Learning Objectives
- You will be able to identify practices that interfere with your ability to keep your client’s best interests as the focus
- You will be aware of 3 common types of financial conflicts of interest that can negatively affect clients
If you look around the physiotherapy landscape in Alberta, you will find a variety of practice settings and business models. Some are more traditional while others are becoming innovative in how physiotherapy services are delivered. However practice sites are structured, failure to generate enough income can lead to business decisions that create an environment where the client’s goals and interests are secondary to the financial goals and interests of the business or the physiotherapist.
On occasion, the College will get a call or email from a physiotherapist, a client, or a funder that indicates that there are issues with business practices or the business model of a practice setting. In some cases, the College has seen business practices that undermine the registrant’s ability to meet the professional obligations established in the Standards of Practice, Code of Ethical Conduct, or legislative requirements. The Standard of Practice – Conflict of Interest states that
“The physiotherapist must identify and avoid, or manage any real, potential, or perceived conflicts of interest.”
The Standard of Practice’s intent is to highlight the expectation that the physiotherapist does not put their personal or financial interests ahead of the client’s interests.
Although any physiotherapist can find themselves in a conflict of interest situation, newer grads or internationally trained physiotherapists may be at greater risk of being caught up in these practices and may not realize the issue or the potential consequences of their actions. The goal of this article is to provide information to physiotherapists and practice managers as to how to meet the Standards of Practice and Code of Ethical Conduct and keep the client’s best interests as the focus.
Common Practices That Can Create Confusion
Group Classes
There are many reasons why group classes can be a great option to provide physiotherapy services. Group programs such as the GLA:D program have good quality research behind them and can create cost savings for clients and the health care system.
It makes sense that physiotherapists may want to try similar group programming with other groups of clients who have a similar condition and would be suitable for a group class. However, for those[LL4] classes to be considered physiotherapy they must meet all the Standards of Practice. The College gets many calls from clients, funders and physiotherapists to clarify whether their group classes can be billed as physiotherapy.
As we have spoken in the past, you must be able to meet the requirements found in the Standards of Practice to bill those classes as physiotherapy. Offering community yoga or Pilates classes do not meet the expectations in the Standards of Practice. Attempting to bill those classes as physiotherapy can result in negative outcomes for both the client and the physiotherapist. The physiotherapist can be met with sanctions or delisting from health insurance companies, face challenging conversations with clients who believe they were misled regarding the nature of the services provided and the profession can be cast in a negative light. Group physiotherapy classes exist because of the many positive effects posted in the research1,2 not as a source of revenue for businesses misrepresenting fitness classes as physiotherapy.
Misuse of PT Support Workers
The Supervision Standard of Practice and the Supervision Guide outline the responsibilities the physiotherapist has when they are supervising and assigning tasks to support workers. It must be clear that the physiotherapist is the one in charge of assigning tasks. Organizations must not be dictating how support workers are used and it should be clear that the client is providing consent to work with a support worker to achieve their goals. You can read this article, listen to this podcast, and view this webinar on the use of physiotherapy support workers in practice.
The College has also been contacted by support workers and physiotherapists regarding the supervision of support workers. In some of these contacts, it seems that certain practices were leaning too heavily on support workers to provide physiotherapy services and appropriate supervision was lacking. Below is a list of practices regarding the use of support workers that are unacceptable. If you have any questions, please contact professionalpractice@cpta.ab.ca.
- Clients not understanding that their care is being delivered by a support worker
- Not following the consent process and gaining appropriate consent for the support worker’s involvement.
- The organization directing the physiotherapist to assign care to the support worker, setting expectations for the number and frequency of physiotherapist-to-client interactions, or setting targets for number of support worker visits billed.
- Support workers making clinical decisions such as taking over exercise progressions and program changes without enough direction or supervision from the physiotherapist.
- Reassessments by the physiotherapist too far apart for the client’s condition, needs and goals.
- Support workers performing restricted activities such as removing acupuncture needles from clients.
Business Models
Another problematic business model is similar to the above in that it involves the use of support workers in a way that does not align with the expectations set out in the standards of practice. It is important to be aware that these models appear to be focused on accessing extended health benefits rather than providing high-quality physiotherapy services.
In the case of the use of support workers, the models will often involve having the physiotherapist conduct an initial assessment with further physiotherapy services delivered by support workers employed or contracted out by the business. In these practices, the physiotherapist may be incentivized or explicitly directed to provide assessments and then have all follow-up provided by support staff who then bill each visit as a physiotherapy service.
