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Direct Access: An Overview

Gatekeeper_2 Direct Access Review:
Direct access refers to the ability of a patient to access physical therapy services without a physician’s referral.  Currently, over 40 states have some form of direct access.  Each state’s interpretation of this is a bit different, ranging from states with almost no restrictions on direct access, to states where direct access exists by name only, not truly allowing physical therapist treatment for health problems.  Insurance reimbursement for direct access physical therapy is variable with Medicare most notably not reimbursing for physical therapy unless a physician’s referral is in place.

The rationale for direct access is one of consumer choice, reduction of the physician gate-keeper role, reduced costs, and improved outcomes through improved access.  Obviously, several parties are opponents to direct access, citing potential harm to patients and possible over-utilization of healthcare resources by physical therapists gone wild.

Is Direct Access Working?
When I was in school in the mid-late 90’s, quite a bit of direct access legislation was being pushed through state legislatures.  As a student, I was very excited.  What could be better than patient’s having easier access to my profession?  And, why is a physician’s referral needed anyway if I’m learning all these examination and differential diagnosis skills?  I looked forward to the day when the state I lived and practiced in approved direct access and I could really rock! 

Well, that day has come and gone, and I must say, direct access to physical therapists has not made much difference.  The vast majority of patients still come to physical therapists via physician referral.  One study investigating direct access in Massachusetts found that only 8% of patients were being seen without a physician’s referral.  The study cited practice limitations and lack of reimbursement as the primary reasons for this low number.  I would also add lack of consumer awareness of direct access to this mix as well. 

Though that study was from 1998, I would estimate that the numbers are still about the same.  With such small numbers of patients using direct access, I doubt that any of the proposed benefits to cost, access, or outcomes are being realized.

APTA Vision Sentence for Physical Therapy 2020

"By 2020, physical therapy will be provided by physical therapists who

are doctors of physical therapy, recognized by consumers and other
health care professionals as the practitioners of choice to whom
consumers have direct access for the diagnosis of, interventions for,
and prevention of impairments, functional limitations, and disabilities
related to movement, function, and health."

That is the vision statement guiding the physical therapy profession into the future.  Direct access is still a priority despite the lack of effect thus far.  The reasons physical therapists support direct access are noble ones (cost, patient access, consumer choice, reduced burden on physicians).  But why, if direct access provides a benefit to the healthcare system, has it not been more widely accepted and utilized?  Why are the barriers still there?

Upcoming Posts:

Over the next two weeks we will look at several aspects of direct access, asking some pertinent questions and examining some interesting evidence.  We will look at the case of a physical therapist from Philadelphia who is trying hard to expand direct access, and we will set forth some ideas about how, if it is justified, can direct access to physical therapists become more pervasive in today’s healthcare environment.

Let’s begin a public conversation about direct access.
ERIC

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Paying for a Bad Job?

"Trying to Save by Increasing Doctors’ Fees"

Here’s a new strategy to increase reimbursement:  do a bad job, for a long time, harm patients, act with disregard…get paid more!

The key to getting paid more is that everyone in the profession needs to do it, and patients must only be seen for brief moments and superficial interactions.

I’m making fun of paying doctors more to do a good job because it is easy to do, but some solid ideas exist underneath the apparent nonsense.  Paying for phone and e-mail consultations is a good idea.  Keeping better track of patients is a good idea, and does require more money (and probably a better healthcare "system" as well). 

I wonder, if this experiment succeeds, and that group of 5 doctors get’s to continue receiving an extra $300,000 a year to do a good job, how then can other professions likewise increase their reimbursement for doing a good job?

Looking ahead at NPA Think Tank

Over the next couple of weeks, NPA Think Tank will take on a couple of interesting topics:  Direct Access and Continuing Education.  Specifically, are physical therapists doing a good job of getting patients into their clinics directly, and is our current model of continuing education a dinosaur?  Stay tuned!

ERIC

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No Pens? Well at Least My CE is Free!

Classroom
Just as the AMA was celebrating the vote in their favor against a reduction in the Medicare fee schedule, the doctors across the nation now have to cope with this.

What’s a doc got to do to get a pen around here?! 

Small advantages like free pens and pads seem trivial, but they are part of the overall advantage physicians are awarded in the marketplace.  Among less trivial freebies is the fact that pharmaceutical companies fund most continuing education for physicians.  (That link leads to a good read in BMJ.)

It may seem like no big deal to require a certain amount of continuing education to maintain license when the courses are free…but for other healthcare providers, like physical therapists, (who are busy buying pens and paper on their own) the cost of continuing education courses can be overwhelming at $400 a piece.  Pfizer’s recent decision to stop funding courses for docs is a pretty big deal.

And then one begins to ponder whether or not continuing education courses are all that effective…

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Can the Wii Replace Regular Exercise?

ResearchBlogging.org

With Wii becoming all the rage lately, not to mention finding its way into physical therapy clinics everywhere, it’s important to realize that not much is know about the effects of using the Wii.  Some argue that it can be a replacement for traditional exercise, while others (me) argue it is not.  Well, the researchers are off and running, and some early data is already starting to come back.

