Written by Wei-hong Chen.
Image credit: Manual Release Myofascial Release Physical Therapy by Needpix license CC BY-NC-ND 2.0
Physical therapists utilise non-invasive physical therapy as a means to restore, maintain, or enhance the physical function of patients or clients by mobilisation, exercise prescription, electrical and physical agents, etc. As deeper and further professionalisation has developed within physical therapy globally, physical therapists (PTs) have become “movement experts” in both medical and non-medical contexts, assessing patients and clients’ physical functional problems, setting therapeutic goals, and utilizing multiple physical means to reach it. Nevertheless, in Taiwan, people must interact with a severely restricted referral system in order to receive physical therapy. According to the 2019 survey from the World Confederation of Physical Therapy, in 79% of its member countries, (as Australia and Canada, and the UK,) PTs can provide services without supervision from a doctor. Taiwan falls into the minority of countries in which PTs can only operate under a Doctor’s orders. This restricted referral model is enforced in legal and medical systems, and as a result, the care quality of physical therapy in Taiwan has been seriously hindered.
In 1995, Taiwan passed the “Physical Therapy Act” which codified the subordinate status of PTs. According to the Act’s stipulations, only those who have had a diagnosis, referral, or an order from a doctor are eligible for physical therapy. Although PTs have to pass the most rigorous examination among all medical professionals, they still have no legal jurisdiction over their own work in Taiwan. The lack of business autonomy—whether one is authorised to determine their work content legally—is unusual for medical professionals in Taiwan. Indeed, midwives, pharmacists, and medical technologists all have full business autonomy. Furthermore, nurses, medical radiation technologists, and clinical psychologists have partial business autonomy as well.
According to official documents related to the 1995 act, the legislative purpose was “to fortify the rehabilitation medicine system by including physical therapists, which are physiatrists’ assistants (emphasis added).” This premise turned PTs into the “hands of the doctors” and has since profoundly shaped the division of medical labour by placing doctors in charge of “diagnosis,” whereas PTs are in charge of “treatment.” This has created a longstanding unequal relationship between the two professions, both in terms of actual power and status.
It is true that in the early stages when the professional system was being built, PTs were still mostly Doctor’s assistants. However, after more than 50 years of development since the first PTs were trained in Taiwan, the physical therapy profession has become much more independent and equipped with the various skills to assess patients and clients on their own. Since 2000, despite the limitations imposed by the new law, PTs have actively tried to develop their ability to diagnose and evaluate patients independently of doctors over the last twenty years. The “Taiwan Physical Therapy Association” has reformed the education and training system of PTs, to the extent that diagnosis and assessment have become significant elements of PTs academic and practical training. If the degree of autonomy should be proportional to the ability to diagnose, then PTs now deserve more power over their work.
Taiwan has a sterling reputation for having some of the most affordable medical care resources in the world as a result of the Nation Health Insurance (NHI). However, there are still many significant issues within the system for medical professionals. As part of the NHI payment system, physical therapy can only be reimbursed following a prescription from a physiatrist or five other medical specialists. Due to the point-value system used to distribute funding, rehabilitation clinics can receive more financial support for offering the same types of treatments that a PT would offer elsewhere. This system has also put PTs in conflict with physiatrists, who benefit from the point-value system. Physiatristsreceive more funding for self-allegedly making more valuable diagnoses than other medical specialists. This serves as an institutional shield for Taiwanese physiatrists, protecting them from market competition. Physiatrists receive more funding for making judgements that would often be identical to what a PT would make.
The NHI payment system leads doctors to prescribe physical therapy not on the basis of efficac for patients, but rather on the basis of efficiency (cost) for clinics. “Modality combo treatment,” which refers to a combination of electrotherapy, traction, and thermal therapy has been widely proven to be a low-value treatment, except when applying to certain forms of acute pain. Such treatment is no longer recommended in medical guidelines set by different countries. Nevertheless, the profit structure created by the NHI reimbursement system has meant that modality combo treatments continue to play an outside role in Taiwanese clinics, and especially in rehabilitation clinics due to the disproportionate point-value of modality treatment. According to a recent special report from United Daily News, 85% of people suffering from neck pain or back pain are still receiving this type of low-value treatment.
Regulated by the Act, PTs are thus meant to follow the Doctor’s “orders” rather than their own professional assessment; lured by the NHI payment system, doctors tend to prescribe modality combo treatment despite its proven low value. This dual institutional predicament has led to an emerging professional crisis in physical therapy. PTs who work in medical clinics often refer to themselves as “machine operators,” because most of their job is simply turning on and off machines. What is even more detrimental is the fact that these machines are known to be ineffective in treating patients. Furthermore, in order to seek higher professional autonomy, some PTs prefer working in private physical therapy clinics. In Taiwan, however, the Doctor’s order is still required for people who are wanting to visit private physical therapy clinics. It is thus hard for PTs to maintain enough regular clients to sustain a private clinic. Currently, there are only 341 physical clinics in Taiwan. Consequently, more and more PTs in Taiwan have simply changed jobs. According to the medical professional statistics, there are more than 10 thousand licensed PTs in Taiwan, yet only 6 thousand are practising, which means nearly 40% of PTs have left the field.
PTs provide more than just medical assistance. Although physical functional problems are the PTs’ primary jurisdiction, not all physical problems are diseases per se. Not only can a PT resolve the bodily pain of a patient, but they can also enhance the sports performance of an athlete. It is contradictory and restricting that a healthy person needs a “diagnosis” to receive physical therapy. Limiting PTs in the way the system currently does inhibit their ability to provide non-medical assistance. This has recently been noticed: in 2018, the Taipei government issued an enforcement rule (a complementary explanation to complete insufficient laws) that a healthy person can receive physical therapy without diagnoses. What we can infer from the enforcement rule is that there is an increasing need for pursuing higher physical performance and that this need does not necessarily derive from illness. People with this kind of needs should have the right to see a PT without a diagnosis.
Twenty-four years after the physical therapy act was passed, action was finally taken during 2019, in an attempt to revise the business regulation stipulations. The new regulation states that a doctor is not required if it is a non-disease-cure situation. What lies at the core of this conflict is the notion that the growing professionalisation of physical therapy has rendered the restricted model obsolete. The new changes were designed to help challenge the original assumption of PTs as merely the “hands of the doctors.” This amendment would make the situation easier for PTs. Moreover, it has granted them greater business autonomy in areas such as health promotion, preventing exercise injuries, and dealing with physical disabilities. Still, since the proposition of this alteration, it has thus far failed to pass the first parliamentary reading. This is due to the relentless pressure from medical doctor groups, who see an increase in the autonomy of PTs as an affront to their own authority.
The current status of PTs is the direct result of decisions taken a quarter of a century ago. These were decisions that ultimately limited the profession to a subordinate role. As PTs have actively worked to increase their own assessment ability, and as the medical needs of the Taiwanese public have changed, we should re-examine the legitimacy of this regulation. PTs are now capable of treating patients or clients independently but lack the legal authority to do so. Hence, work needs to be done to allow PTs to be more independent of medical doctors whilst still ensuring a reasonable amount of medical labour. This will be best not only for the development of physical therapy and for PTs themselves, but most crucially, it will be the best way to improve health outcomes for the Taiwanese public.
Wei-Hong Chen graduated with a Masters degree from the Department of Sociology, National Taiwan University, where he now works as a research specialist. His research focuses on the medical care system and its quality, especially in terms of chronic illness treatment.
This article is part of a special issue on Challenges to Taiwan’s medical system beyond COVID-19.