attention, scope of practice and other issues central to the practice of orthopaedics also emerged as legislative battles in the state capitols.

1. Scope of Practice

I. Direct Access to Physical Therapy

The American Physical Therapy Association continues to push for state laws permitting direct access to physical therapy services without physician evaluation or oversight.  Although the vast majority of managed care plans continue to require a doctor’s referral, the AAOS and the orthopaedic societies remain concerned about the potential for misdiagnoses, delayed treatment and complications resulting from this practice.

In Florida, HB 1165 & SB 19992 sought revise the definition of physical therapy and remove a provision from the law that requires patients to see a physician if physical therapy treatments exceed 21 days.  The bill died in Healthcare Council.  Virginia orthopaedists witnessed the passage of a similar bill (HB 2087) that will allow access to physical therapists without a referral under certain circumstances, but requires the physical therapist to notify the physician within three days of treatment and provide a copy of the patient evaluation and patient history.  In Oregon, Governor Ted Kulongoski signed HB 2386 into law, extending the time limit for direct access from 30 to 60 days. AB 1444, a California bill that would expand the definition of physical therapy was set for a hearing in April. Although the hearing was subsequently canceled at the request of the bill’s author, Assemblyman Bill Emmerson, officials expect it will be taken up next year.  The Illinois Association of Orthopaedic Surgeons took a strong stand on direct access this year, successfully opposing S1626, which was never reported from committee, effectively killing the legislation.  In a slight twist on the usual direct access challenge, Missouri lawmakers passed S577, a bill that grants an HMO’s ‘health care advocate’ the authority to refer patients directly to physical therapists.

II. Podiatry

The podiatrists have been working hard to expand their scope of practice under state law, seeking greater freedom to perform surgery and amputations above and beyond the foot.  Despite these aggressive efforts, the state orthopaedic societies have prevailed in several legislative fights this year.

The Massachusetts Orthopaedic Association testified against HB 2132 and HB 2269, which sought to redefine the practice of podiatry to include diagnosis and treatment of the ankle, allow podiatrists to operate on the ankle and to perform amputations on the foot and toes.  Thanks to the MOA’s successful lobbying efforts, the bill is not expected to come up again in this session.  New York is currently witnessing an even more contentious fight over this issue, with the introduction of SB 1443/AB 3168-A, bills that would grant licensed podiatrists the right to perform procedures on soft tissue to the knee.  In a win for Illinois orthopaedists, Governor Rod Blagojevich recently signed HB126 bill, prohibiting podiatrists from treating any pathology higher than 10 cm from the tibiotalar joint.

III. Chiropractors

The AAOS and state orthopaedic chapters have been highly successful in engaging state legislators in efforts to address concerns of physicians regarding the expansion of chiropractors’ scope of practice.

        Georgia SB 102 passed the legislature in the final day of the session, expanding the chiropractors’ scope of practice in that state. However, the Georgia Orthopaedic Society and others in the medical community effectively fought to repeal the most drastic provisions of the legislation, which would have allowed chiropractors to refer patients for diagnostic imaging, neurodiagnostic studies and laboratory tests. The section was removed from the final version of the bill. Two Arkansas bills (SB 145, SB 146) that would have enabled chiropractors to expand their practice services died in committee. In a positive move toward higher standards for alternative medicine, South Dakota lawmakers passed SB 20, which will now require a bachelor’s degree for persons applying for a chiropractic license.

2. Quality of Care

In an effort to improve patient care and reduce health care costs, many states are moving toward establishing more comprehensive, centralized data collection and reporting programs for both facilities and physicians. The AAOS supports those measures that provide patients with greater access to accurate information about their health care system without penalizing skilled physicians who choose to take on high-risk, difficult cases.