A significant issue with this model is that the physiotherapist is not able to meet the expectations found in the Supervision Standard of Practice. There is an inability to have appropriate oversight over the support worker or the opportunity to supervise them or assess their skills. The College has seen instances of this business model in clinics, fitness centers, and virtual care. The physiotherapist may work at several locations or can be limited to one practice site. Regardless, the business model creates a situation where the physiotherapist cannot properly supervise the services being delivered or play an appropriate role in the client’s care.
The College has previously addressed providing services such as bike fitting, personal training and golf lessons as physiotherapy services in order to access funding through extended health benefits here. The bottom line is that for a service to be a physiotherapy service it must meet all the expectations found in the Standards of Practice. It must also align with the definition of physiotherapy found in section 3, schedule 20 of the Health Professions Act. If a client came to you for assessment and treatment of dysfunction and part of the treatment plan included a bike fitting or strength work designed to address the pain, injury, disease, or condition then that could be considered as part of the physiotherapy treatment plan. If the client came to you wanting to increase their performance or shave time off their next race, then that would create significant questions around whether you are practicing physiotherapy, even more so if your involvement did not include an assessment, identification of a problem or problems, development of a treatment plan, and documentation of the services you delivered.
You will need to explain to the client that their assessment or treatment session is not physiotherapy and not eligible to be covered by their extended health benefits because it does not address pain, injury, disease or condition and does not meet the requirements of the Standards of Practice.
Equipment Sales Conflict of Interest Scenarios
Equipment sales can also create potential conflict of interest situations. Let’s look at June and Varun’s situation to discuss some common examples.
June is a physiotherapist who has recently been hired at a new physiotherapy clinic. She is treating Varun who injured his shoulder and is recovering from a recent post-operative rotator cuff repair. A few weeks into the program June suggests Varun needs a set of shoulder pulleys to assist with their range of motion.
- Denying access to equipment due to funding concerns
June has been told that since Varun is covered by a specific funder the shoulder pulleys are not to be sold to him. The owner told June that the funder does not allow them to sell the equipment at an adequate price to make a profit and the pulleys need to be saved for clients who are paying privately or through another funder that allows them to charge a higher rate.
2. Limiting client options to purchase equipment
Another scenario is that funding isn’t an issue and the clinic can make a good profit off of the sale of equipment. June has been told that she shouldn’t tell Varun where else he can get the pulleys and must instead get him to purchase the pulleys from the clinic so they can make a profit off of the sale.
3. Incentivizing the sale of equipment
The last scenario is that June has been told that she will earn a 20% commission from all privately funded equipment sales through the clinic. When talking to Varun she is pushing him to buy the pulleys through the clinic even though they are more expensive than at the pharmacy down the street. She does not tell him about other options available to him and is pressuring Varun to buy them.
In all the scenarios provided, June is facing pressure from the owner which is driven by financial conflicts of interest. First by placing restrictions on what the physiotherapist can provide to the client, second by pressuring her to not disclose where else the client can purchase equipment and lastly by incentivizing her to try and sell products carried by the clinic.
These are all situations where June’s professional judgment could be compromised or is for their personal gain. Varun’s best interests are clearly not a priority. If he needed shoulder pulleys to assist with his post-op rotator cuff repair but the clinic is unwilling to sell them to Varun, it creates a barrier to fulfilling the treatment plan. The other two scenarios create a conflict of interest for June facing pressure from clinic ownership and creating a financial incentive by being paid to sell products.
Regardless of the organization’s needs and wants, the client and their interests must be the priority. The Code of Ethical Conduct instructs physiotherapists to “act honestly, transparently and with integrity in all professional and business practices to uphold the reputation of the profession”. It is important for you to understand that your decisions and business actions can represent conflicts of interests and result in conflicts with clients and funders.
Action Items
- Review your practice and identify if there are areas of concern
- Does this group class meet all of the Standards of Practice?
- Is there appropriate supervision of support workers?
- Is this physiotherapy?
- What are the organization’s expectations about equipment sales?
2. Make changes to ensure that you are avoiding or managing conflicts of interest and avoiding situations where your professional judgment is, or could be, compromised.
References
- English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD007513. DOI: 10.1002/14651858.CD007513.pub3
- Malcolm, L., Mein, G., Jones, A. Talbot-Rice, H., Maddocks, M., Bristowe, K. Strength in numbers: patient experiences of group exercise within hospice palliative care. BMC Palliative Care 15, 97 (2016). https://doi.org/10.1186/s12904-016-0173-9
