Michigan PTs oppose chiropractors prescribing physical therapy

​Michigan chiropractors support a bill (House Bill 4712; more information here) allowing them to prescribe physical therapy for their patients. Physical therapists oppose the bill, along with medical doctors, as well as business and insurance interests, who are concerned about costs.

Current law allows medical and osteopathic physicians, dentists and podiatrists to prescribe physical therapy for patients. Patients can also directly access physical therapy, without a prescription, if limited to 21 days or 10 treatments.

According to a legislative analysis, chiropractors argue that, if they feel a patient needs a prescription for physical therapy, under current law they must go through a physician or other provider with prescription privileges. But physical therapists argue this is as it should be. Chiropractors do not have adequate education and training to fully assess a patient's medical needs. A visit to a physician permits a thorough examination and diagnosis of the patient's bio-medical issues and prescription of an appropriate treatment. For example, the physician may determine that the patient's problem really requires drugs or surgery, not physical therapy. And only physicians and similarly trained professionals are competent to decide this.

And, the PTs argue, it is not true that patients must go through another provider. If a chiropractor feels a patient needs physical therapy, he can already refer the patient for evaluation and treatment without going through an MD, DO, DPM or DMD/DDS, because of the patient's right of direct access to physical therapy.

The PTs note, in a letter to legislators, that Medicare, after extensive review, determined that a chiropractor cannot approve a PT plan of care for a beneficiary. And they are worried that the bill would give chiropractors an unfair advantage in a competitive market for treatment of musculoskeletal issues. They don't explain how this might happen, but I'd wager it's because chiropractors will market themselves as the first health care provider a patient should try and promise to send patients to physical therapy if they need it. But will the chiropractor ever decide the patient needs physical therapy?

I imagine there is a distaste among PTs for taking direction from a chiropractor. After all, PTs are part of the science-based health care world. They are educated at universities along with medical and allied health professionals and train in health care facilities, such as hospitals and rehab facilities. They work with physicians,dentists, podiatrists, nurses and other therapists (like occupational and vocational) every day. Chiropractors, on the other hand, are educated in small, independent schools outside the mainstream American university system. The vast majority of their training takes place in school-based clinics, where they see a very limited range of patient conditions. They rarely interact with other health care providers in their daily work.

Chiropractors also employ an entirely different diagnostic and treatment scheme than PTs and other health professionals. Michigan law defines the chiropractic scope of practice as

"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."

No other health care professional believes the chiropractic "subluxation" exists or that the human spine can become "misaligned," or that "detecting and correcting" these putative conditions can "restore and maintain health." How is the PT to react when a chiropractor, having diagnosed the patient as having a "subluxation," prescribes physical therapy? He or she will likely be as confounded as, for example, an orthopedic surgeon is when he looks at a chiropractor's indecipherable chart notes, with their mysterious markings of supposed "misalignments." They just don't speak the same language.

The PTs did mange to get the bill amended so that any prescription has to be in compliance with the prescriber's scope of practice. If the prescriber is a chiropractor, the PT is not required to accept a prescription that is "more specific than to treat and evaluate the stated diagnosis." We can only hope, for the PTs' sake, that the "stated diagnosis" is not a "subluxation."

The bill is now before the Michigan House of Representatives. Even if it passes there, it must still get past the Senate and the Governor.

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