The Relationship Between Physicians‘ Ownership of Physical Therapy Services and Referral Patterns to Hospital-Based Outpatient Rehabilitation Centers

Background and Purpose A debate over the practice of physician self-referral has been ongoing in health care since the 1980s. At issue is the practice of physicians who refer patients to facilities in which they share a financial interest, a phenomenon known as referral for profit. Physician investment or ownership interest in ancillary (e.g., physical therapy) services has been shown to have an impact on utilization rates, costs, access to care, and quality of care. What has not been identified in previous research is the influence of physicians‘ selective referral on competing clinics, particularly the hospital-based outpatient centers that share their health care markets. The purpose of this research was to examine the relationship between the emergence of orthopaedic physician owned physical therapy services (POPTS) and changes in physical therapy referrals made to two groups of not-for-profit, hospital-based outpatient physical therapy (OPPT) centers in one health care market. Methods This study examined the referrals made by orthopaedic physicians to two large hospital systems in the Orlando, Florida, outpatient physical therapy market between 1999 and 2007. This study was conducted using existing proprietary databases maintained by the Orlando Regional Healthcare System (ORHS) and Florida Hospital System (FHS), as well as phone surveys conducted by the primary investigator. Information regarding the orthopaedic physicians‘ ownership status and the patients‘ payer types was combined into analyses to determine if physician status was related to the number of physical therapy patients from each payer type referred, or the number of total referrals made to the hospital-based outpatient physical therapy facilities. Comparisons were made between physicians who became owners of physical therapy services during the study period and physicians who never became owners of physical therapy services. Mixed Linear Models (MLM) were used to test for the effects of physician ownership and the combined influence of physician ownership and payer type on referrals for OPPT. Point estimates and 95% confidence intervals were calculated for the mean differences between Group 1 and Group 3 physicians for changes in OPPT referrals over time. The analyses were conducted first with samples of physicians who met a minimum criterion of ten referrals within the first year of data included in the data sets. Use of this criterion resulted in a small pool of physicians who qualified for inclusion in the testing. Data were compared between years 1 and 5 and then between years 1 and 2 versus 4 and 5. The criterion for physicians‘ inclusion was revised for post hoc analysis in an attempt to increase the sample size. All of the statistical tests were repeated in post hoc with the larger samples of physicians who met the minimum criterion of an average of ten referrals per year for years 1 and 2 rather than just the referral count for year 1. Results Overall, there was no statistically significant change in the total referrals as a result of a change in physicians‘ ownership status. Tests for the influence of payer type, physician group, and ownership status on referrals also revealed no significant differences between the two physician groups. Point estimates of the differences between Group 1 and Group 3 for changes in mean referrals supported the hypothesized relationships between physicians‘ ownership status and total referrals, referrals of commercially insured patients, and referrals of underinsured patients; however, the 95% confidence intervals for the point estimates were consistent with the non-significant MLM results. The hypothesized relationship between POPTS and referrals of Medicare patients was not supported in any of the analyses. In post hoc testing of the combined influence of payer type, physician group, and ownership status on referrals, a three-way interaction between physician group, payer type, and status was found (p=0.034, α\u3c0.05). Including a larger sample size in the post hoc analyses led to outcomes that were different than those seen in the initial statistical tests. Conclusion This research outlines a novel approach to analyzing the influence of physician ownership and payer type on referral behaviors. The findings suggest that physicians‘ ownership of physical therapy services was not a predictor of their referrals to hospital-based OPPT services. Specifically, there was no significant effect of physician ownership of OPPT services on the total volume of referrals made to two hospital-systems‘ OPPT clinics. There also was no significant relationship between physician ownership, payer type, and referrals made to the hospital-based clinics. The theory predicting that POPTS physicians would work to eliminate market competition by reducing referral volumes and retaining patients with more lucrative reimbursement for their own practices was not supported. However, post hoc analysis with a larger sample size provided some evidence that a larger sample may have revealed the hypothesized relationships between physician ownership, payer type, and referrals for OPPT. Future research utilizing larger samples and data tracking physicians‘ OPPT referrals from their origins to their final dispositions are needed to clarify the relationships between physicians‘ ownership of OPPT services and the referrals they make for those services

Bibbies, salinity and a question of balance

This book is designed to be used in conjunction with the manual \u27Salinity in the classroom\u27. Published with the assistance of Greening Australia Western Australia, Department of Conservation and Land Management, Department of Education Western Australia.https://researchlibrary.agric.wa.gov.au/books/1017/thumbnail.jp

