~~1~. 'phj,~:~the!'ap¥. ed).!c.~QQn. ~"'!uli 1l9,s.'grilfiCa<l.1 ..

I

IV/}

o

CII

AI'

lLR

~"

r

tl' ,.l

ini.

I,.,

,II d

iik

l.n

L:;

,l

diai

;II':J

. ... i~

; .. d

OC

l/.,U

Oi-

ht..:

.phy

./ii

u.th

ClA

lPi.

d14Q

.lx!

_J

l}r~

~~i}!,er'\ ,r

:f p]:'mfir};h~iJ!!u::srtJ:;i\lort'"vl'r,\Vr

1I0

1c'

11

t;\1

thl'

staf

f o

f.th

· r'

!'>~I"rllt'r;lp}

' \ .

. t.C

><l!

~ atl

' ti

ll!

III~

.II.

I)

'.l·

ul"

:I',

J

:\1';0

11

fr(J

ttl

},:I

II.l

ltlW

.

\ I"

'I' •

• ! 'I

;tfl

. :,

v('ry

J~""

.hi1

.Vl:

~~Il

:Ulh

C;th

olg\

..tm

)·OJ

l{1

l/lt

ph

~'S~

()t!

lf;f

apy.

:$

..

j ,f"

~~~~

,::"

:",·

:~~"

,,,.

:k.~

~:";

'~''

''''

'''·

''''

''~~

\o..

.a .. A~~~'~~

~~~ (

II J i '

_' .•

t, l

:

~."""'_li:. ..

.. ",.

'

IHA

I0iI

;-;(

; iN

t\

IAN

II'U

I..\

T!V

E T

IIE

HA

I'Y

7.

\\'c

' (''

'ill

t'

no

w t

o t

rall

tln

g i

ll t

1tal

lipu

!ati

\'(,

the

rap)

", t

o u

se t

he

terr

n

adc'

l'l(

'd I

» ti

re phy~i()therapisb. '1

his

i.>

,.k

fill

ed b

y t

hn

ll t

o be

IlI

UV

eIlH

'nt

of

jili

n'"

lit

') l

ind

"w

il

IHII

lIla

l p

assi

ve

rang

t'o T

he b

a!>i

,'S a

re t

aug

ht

earl

y,

hili

Old

) ill

til(

' la

st y

ear

i<; S

Olll

e li

mit

ed i

nst

ructi

on

giv

ell

illl

llan

ipu

lati

on

, il

ldut

iil'L

·. I

II,'

join

ts o

f th

e sp

ine.

g,)

lh i

ll N

ew Z

cala

lld

.\I

Id i

ll E

ngl'I

IHI

the

ill~

lrll

< li

llli

ap

pealn

l 1

0

b('

eiel

llt'

lIla

ry,

nell

cr

ud

e.

At

St.

Th

om

as'

il

l L

()nd

, '".

nT

II u

lld

er !

\Ii%

J.

Hic

kli

llg

wh

o h

as

so m

ud

l in

flue

llce

d N

ew

I.c,

tlal

ld

t1w

lap

ists

, th

t'

trai

nil

lg ap

pean

'd 1I

I1st

ruct

un~d

. II.

II

I '''

;t'''

Z

eala

lld

, p

hy

sio

ther

apis

ts w

i~hi

llg

tl.l

spec

iali

se i

ll tl

tis

ficld

lI

lust

U

lld

!'ll

,ik

e th

e p

ost

-gra

du

ate

cu

urs

e arr

an

ged

by

tlt

e N

ew Z

eala

lld

!\

L'l

lil"

t1.l

Iin

· T

hera

pis

ts'

Ass

oci

atio

ll.

\V"

hav

e b

rid

ly d

i:;(

'uss

ed I

his

in

Cb.

lptl

'r

:J T

he

(ou

rse

n';

tch

es

Ihl'

stan

dald

s of

th

e Il

ller

nat

ioll

al

1,('<

1<'1

dll

lO" o

f O

Jlh

np

ard

ic !

\lal

lip

ul,

Hi\

'c T

hel'

ap

y a

nd

tll

I're

is

11

0 d

ou

bt

thai

."

"",.

'~

,.\\

Z

rala

nd

p

ract

itio

llel

s ale

h

igh

ly

skil

l(·d

.

