The effect of third-party payers on the clinical decision making of physical therapists

According to Freidson, third-party payers have eroded the political and economic authority of medicine. To what extent is this also true for alternative practitioners such as physical therapists? The effect of Medicare's restrictive guidelines on physical therapy practice in skilled nursing facilities (SNFs) is examined. SNF physical therapists in Connecticut were surveyed (response rate 99%) using a mixture of open-ended and fixed-alternative responses. Results indicate that SNF physical therapists recognize Medicare criteria and view them as important. Twenty-five to 33% of SNF therapists recommend care based on the guidelines. Younger therapists, therapists with fewer years in the field, and contract therapists are more greatly influenced by the guidelines than older, more experienced, staff therapists (P < 0.08). Those who recommend care based on the guidelines may do so because of possible nonpayment for services already rendered, or because they fear loss of their positions. The majority of Connecticut SNF patients who qualify do receive therapy and Medicare coverage. Therapists may use their knowledge of the guidelines to secure services for their patients, or SNFs may be selecting patients that have the best chances for recovery. Like physicians, SNF physical therapists are under pressure from third-party payers to economize and rationalize, but most continue to secure services for their patients.