The Promoting Integrity in Medicare Act was reintroduced again this year in the US House of Representatives. This bill seeks to exclude Physical therapy from the Inter Office Ancillary Service Exception on the Stark Law (IOAS). Although this bill is well intentioned, I feel it does little for Montana and other rural areas.

The Stark Law was written to stop referral for profit, and decrease overuse of medical services. The original Stark legislation was passed by congress in 1995. There were many exceptions to the original Stark law, including IOAS. This was created to allow for same day services to be provided in a physician office as a convenience for patients. In effect this allowed physicians to have ownership in physical therapy practices within the same facility as the physicians. While the intent may have been honorable, a GEOstudy found that only 3% of all scheduled physical therapy visits were on that same day as those of a referring physician visit.

The IOAS has lead to overutilization of treatments, not just in PT, but also in other ancillary services including clinical labs and imaging. The Alliance for Integrity in Medicare (AIM) coalition was formed by professional organizations to promote and support this legislation, and APTA is a member of this coalition.

Unfortunately, as important as this legislation is, the rural exception to the original Stark law was left intact. Section 2.(a) 17 states “the exception to the ownership or investment prohibition for rural providers in the “Stark” rule is not affected by this legislation.”

What this means is that the proposed legislation only effects metropolitan areas. So sorry Bozeman, Kalispell, Darby, and Havre. Integrity defined by this legislation is only for the big cities. The rural exception was initially intended to make sure that rural areas had ac-cess to medical services. This may have made sense in 1995, but I feel it is no longer practical. PT departments are thriving in areas outside of metropolitan areas. And alt-hough there are a numerous shortages of physical therapy services in some rural are-as, physician owned parties are not helping to fill the gap.

So why is the rural exception safe? No one has been able to answer this ques-tion. It is not mentioned in any of the APTA publications supporting this legislation. It is not mentioned in the AIM publications. When the question has been brought up, and it has been many times to the APTA , the response has been vague at best. “We’ll get back to you”, has been the battle cry, but my phone isn’t ringing. My best guess is that this is being left in place as a compromise to those legislative areas that are rural or micropolitan to garner more support.

Politics are full of this type of arrangement. But with this compromise, rural and micropolitan PT’s are being thrown under the bus in hopes that a watered down bill might pass. But if it is integrity that we want, then it needs to include all providers of ancillary services. We are physical therapists. We should not be defined by the popula-tion of a town we chose to live in, by our gender, sexual orientation, religion preference, or skin color. If it is good legislation, then it is good for all of us.

Let’s have a discussion on the merits of this legislation not for a few, but for all PTs. And let’s not allow national endorsements to hide the fact that this legislation is not for all PTs. This needs to be heard in all rural states and regions. Rural means small, but we are an important part of health care from border to border. And if APTA chooses to continue to support this legislation as it is written, I believe they need to get rid of the word integrity - it doesn’t fit.