II ..

i1c,

.1

c!~,

tb

e C:

~'li

lJli

i".i

llll

h .. ,

rr .. ~

~rya.tj(!11li.~t!<}.I~ttbs,~~·~~i,rl wl.

~idl

}

pI.I Y

Slo

lb·r

af~ls~

". as

. a .. , :.

;.~.~.9U

P ... ,.~~q

I~.;~,r ... , .. e.

}.t!f

t. l.·

m. ' • .i.

~~~l?,

Ul ... ~,t. ~r~

... :;~.:r~ ...• m

. ) .... !lg

....

)1.'.:

~ .• ;5¥;a

r.~ :J1

i' > 9

\ug

ht

! ('.r:ll!llqu~~~~~,A?~r'~~~119 ,.

t.'~

~H~·

mm,t

~i;a

.t~:

~!l~

~~Y'

«;::

'. pra.~u-.,;,...iJa_~~~upl!r-v.sf!d~ .

. ~ei

orc;

i:th

ey.~

~~f~

~~_!

,).,

ti[~

1f}e

'1i!

,. ,

he

' .. ( .1

111111

'" 1

I.1

l li

as

it ;.

~lm~!a~n;~rr~'i~t,~p,:, ~~

4t~h

~~:~

PfSl

lfa,

l~.p,rac:m~p:,:r?~;

. ,.

tIl,I

. \'.

I, II

(. ·f:

a !c

'i~,

J!r~

l!1~

~g, }

ll: fa

s;~,

(,:q

~lS!

~~~t

~~l.

r~~i

:,~~

l~~~

~~~p

in~

a itU

(I

t! I!

" r

1JlM.lfiut~tf9«-t,C\f.~}·:~~, '

~!lnshf4(.~~0iV£j:t.h.(f,~;f~~le?,t ,

:;s;~#

m;:~!;

A tn

. au

iIll

l ta ti

\'~

M;;I

.,liw

n.i2

.t',.l

l .... .

J\~ii:{:iit:N'O;;~ ~.

;;:.:L

ii;:~~

C:r;.r

"'it:-

...·::

.A::lr

o'ni'!

\r.-tR

r -

. .

"'~e

i:..

j,,~

.,.~

~~ ....

.. ·m-,.&K~..

"~~!-l.,..;l.ii;;r:.::-_~~

UO

::....

"l·h

e tr

~lIl

llll

g u

f pli>siut

JH~l

api,

15

ill ;t

n'a~

III

IlI'r

,h,

m l

lIal

lJpi

lfat

lve

thn

ap

\ Jt

~akcs.J!tI"I~.:vqyx.a.

l!l,

a~k ~1

(·m~

)e~{

lof.

tpf:

;9-e

alth

te~Il~.Jt \

\'oil

id

,~('t.'1

1l11; "

[' rt1l

"~: ;<

;\10. :.H

l<;l ..• ;

l:~m~-

:7.I:)

~~~t.~

.•. t~l.(

,. 1!·.e

."~erg

.. I .. ~ .. es .. '.: .

...•.. ~~tf

.. r.Jro

.. rnot~ng ... , ..

J.).d.

?r,~r

,~

)Tg:

ll.I

".d

1l\~

:dH:

I~~e

;:r(

~~:J

{(~~

'f~.

9rp.

h~'5

1~~:

:~r.

~y~.

1lt"

!!:1

.-".

o~Jm

prOV

1{l~

jj;

tM'it

ed

ucau

~?U:

<\$t

il*'

iiM.

~aii

l ~~

...,

.;A,

"i ...

....

....

.. ;.!;

Qi~~

:,\~~ ii .... ~'i;;;~;.Jr

~#'...