In Florida, SB 770 creates the Physician Workforce Assessment & Development Office within the Department of Health and requires each allopathic & osteopathic physician to complete a survey concerning the physician's practice as a condition of license renewal. The bill, signed by the Governor in March, will allow the state to better assess the state’s health care needs with the intent of attracting and retaining physicians. In a distinctly different approach to promoting quality of care, Governor Ed Rendell of Pennsylvania recently signed an executive order to implement quality of care initiatives focused on chronic diseases as part of the governor’s “Prescription for Pennsylvania” health care reform plan. The commission responsible for implementing the program will develop quality controls, including measures designed promote the use of evidence-based medicine in making treatment decisions. The AAOS and Pennsylvania Orthopaedic will be carefully monitoring the program to ensure that physicians are not restricted when making medical decisions.  A Virginia bill (HB 2583) that would have required physicians to report complications resulting from elective, outpatient surgical procedures, essentially sought to institute an unfunded reporting mandate. It was defeated in the House Health, Welfare and Institutions Committee. In Massachusetts, the use of physician profiles that measure practice quality has been expanding rapidly among the state’s insurance plans. The Massachusetts Medical Society filed a bill (HB 104/SB 653) to address inaccuracies in the collection, analysis and use of data to profile doctors that is currently pending. It also calls for greater public disclosure by the plans on the process by which physicians are rated, more input from independent medical sources, a requirement that physician ratings be risk adjusted and use a case mix component.

4. Liability Reform

Although liability reform no longer receives the attention it once did, states across the country continue to pursue reforms aimed at lowering health care costs and maintaining a robust health care workforce.

In March, Arkansas Governor Mike Beebe signed HB 2612 into law, amending the state’s Good Samaritan law to remove liability for physicians acting in ‘good faith’ rather than the previous standard of ‘acing as a reasonable and prudent person.’ The North Dakota legislature enacted HB 1333, making expressions of empathy inadmissible in civil actions; similar bills also passed in Hawaii (HB 1253) and Nebraska (LB 373). In Oklahoma, SB 930 was enacted, and it will extend coverage under the Governmental Tort Claims Act to health care providers who provide uncompensated care to the indigent. Pennsylvania Governor Rendell announced in July that the primary liability insurance level would remain at $500,000. The efforts of the Pennsylvania Orthopaedic Society and its coalitions to maintain the current levels helped prevent a 20% to 48% premium increase for high-risk specialty physicians according to the Rendell Administration.

5. Ambulatory Surgical Centers

The AAOS and state orthopaedic societies seek to promote the value of highly specialized, quality patient care available through single specialty hospitals. However, in many states, legislation intended to restrict the ability of such facilities to practice highly specialized medicine poses a challenge for orthopaedists practicing in these settings.

On Beacon Hill, the Massachusetts Orthopaedic Association was successful in defeating SB 1318, a bill that would halt any new construction of an ambulatory surgical center. However, a similar effort in Montana prevailed and SB 417, which extends a moratorium on the licensure of all new specialty hospitals from July 1, 2007, to July 1, 2009, was enacted in May. In Washington, Governor Chris Gregoire recently signed legislation (H1414) that will require extensive quality reporting by Ambulatory Surgical Centers, the establishment of a facility safety and emergency training program, including transfer agreements with other hospitals and the promulgation of regulations governing the use of anesthesia in such facilities by the Department of Public Health.

6. Physician-Owned Physical Therapy

Physician-owned physical therapy services (POPTS) are under careful scrutiny by policymakers following a 2006 ruling by the South Carolina Supreme Court that upheld a ban on POPTS, and the prohibition of POPTS in Missouri and Delaware. Although related legislative action was limited this year, the AAOS expects the issue to pick up in the 2008 session. 

The Montana legislature adopted a non-binding resolution (MT SJR 15) in April requesting the formation of a committee to study “changes in the health care delivery system, such as the development of physician ownership of health care facilities… that may affect the future and financial viability of Montana's health care delivery system.” In Alabama, S 178, the legislature enacted a bill prohibiting the Board of Physical Therapy from “promulgating any rule relating to licensure denial, suspension, or revocation, or from taking any disciplinary action against a licensee by virtue of certain employment arrangements, contractual agreements, or referrals by physicians.” This preemptive move represents a positive step for physicians as threats to physician ownership rights are on the rise.

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