Gatekeepers: If You Own The Keys, Learn To Drive Responsibly

First of all, I find it ludicrous that a physical therapist, in this day and age, requires a gatekeeper to decide when physical therapy is and is not necessary and appropriate. I’ve written about it extensively, and frankly it just evades the power of logic. I don’t tell an orthopedic surgeon when surgery is appropriate, nor do I tell them how to perform it. I don’t tell a gastroenterologist when surgery is appropriate, nor do I tell them how to perform it. And I sure don’t expect anyone other than a physical therapist to know when physical therapy is appropriate, or how to perform it. A pretty simple issue of professional autonomy, I’d say.

Of course, don’t tell that to a physician or osteopath or chiropractor. I might start sounding like some kind of uppity therapist that just wants to … do … his … job … in the context of his professional training and licensure. Sound familiar?

What makes it even worse is that if you are going to take on the role of gatekeeper, then darn well know your responsibilities in order to perform the task properly. If you are going to own the keys to the car, then learn how to drive that car responsibly. Sadly, this doesn’t appear to be the case in the vast majority of scenarios.

First things first: most patients are dumbfounded when they are told that they need a script for physical therapy treatment to be initiated. They invariably wonder “why do you need that from someone else?”. It is to the point nowadays that I smile, agree with them, and then just defer to the law as always. The law of the land is, well, the law of the land.

Most gatekeepers (and their office staff) don’t seem to know that they hold the keys to the car in the first place – or if they do, simply don’t understand the rules of the road.

They will tell you that your insurance plan doesn’t require a referral. Well, last I looked, the insurance companies don’t write the laws – at least not yet (though looking at campaign contributions, you would have to wonder). Your insurance plan doesn’t have any effect on the law whatsoever – and gatekeepers must be aware of this. The issue is not the payer source, the issue is the medico-legal ramifications. If gatekeepers are going to take on the responsibility of holding the keys to referral, then they also need to fully understand the laws underlying this.

If you are responsible for making clinical decisions, shouldn’t you know the law of your own state? And if you are the gatekeeper for another health care provider, wouldn’t it be simple common courtesy to fully understand the legal ramifications of this?

Of course, then there is the issue of not only owning the keys, but then understanding the rules of the road and choosing to drive responsibly (or not). I’ll bet that the gatekeepers never have an issue when they have a physical therapist working for them directly. Ahhhh, the sweet smell of self-referral and over-utilization. But that, my friends, is a whole ‘nother topic.

Photo credits: Wikipedia