...,

.:-t

;..0

. __

~~~/~~

(:R

ITIC

IS!\

l 0

1'

(:f1

IR()

I'R

:\C

TJ(

:

. I 1

. Y,

l:., 'I

':' l:

er,~}.li~t". 0

H,'

;::i

C

djll j,i

" <

.uk.

b(;

~:<}

,~:W

. ~ h

(.;¥c ,

q\l~~d

qll,_.

tJI~·,

!;::,"

::;'

~nplt

Ih.·

HaU

lin

g o

{ Ch

lr.:

lpl·

dctO

J~ a

nd

,' hI

:; sC1q~Jbc;IiA!U~"tm:~£l

!!#;

J' . .t.h~~r~

.I$:.l

....;d

l as

Ih~,.way:."Jiti""hilt.thdr·grul.lud.J.iiJlell t

ryin

g t

o y

;lIid

;111

' th

osf

·.

thcc

JI

i."

II,

'\\"

\C'I

, :J

." "('

C!i~t'lIs"

Ia t"

1 I,

k\ (

II ('I

'J

Il),

theC

llir

opra

<;lQ

r~.~

;J~"

~;~i~~

!·:~:~

~i~~t~

~~~~~~

~/~i~~

~j~:\.

~i·~;~

~~ti~~

ikil~~~t~~~&~~YiP

fully

i,

i-ch

aptt

"r 3

7 \\

'I~t c

ntll

'isll

I'>

of

the

lI/l

(k.-

lyillg

scit~

lItifi

c bas

is o

f th

ilo

pla

( Ii

,' il<

;f'lf

. t\

s fu

r lh

t"

aS51

'1 ti

on

lh

al

clli

lOpr

aCI(

)fS

"s

hif

t tl

H:i

r g

llll

llll

'"

\\t'

Ita"

t'

tUll

cbu

l o

n th

e p

oi:

" il

l 1

'/J:

ll't

IT H

, p

ara.

17

It

is

all

;u g

llll

ll'l

I I

th.1

t k.H

b 1

I" ..

.. h

l'le

. 't

call

SlI

pp

ort

th

t' v

iew

th

ai c

hir

op

r,tt

:to

rs

ale

lI

dtJ'

,I~.

it

,;\1

1

!'<

I'la

lly

SlI

Pl,

ilrt

!l

w

\ in

\'

!lla

! th

t,y

h,

jv('

li

lt'

0P

CI!

'

Ilti

l)(J

.-d

dl'I'

I',:

\t·l

t (I

I ri

te

<;,

i'·lI

lis\

. I:

!. I'

ll;"

i. ,I

ht'

l al'

i ~ ts

ni

I i( i~e

I lit

' ,j I

I,~ !

,. IIl

C Id

" I j!

Y 01

tll

f' "h

i r"p

i al

'lm

.u

ld

(·"I

II(l

.II"

il

. ti

l th

e la

llfT

's

di';<

tt!\

,all

tagt

:,

h·il

l!

thei

l O

WII

ra

ng

e "I

11

1':11

111(

'1)1.

II

i~

to

tle

that

N

t'w

It

'ala

lld

d

lirt

Jl'l

'I<

·IO

h

(lh

pll

gh

lU

ll

lIt'

cT~\

," d

v :

--;"

nl.

'1

)('1

iea

ll 0

11

1'.

,) C

Oli

Ii II

". tl

l(,l

II~c

I\'c

s II

) m

anu.

1I t

lwra

py

\\

IW

II·.I

·, p

h)

\11

J,";

,PIs

tS !

II;I

)' u

ttiI

S('

lw

ac I

:.~h(, 1

IItl

c,~I

,-~"

IIJt

1~1

watr

r ..

_ ..

_ a

il'

_n'w

l ..

. _

.,

~

_\.

CII

AV

I'E

K

:tti

I""'

.,

, 1

~ ~

I ....

. /

1....

I..

J I<

lWI'

VI'

I',

un

less

p

lty

sio

thrr

apis

ts

wis

h

to

enco

llq

lge

a d

up

lica

tio

ll

,.1"

d

loll

, W

I' Sf

'c' l

Ioth

ing

oh

jl'c

lio

nab

le i

ll t

lte

ch

iro

pra

cto

r's

cho

icr

of a

!li

llf,

;k ~

lI

Ioda

lilY

in

wh

i .. h

he

spl'

Cia

lise

s as

IO

llg a

s h

e is

ful

ly i

ltfo

rlll

ed o

f th

e" v

aili

f'

o!

phys

iotl

H'1

ap

t'u

t it:

IIlI

'th

od

s am

i of

th

e ci

rcu

llls

tan

ces

wh

ere

they

;\1

('

ind

icat

ed.

