Avenue Medical drives PT debate

DOVER, Del. - Adam Samuel's competition screamed “conflict of interest” last summer when he hired a physical therapist to run Avenue Medical's new seating clinic. Avenue Medical's Adam Samuel fits Hali Shiber, 6, for a standing frame. Avenue's PT, Lois Brown, doesn't just evaluate the customer's physical condition. She also recommends equipment, fits it and provides it. “It is controversial,” admitted Samuel, Avenue's president. “But ultimately, what happens is my clients get better service, better equipment and they get it quicker because they don't have to go through all these layers of nonsense.” From a business perspective, the new venture has been a great success. The company's rehab business grew 50% to 60% in 2003. The reason? Payers like the simplicity of dealing with one company, and they respect a rehab provider dedicated to raising the clinical bar, Samuel said. To many, however, the process, even if it's above board, appears dicey, even suspicious. “The therapist has a vested interest in that client getting a wheelchair because they are on the payroll,” said Nancy Lansing, marketing director for Connecticut Rehab. “We wouldn't do it.” Normally, a PT works for a hospital or clinic and serves as a referral source to HMEs. After evaluating a patient's physical condition, the PT suggests a prescription to the doctor, who generally signs off on it. The PT or doctor then refers the patient to the rehab provider who customizes the order to meet patient's specific needs. By evaluating the patient, recommending the equipment and then supplying the equipment, Avenue Medical appears to have a “captive” patient base, said Simon Margolis, vice president of clinical and professional development at National Seating and Mobility. “I applaud anyone who wants to provide better service, but if you are going to do it that way, don't be surprised if someone is going to be opposed to it,” Margolis said. “If his competitors had done it, they wouldn't be screaming.” When it comes to providing services in rural areas like the one Atlantic Medical serves, a different set of rules exist. Medicaid and some private payors understand that rural providers sometimes have to go outside the box to adequately service patients, Margolis said. Nevertheless, as a rule, to avoid the appearance of a conflict of interest, NSM doesn't employ PTs who perform evaluations. Neither does Care Medical Equipment, a larger rehab provider with eight locations in Washington and Oregon. “If the PT is working for the DME business, it looks like you are trying to spice up your game, and I don't want to be subjected to that,” said Tom Coogan, Care Medical's vice president. Lois Brown Samuel decided to hire a PT and start a seating clinic because patients in his rural area had to travel more than an hour to attend clinics in Baltimore and Philadelphia. What's more, when the clinics sent PTs to Dover, they came ill-equipped with only “a chair or two and would say, ‘Which one do you want? This one or that one?'” Samuel is well aware that Medicare, with its hyper-sensitivity to power chair fraud and abuse, wouldn't tolerate the business model he's set up. That's why his in-house PT doesn't evaluate Medicare patients. But Delaware Medicaid and private payors have embraced his one-stop-shop for evaluating patients, fitting and providing equipment. To avoid any appearance of a conflict of interest, Avenue pays Brown a salary - not a commission based on business generated. “Is this the wave the future? Probably not.” Samuel said. “I think you need to be in a market situation where you don't have access to an urban seating clinic. And this was a huge investment for me. To build the building, to have the personnel, to have the inventory - it is a major financial investment, but it is paying off.”