Security of Tenure and Land Registration in Africa: Literature Review and Synthesis

In 1984, the Land Tenure Center embarked on a project to evaluate the experiences with land registration and tenure reform in Africa. The goal was to determine is African states been able to use tenure reform and land registration to provide greater security of tenure than was available through customary tenure systems. Donor agencies focused attention on the creation of individual freehold title, emphasizing the heightened security of holding, marketability, and access to credit under such tenure. National governments, on the other hand, were more concerned to see that land was used productively rather than merely accumulated for purposes of prestige or inheritance or as a hedge against inflation, and for this reason have tended to favor granting more circumscribed rights, such as leaseholds or rights of occupancy. This literature review and synthesis was prepared as part of an effort to increase very substantially our knowledge, especially on a quantitative level, of tenure and development relationships in Africa. The literature review is an attempt to gather in one place data about the diverse efforts at land registration and to describe briefly for each country the various registration programs that have taken place (if any), why they were undertaken, and what subsequent studies of these programs have found. Among other things, it will be seen that the intended benefits, and beneficiaries, of land registration have changed over the century or so since the first systems were put in place. In addition to these variations over time, there are also differences among Anglophone, Francophone, and Lusophone countries, differences that not only influenced the structure of registration systems established during the colonial era, but also continue to inform the kinds of registration systems adopted today.Land Economics/Use,

Aligning Instruction with Extension Professional Competencies for an Enhanced Undergraduate Extension Education Minor

This paper reports on a three-year initiative to enhance the undergraduate Extension Education minor at a state land-grant university. Specific initiatives to improve the undergraduate Extension Education minor curriculum involved (a) revising the Extension Education minor due to varied curriculum and faculty changes and (b) aligning eight Extension Education courses’ units of study with Extension professional competency domains. The described processes helped understand the Extension Education curriculum by mapping competency domains and showing which domains were and were not taught in the eight courses. A key recommendation is to incorporate the alignment of Extension Education curriculum and Extension professional competencies into the Extension summer internship program, among other uses. Furthermore, it is recommended that faculty engage in a similar effort to map college curricula to professional competencies to ensure that academic minors have a clear purpose in preparing students for careers

Outlook for potential third-generation immersion fluids

In a search for alkane candidates for 193 nm immersion fluids, several alkanes and cycloalkanes were synthesized, purified and screened to ascertain their absorption at 193 nm, refractive index and temperature dispersion coefficient in the context of the actual application. In general, cycloalkanes, and more specifically polycycloalkanes, possess a higher refractive index than do linear alkanes. Decalin, cyclodecane, perhydrophenanthreme (PHP), perhydrofluorene (PHF) and perhydropyrene (PHPY) are examined as potential second and third generation immersion fluids. The use of perhydropyrene, which possesses a high refractive index of 1.7014 at 193 nm, may be limited as an immersion fluid because of high absorption at 193 nm. Mixtures of cycloalkanes can lead to a higher enhancement of the refractive index together with a decrease on the viscosity. Exhaustive purification of the fluids is a critical step in determining the real absorption of the different fluids at 193 nm. Two simple purification processes of these cycloalkanes were developed that led to low absorption fluids in the VUV region. The possibility of forming the oxygen complex in aerated fluids was reduced by purging samples with argon or nitrogen. This easy elimination of the oxygen complex shows the weak bonding nature of this complex

Amplification of the Index of Refraction of Aqueous Immersion Fluids by Ionic Surfactants

In order to find new immersion liquids to improve the resolution of 193 nm immersion photolithography, we have attempted to discover aqueous system possessing an index of refraction greater than that of water using aqueous surfactant systems. The index of refraction (RI) of both cationic and anionic surfactant systems were examined in the presence of wide range of inorganic salts, and parameters such as size of surfactants, concentrations, and temperature were varied. The refractive index (RI) was found to be increased in the presence of both anionic and cationic surfactants compared to those of water and also increased as a function of surfactant concentration. However the refractive index tends to increase much more strongly as a function of salt concentration. In our study, a maximum RI enhancement was observed from 6.5 M CdCl2 in 8.2 mM aqueous SDS solution. The effect of micellar properties such as the critical micelle concentration (cmc) and degree of ionization were systematically studied for aqueous SDS system in the presence of CdCl2. The correlation on index of refraction between empirical data and theoretical prediction were performed using the concept of molar refraction. Wavelength dependence of RI from theoretical prediction based on empirical equation was examined for various concentration of CdCl2 system and the results are reported in the paper