All

op

en a

ttit

ud

e t

ow

ard

s re

ferr

al b

etw

een

ch

iro

pra

cto

rs a

lld

p

hy

sio

ther

apis

ts

is

Ihe

bes

t sa

feg

uar

d ag

ain

st a

ny

dif

ficu

lty

th

at

lIlif,

;t.1

~~

( . I

:1. ~anLial

Ih('

rap

y

in

the

han

ds

of

ph

ysi

oth

erap

ists

, it

is r

xp

lair

)(',

I. ~es

tr{'

aln

len

t lo

r th

e ex

trem

ity

jo

ints

, n

ot

just

th

e sp

ine.

T

heil

p

ract

ilim

lc, S

off

er a

to

tal

rnu

scu

lo-s

kel

etal

th

erap

y,

wh

erea

s, i

t is

c1

aim

!'d

. ~h

il'l

)pra

ctor

s are

lim

ited

to

th

e sp

ine,

\V

e h

ave

alre

ady

sta

ted

th

at

cu

rren

t ch

iro

pra

cti

c

cou

n,e

s p

rov

ide

ad

eq

uate

tr

ain

ing

in

ex

trem

ity

jo

illl

p

roce

du

res

(sec

ch

ap

ter

38).

T

here

is

1

10

le

gal

im

ped

imel

1t

t"

ch

iro

pra

cto

rs

tre;

llin

g e

xtr

emit

y j

oin

ts,

an

d

man

y d

o.

14.

Ph

ysi

oth

erap

ists

are

co

nv

ince

d o

f th

e v

alu

e of

m:l

Ilip

ul:

Jtin

n a

.,. I

arg

ll('

st

roll

gl)

, in

it

s fa

vo

ur.

H

ow

cv

er,

.\S

CC

;,D

Q

nee

d.

fQl'

un

dl;

('

. so

ph

isti

cati

un

int

hi~

tieJ

.~' "I

t is

ou

r sl

an

e

. ~","huien,·u!l~rm. A~

ii ~!~!P ......

. ljt>Si~lOlIld

no

t h

e al

low

ed

to

hcco

rJIl

' sh

rou

ded

ill

II

l11l

t'ccs

silr

y so

ph

isti

cati

on

wh

ich

lea

ds

to o

ver

clai

m i

nev

itab

ly a

nd

thi

., I

, p

arti

cula

rly

so

wil

h r

egar

d t

o t

ed

llti

qu

es"

(T

ran

scri

pt,

p.

13

(4).

Cle

arl

\'

t/re

rc

are

tw

o

dis

tin

ct

an

d

stro

ng

ly

hel

d

pu

iuts

01

v

icw

: th

at

of

tlte

p

hy

sio

ther

apis

t an

d

that

of

the

chir

op

ract

or.

I S

. T

he m

anip

ula

tiv

e th

erap

ist

lear

nin

g h

is t

ech

niq

ues

as

he

do

es i

ll a

Ir

agm

ente

d f

ash

ion

, fi

rst

ver

y s

ket

chil

y a

t a

ph

ysi

oth

erap

y s

cho

ol,

th

ell

ill

a ('

ou

rse

SPI c

ad o

ver

3 Y

C<l

rs o

r m

ore

in

sm

all

sect

ion

s, c

on

tell

ds

that

wh

d.·

p

ract

ice

is c

ssen

lialt

here

is

lill

ie p

oin

t in

ov

er-r

dil

ll'l

llC

llt

of w

hat

i~

0111

" I

slri

(~ll

y li

rnit

c'd

ran

ge uftcchlli(!,Jes"e~~~i~p'~~ct~r.on (h~()!her han~j.

;'~~

:;;~

rt;;

