THE EFFECT OF 3RD-PARTY PAYERS ON THE CLINICAL DECISION-MAKING OF PHYSICAL-THERAPISTS

According to Freidson, third-party payers have eroded the political an d 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 skil led 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 physi cal therapists recognize Medicare criteria and view them as important. Twenty-five to 33% of SNF therapists recommend care based on the guid elines. 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 r ecommend care based on the guidelines may do so because of possible no npayment for services already rendered, or because they fear loss of t heir positions. The majority of Connecticut SNF patients who qualify d o receive therapy and Medicare coverage. Therapists may use their know ledge of the guidelines to secure services for their patients, or SNFs may be selecting patients that have the best chances for recovery. Li ke physicians, SNF physical therapists are under pressure from third-p arty payers to economize and rationalize, but most continue to secure services for their patients.