Direct Access to Physical Therapy Services
Direct Access to Physical Therapy Services
As a physical therapist in the great state of Texas, the topic of direct access is one that hits close to home. I absolutely love Texas; I really do. However, when it comes to access for patients to physical therapy services it really rubs me the wrong way for a number or reasons. Increasing cost to patients, increasing utilization of unnecessary services, lengthening duration of care, and failing to recognize the skill and education of physical therapists are a few that will be elaborated upon.
So what exactly is direct access? Well direct access is the ability and right to choose to see a physical therapist as a first line of treatment for neuro-musculo-skeletal injuries/conditions without the need for a physician referral.
In Texas, the current laws allow for a patient to evaluated but not treated by a PT. Essentially, the way this works is you could sprain your ankle/have shoulder pain/have back pain, and seek out an help from a PT. The PT could look at you and decide what all of your impairments are and what he/she feels would benefit you the most, but after that could not lay a hand on you or even give you any advice on how to manage the issue on your own without being in violation of the law. I would like to take this opportunity to point out that you can currently go and see a personal trainer, massage therapist, acupuncturist, chiropractor, rolfer, reiki practitioner, pilates instructor, yoga instructor, etc without a prescription. Yet, a Doctor of Physical Therapy that practices with direct communication to medical doctors and under the umbrella of health care supported by evidence based practice and research is off limits.
Currently all 50 states, D.C., and Puerto Rico all have some varying form of “direct access” to physical therapy. Over forty of these states have better access to Physical Therapy services than Texas does. Additionally PTs, or “physios” as they are called in the rest of the world practice, and have for years, as primary care providers for neuro-musculo-skeletal conditions in the U.K., Germany, and Australia just to name a few other highly developed countries. In fact physios in the U.K. have limited medical prescribing rights, order imaging, and even perform corticosteroid joint injections. Domestically, our own military in the U.S. has utilized PTs since the 1970’s (even long before the entry level degree was a Doctorate in Physical Therapy) as direct access providers as well as allowing for the ordering of diagnostic imaging.
If other countries and our own military are practicing this way, then why aren’t we? Believe me it isn’t because our governing bodies aren’t trying very hard. The Texas Physical Therapy Association (TPTA) works tirelessly through their political action committee (PAC) to move the profession forward in Texas. However, these efforts have been met with quite a bit of opposition from the Texas Medical Association and Texas Orthopedic Physician’s Association when attempting to bring up new legislation at the bi-annual legislative conference in Austin, TX.
When the legislation is brought forward (we will be pursuing this again for the 7th consecutive legislative session this spring in Austin) there tends to be two arguments from these groups as to why direct access isn’t the best idea for the medical system. Historically, one argument by the opposition is a matter of cost, stating that PTs will take advantage of the system and keep patients in therapy for much too long. However, it was found by Mitchell et al in 1997 that:
· ”Direct access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classified as physician referral episodes. There are several potential reasons why this may be the case, such as lower severity of the patient's condition, overutilization of services by physicians, and underutilization of services by physical therapists. Concerns that direct access will result in overutilization of services or will increase costs appear to be unwarranted.”(1)
Heidi et al. in a systematic review also found that:
· “Physical therapy by way of direct access may contain health care costs and promote high-quality health care. Third-party payers should consider paying for physical therapy by direct access to decrease health care costs and incentivize optimal patient outcomes.”(2)
Badke and Boissonnault found in 2014 that:
· “Direct access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classified as physician referral episodes. There are several potential reasons why this may be the case, such as lower severity of the patient’s condition, overutilization of services by physicians, and underutilization of services of physical therapists. Concern that direct access will result in overutilization of services or will increase costs appears to be unwarranted”(6)
Finally Pendergrast et al. found that:
· “Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00)”(3)
The next, and most common argument, is that “patient will seek treatment for back pain and they will have a non-musculoskeletal condition such as cancer, infection, abdominal aortic aneurysm, etc causing their pain that will be missed by the therapist. However, Physical Therapists are trained very well in the diagnosis of musculoskeletal (MSK) dysfunction, and are very good at determining non MSK issues. Additionally PTs are trained in medical screening for red flags that would indicate a more ominous underlying condition just as physicians are. Examples of this can be found in the following research studies.
Childs et al. found that:
· ”Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists”(4)
Additionally Moore et al. in a military based study (remember PT is direct access in the military) that:
· “findings from this preliminary study clearly demonstrate that patients seen in military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. The significance of these findings with respect to direct access is important for not only our beneficiaries but also our profession and the facilities in which we practice.”(5)
Finally, the follow up argument to this is that PTs are not allowed to make medical diagnoses, and they can’t diagnose cancer! I will agree with this statement. PTs cannot diagnose cancer from a physical examination. In fact, NO ONE can diagnose cancer completely from a physical examination. There has to be additional diagnostic imaging, bloodwork, and possible biopsy to make a diagnosis. Physicians have to first do a medical screening and take a history just as a PT would. Then, if something seems out of the ordinary they will send for imaging, bloodwork, etc. Concurrently, after recognizing any red flags the PT would refer the patient to their PCP to get additional workup leading to the same course of care.
I also want to point out that all PT schools in the U.S. are doctorate level programs that require their curriculum to include differential diagnosis/medical screening, pharmacology, radiology, and evidence based practice research courses. The PT of today is trained from the beginning of school to practice in a direct access environment. Not being able to do so restricts patients’ access to care, increases health care costs, bogs down the medical system with multiple unnecessary PCP visits, diminishes the way in which PTs can market their skills/knowledge to the public.
This is a topic I could continue to elaborate significantly on, but I will leave it relatively short, and end by saying that it is clear that PTs are adequately trained to be direct access providers, are safe, decrease cost, and decrease utilization of services. All of these points become that much more important as the scope of healthcare continues to change and as primary care physicians continue to have a shortage/become more overwhelmed.
References
1. Mitchell JM, De lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77(1):10-8.
2. Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30.
3. Pendergast J, Kliethermes SA, Freburger JK, Duffy PA. A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Serv Res. 2012;47(2):633-54.
4. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.
5. Moore JH, Mcmillian DJ, Rosenthal MD, Weishaar MD. Risk determination for patients with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther. 2005;35(10):674-8.
6. Badke MB, Boissonnault W, et al. Physical therapy direct patient access versus physician-related episodes of care: Comparison of cost, resource utilization and outcomes. PTJ-PAL. 2014; 14(3)
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