;;]t

~ft~

n~tu

~.a·

··~~

ft~k

~the

o.~i

~~~;

· \l

CY;h

te.y

~Uef

ore

lle

use

s th

ese

tech

ruq

ues

, u

nsu

per

vis

ed,

on

lii

spall

en

ts,

i'il

usi~

wlth

ftl

l'!lw

r p

racti

ce g

ive

him

a g

reate

r ~b

ilit

y to

hel

p t

ho

se p

atit

;llt

s.

~*!f$Ll}L~sn~~ .~ .. ,b;e.qc:J1.}l~ ~~

i~I~

(:a~

('~1

]:U~;Sp~!\p":

fG.J

t IS

dan

llt'

('f

llia

idu

rop

racto

rs o

ver

-rel

i'il

e n

Ick

sTul

l. A

t tl

te s

alll

f'

lill

ll'

it

is

allt

-gcd

th

at

thei

r te

chn

iqu

e co

nsi

sts

mai

nly

of

the

"dy

nam

ic­

thru

st".

T

his

is

cl

aim

ed

to

be

dan

gero

us

bec

ause

it

is' a

su

dd

en

hig

h­

\'d

ot:

ity

1l

l0V

('IIW

llt,

Ihe

pati

en

t can

no

t se

e w

hat

is

bei

ng

dO

lle,

Cal

l1ll)

1 r(

';.is

t th

e th

rlls

t, a

lld

is

ther

efo

re a

t th

e ch

iro

pra

cto

r's

mer

cy.

Un

til

tl ..

. (:

oltl

llli

s~io

ll s

aw c

hir

op

racto

rs a

t w

ork

it

imag

ined

fro

m s

uch

descriptioll~

IIla

t Ih

is

wa

s

tlil

' o

nly

w

ay

Ihe

ch

iro

pra

cto

r o

pera

ted

w

hil

e th

,.

ph

ysi

oth

era

pis

t/m

all

ipu

lati

ve

ther

apis

t w

ith

h

is

gel

ltle

d!f

ti~l

a~)I

I-t •

. ex

ten

sio

lls,

or

Ilio

hil

i\al

ioll

s w

as I

I \,

IT}

' d

iffe

ren

t pra('tiliOlI!'r=TI~

tr&

fh ~,

that

wh

ill'

th

e '€

1.ti

~lU;

e(l~

l,.~

~!.;

;. .. r

~,A!

!d~;

.~~A

A:~

." . "

ilk;;.

pC

! hap

s Il

IOH

' S

II

Ihan

tJlI)~la-ilipuiati'f.e t

rler

apls

i,'?

Dle

ar

c-al

~r.

usu

ally

~ma

ll ~nq

.. Drc(;i~~·

.' T

he

mo

st f

orc

efu

l m

anip

ula

tio

ll

w

aw ~rr

e.;.

""

t~t'

=···

~·~"

''''

''''

'''

I .

. ~

pcJ

ioll

lle(

J)

Y II

ILln

ll'II

1a 1

\'('

t

lera

plst

'>.

t ;:J::>

1.7 ..

'. \. '.

h .. i.I

I.' 11 ..

lt' ...

. l'h)

.<;i

fllh

t'rap

iSls

a~ser

tcd th

at ..

pat

if'I.

lt. ~ a

. r.I'

\I

a .

I1I1

"t:'

,1

1\ ~,~

:fr'~f

!::al\

{~~ . .!~

~~~~

i!!W

jtD I

,>y d

liro

.1Ia

.((O

!<;, ~i

gt;!

1~ j

t 'I

ll.

war

1I,il11!j~li&!?H

tJl¥X¥lY~ali(rwe f

tnd

thal.l~l~9.Pf!~~!!·~

"'"

.

f .

,.(i

t l'

ltaj

ltn

l!tf·~\t'l'i{tZ~T'lt) n

idcll

l'('

wh

it'

v·()

\iI'

tlju

stif

y iis

-,it

I(~'I

(,(J

llcl

llti

ed "

inv

;li

luu

t ti

lt'

safe

ly o

f sp

inalm

all

ual

ther

apy

('

I'l'

lict

ilin

lln

s Il

ther

th

all

ch

iro

pla

cto

rs,

It i

s as

ton

ish

ing

hn~l.

_ Ilf

th

e p

njc

Tlc

d

tI'C

hlli

'lllt

':-i

,HC

w

ho

ever

th

e practitioners~ ...

