INTERNATIONAL PRIVATE PHYSIOTHERAPY PRACTICE: ARE WE MORE THE SAME OR MORE DIFFERENT?Tim
Worldwide a large proportion of physiotherapists work in the private sector, but very little is known about the differences and the similarities of the organisations within which they practice and the driving forces affecting this sector. It is important to understand these factors and how they influence the quality of services and patient outcomes.
Individual practitioners, owners of private physiotherapy clinics and professional organisations might be of the opinion that their own or national situations or challenges are unique. However, the situations, challenges and driving forces might be named or termed differently in each country but the similarities and the effect thereof on the individual members countries are striking.
The term for our profession differs in different areas, it may be termed Physiotherapy, physiotherapy or kinesiology but in essence that is still the same profession. At the 2015 Graham sessions in the USA it was said that globally we might be a profession with an identity crisis. Globally physiotherapists find it difficult to effectively describe what we do. Physiotherapy is not a list of physiotherapeutic interventions, it is not ultrasound, massage, exercises and rehabilitation. Those are just tools used to achieve a goal. What make them “physiotherapy” is the fact that a physiotherapist is using them—not a medical doctor, not a patient nor a nurse. Currently the perceived value of physiotherapy lies in the tools we use and not it the professional using the tools. The phrases we use “We are going to do physiotherapy” or “a patient is referred for physiotherapy” perpetuate this problem. This problem doesn’t seem to exist in other healthcare fields. Nobody say that they are going to do “dentistry” when going to the dentist. The difference in phrasing is important, because it places the value on the person providing the service—and the customer’s relationship with that person—instead of the tools used during the service.
Although many physiotherapists worldwide have direct access status the previous referral system has created a sense of dependence on medical doctor’s orders. Physiotherapists are finding it hard to break free from that invisible lock to patients and autonomy of treatment. Direct access to physiotherapy and autonomy of treatment by physiotherapists will reduce the medical dominance to the benefit of patients and maintain professional dignity.The result of the non-referral, delayed access to treatment and managed care tools are increase medical cost due to unnecessary tests and medication and the possibility of preventable complication.
Internationally health care systems are under economical strain due to various factors: An aging population, global warming-leading to naturally disasters and health issues, increase in terrorist’s attacks and regional wars resulting in an increase demand on the health care system. All of this is a threat to the sustainability of health care systems, whether it is state funded, privately funded or a mix of different funding systems. Health care competes with other sectors of the economy in for a share of government spending. There is a constant trade-off within policymaking in deciding how resources are allocated to different sectors of the economy. The scarcity of resources means that there are not enough resources to satisfy all human needs. The concept of health care cost is very important in policy and decision making towards a sustainable effective, efficient and equitable health system. Economics deals with evaluating and choosing among alternative courses of action and examining the costs and consequences of the alternatives. This concept could largely affect how health care is funded within the economic constraints of countries. Hence, when it comes to providing health services, the rule that the person with the purse make the rules applies. While this may be the unfortunate reality, exploring alternative re-imbursements models, while balancing priorities and the needs of various stakeholders is essential. Different physiotherapy private associations are currently facing this issue where they are negotiating and considering global, fixed fee, network arrangements and/ or outcome based re-imbursement models on behalf of their members. In many instances these negotiations are not done on an equal playing field as third-party payers and other external role-players often have access to billing data that the professional associations don’t have. Important decisions affecting the business of the private sector physiotherapists are made on billing data alone and not on outcomes and clinical data.
Worldwide healthcare professionals are confronted with a range of ethical and regulatory issues in today’s ever-changing practice environments. Doing what is best for the patient is often influenced and, at times, compromised by external factors, including rules and regulations associated with third party payment systems. Funders have established conditions of participation and economically driven regulations, such as payment caps, pre-authorisation of treatments and cutting of non-essential services that may affect patient care outcomes. Providing optimal care for a given patient may be compromised by limited benefits. Ethical issues may confront practitioners that can create dilemmas between what is and what should be. These limiting factors contribute to the economic burden of already overburdened health care systems due to a fragmented health care system. Globally the aim should be to get the right patient to the right health provider at the right time.
According to Colgan A, 2002, the drive and push by the World Bank and IMF towards privatization of health care may not always be positive. She states that “the privatization of health care in Africa has created a two-tier system which reinforces economic and social inequalities with devastating consequences for the poor. Throughout Africa, the privatization of health care has reduced access to necessary services. The introduction of market principles into health care delivery has transformed health care from a public service to a private commodity. The outcome has been the denial of access to the poor, who cannot afford to pay for private care. For example; user fees have actually succeeded in driving the poor away from health care while the promotion of insurance schemes as a means to defray the costs of private health care is inherently flawed in the African context. Less than 10% of Africa’s labor force is employed in the formal job sector”.
Although there might be some differences in physiotherapy culture, education, funding models and regulation there are many more similarities than differences.
In my opinion all physiotherapists are passionate about their profession, caring about the needs of their patients, have lots of patience and are not driven by professional or financial status. They can also be stubborn, set in their ways and reluctant to change without clear reasons, evidence and directions for the change. At times we are not good team players and are reluctant to share knowledge resources and experiences with other physiotherapist and health care providers. Physiotherapists often tend to reinvent the wheel when facing with finding solutions, rather than asking for advice, assistance and learning from others who have walked that path previously.
In a changing health care environment with a plethora of external driving forces, collaboration between professional physiotherapy organisations and individual physiotherapists by means of sharing of knowledge, experiences and resources, will enable the profession physiotherapy practice to prosper, nationally and internationally to the benefit of all.
Physiotherapists and the practice of physiotherapy are more the same than different worldwide, lets embrace it.
- 2012 IPPTA Data Collection Survey. IPPTA GM 2012.
- 2017 IPPTA Fee Bench Marking Project. IPPTA GM 2017,
- Are PTs Facing an Identity Crisis? Here are 5 Takeaways from the 2015 Graham Sessions.WebPT; https://www.webpt.com/blog/post/are-pts-facing-identity-crisis-here-are-5-takeaways-2015-graham-sessions. (2018/02/01).
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- Colgan A, 2002. Hazardous to Health: The World Bank and IMF in Africa. Africa Action, April 18, 2002. http://www.globalissues.org/article/588/global-health-overview