.. e. ~j) t\t

'I~

IIH

li'(

' <

,s.to

llis

hi,.l

g h

ow

IIl

laW

are

lh

ey ;

rre

of

this

sim

ilari

tyl 'w

e\le

~whi

le

nt"lW

iir,H

f a **

'1ph

ys~i

II.r

,pi"

lld

_al .t

1lilJr,,

'ho

iii

II

SB 31

SENHi [ HU\UH & W£LFARf EXHIBIT ~:O . ....... /f-£..I ___ _

DATEt--~/--?-/.~~_-~1-7-BILL NO._;l..,.L-II(3-'-... ..3"'"'-+-,-

ALLOWING DIRECT PATIENT ACCESS TO PHYSICAL THERAPY

TESTIMONY IN OPPOSITION OF THIS BILL BY:

MONTANA ASSOCIATION OF HEALTH UNDERWRITERS

MONTANA ASSOCIATION OF LIFE UNDERWRITERS

PREPARED BY:

MARIE DEONIER, Registered Health Underwriter (RHU) President, Montana Assocation of Health Underwriters Chairperson Health Insurance Committee,

Montana Association of Life Underwriters Member Legislative Committee, Montana Association

of Life Underwriters Legislative Chairperson, Montana Association of Health

Underwriters

As claimsd are paid for "medically necessary care" it is our feeling that this bill will jeopardize claims payment to our clients covered by the majority of health insurance plans written within the United States.

MEDICALLY NECESSARY CARE is defined as "any confinement, treatment or service that is prescribed by a physician".

Therefore, if there is direct access to the physical thereapist without having this treatment first prescribed by a physician the claim for treatment would more than likely be denied.

Therefore, on behalf of the many persons within the State of Montana who are covered by health insurance that could suffer refusal of claims payment due to this legislative action we recommend that this bill NOT BE PASSED.

~--~

~C7r:~:ejJrJ/~ MARIE DEO~ ~ MD/mp ,'-

, "

WITNESS STATE!-1ENT

DAVID UCKHAN

ADDRESS 1400 Winne Avenue Helena. MT 59601 443-349/.}

., 1'- .. _i"U H & Wt.LFARf

.. ,\~lliJi i :W. -t,,£/-,<"'c----DATE /- L'b"... £ 4: BILL NO~ Ii C3 '3 I "

SB 6 BILL NO.

1/16/R7 DATE

WHOM DO YOU REPRESENT? Hontana Public Health Association

SUPPORT xxx OPPOSE AMEND

PLEASE LEAVE PREPARED STATEMENT WITH SECRETARY. SB6 Requiring Hospital Ad~inistrator to request anatomical gift. (Lybeck) 1/16/87 Senate Public Health

Corrunents: 1:00 P.M. Room 410 10 There is an acute shortage of organs for transplantation; especially

kidneys •. Recently a priest in our diocese died because a kidney was not available

when needed. His condition deteriorated until it became too late for one •.

2. The cost. to medicaide an1 medicare. of the kidney dialysis program is

approaching two bi1lion rlollars per year. Incrp-asei transplantations would low~r

this cost dramat:cally.

We consider this to be :J:'Rtinhx:p.x dpsirpable lpl!isla~,ion. It would rpsult

in ~aking people more a~are of the nep-ri for or~ans.

CS-34

"'.;.". j t IitAUH & WiLfARE £"H:u., ;!'J / 2--- ~ . DATE __ -~--/h -)= '/7 BILL ~''1 __ 3 P; '5 /

;

DEFINING PUBLIC HEALTH

During the 1983 legislative session, I was asked to define public

healthi especially the role of the laboratory. Some legislators

wondered where I would next appear. They were f2:'jJt!..d1 f

confusedi.

when I promoted the public health laboratory. My first

involvement in this field was in 1929. After 55 years of concern

in the field of public health, perhaps my testimonials were

somewhat overdrawn. Now, I have again been requested to define

public health- so here goes:

PUBLIC HEALTH is the art and science of preventing disease,

prolonging life, and promoting physical and mental efficiency

through organized community effort. This concerns the physical,

social and economic well being of all persons. Of prime

importance in this effort is the PUBLIC HEALTH LABORATORY.

Virological, bacteriological, serological, and physical science

testing is done for the prevention and control of communicable

and other diseases.* Chemical, radiological, and microbiological

testing is also done to assure the safety of water, air, and the

physical environment.

* e.g. hereditable diseases

A more detailed discussion of public health may be found in:

Encyclopedia Brittanica, 15th edition 1974, Macropedia V. 15

pp 202-209

David Lackman, Legislative Lobbyist, Montana Public Health

Association. January 19, 1983 - reprinted February 26,1985