A group of researchers in the UK measured energy expenditure while playing the Wii and compared it to similar sedentary video games, in this case, the XBOX 360.  Energy expenditure was measured using a system that estimates energy costs using sensors called the IDEEA (intelligent device for energy expenditure and activity).  The group studied was boys and girls aged 13-15 years.  They played Project Gotham racing on the XBOX, and Wii Tennis, Bowling, and Boxing.

Not surprisingly, the Wii resulted in greater energy expenditure than traditional sedentary video games.  The average increase in energy used during Wii-play was about 51% greater than when playing the "old-fashioned" video games.

But, when researched compared the increased energy expenditure when using the Wii to actually performing the activity the Wii came up short.Wiienergycosts_2
 

The researchers conclude: 

"Active gaming used less energy than authentic bowling, tennis, and boxing, and the exercise was not intense enough to contribute towards the recommended amount of daily physical activity for children"

A couple of caveats are that the IDEEA is not the best way to measure arm activity, which is what the Wii entails, and that the children were standing up and playing, which is always a good thing for breathing, bones, joints, posture, etc.  Also, in terms of Wiihab, perhaps the use of the Wii as a graded activity is warranted.  Finally, the Wii Fit seems the most likely aspect of the Wii to serve as an alternative to traditional exercise, but that was not evaluated in this study.

So, exercise, Wii is not.  Fun, active video game…Wii is.  One more interesting fact from the study…boys used more energy than girls while playing the Wii. 

Link to Abstract.

Graves, L., Stratton, G., Ridgers, N.D., Cable, N.T. (2007). Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross sectional study. BMJ, 335(7633), 1282-1284. DOI: 10.1136/bmj.39415.632951.80

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A New Scientific Method?

I found this post about science without theories to be fascinating. 

"It may turn out that tremendously large volumes of data are sufficient
to skip the theory part in order to make a predicted observation."

This correlative science is discussed as part of medical care further down in the article.  Perhaps this should be the biggest motivation to comprehensive, vast electronic medical records capable of providing such large data sets that useful information can come from patient encounters.

"…computers can extract patterns in this ocean of data that no human could ever possibly detect."

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Dr. Miss America? Dr. Mr. President?

Ashley
I must first point you to my post at EIM, where I have links galore about Ashley Glenn, the Quinnipiac University Doctor of Physical Therapy student who has been crowned Miss Connecticut. 

Next, go check out Respectful Insolence, and find out more about the chiropractor running for president.  Seriously.

This listing of presidents by educational level is interesting; Woodrow Wilson served as president with a PhD from Johns Hopkins University.  A precedent also exists for Miss America contestants and higher education, in 1974 a law student crowned a doctoral student!

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Does Anything Change In Healthcare? Well…

If you don’t subscribe the the New York Times Well Blog, written by Tara Parker-Pope, you may wish to.  It is very thoughtful and I enjoy reading the author’s insights into a wide variety of health issues.  A recent post looked at a 1980 letter written by public relations man, Larry Ragan, who ultimately died from Lou Gehrig’s disease in 1995.  In reading Mr. Ragan’s letter, it becomes clear that many of his issues still exist today.

I also enjoyed the post entitled, "A New Twist on Ankle Pain," which begins to tell the tale of current evidence regarding ankle sprains.  I do wish the expert went a bit further explaining the importance of early weight bearing in gaining control of the joint following a sprain.

Happy reading!
ERIC

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Insurance Report Cards

ReportcardRecently the American Medical Association (AMA) issued a report card on the nation’s health insurance providers.  The report indicated that 14% of physicians’ total revenue was spent to collect their claims.  Not paying at the contracted rate was a big problem, with United Healthcare leading the way. 

"Physicians are spending 14 percent of their total revenue to simply
obtain what they’ve earned," said Dr. William Dolan, an AMA board
member.

I wonder if physical therapists created the same report, would that 14% number be much higher simply because they "earn" much less than physicians.  If it takes 2 office staff to submit and collect claims, and they are paid similarly in physical therapist and physician offices, and the PT bills $100 per patient, but the physician bills $200 per patient…well?

If that case is true, then physical therapists should be under more pressure to upgrade to more efficient record and claims systems, in addition to the everlasting battle to gain more leverage in negotiations with insurance providers.

I would love to see the APTA report card on insurance!  Perhaps, in conjunction with next year’s AMA report.

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Why is Standing Up So Difficult?

ResearchBlogging.org

I’m always amazed at how millions of individuals use similar movement strategies during normal human development.  No one invents a new way to stand up or walk or crawl, as our brains seem to instinctively know the most efficient way to move our bodies around.  But, it seems we may be wired to learn how to stand properly only one time in our lives! 

Well, that may be taking this a little too far, but a recent research study out of the University of Delaware found that in patients with Total Knee Athroplasty (TKA), learning to stand normally is certainly not intuitive.  It is a research study which has personal implications for me, though I’ve never had a knee replacement.

Investigators wondered why patients with knee arthroplasty continued to demonstrate reduced scores on functional movement tests despite reduced pain and normalized strength.  To try to answer the question, the research team analyzed a sit-to-stand task, measuring joint angles, ground reaction forces and other variables of the motion.  The subject group compared patients with TKA to age-matched controls up to 1 year after the procedure.

The surprising result was that even as the quadriceps muscle strength normalized, patients continued to use substituted patterns of movement.  When rising from sitting to standing, patients with TKA relied on less quadriceps muscle function and more hip extension muscle activity.  They achieved this reduced quad requirement by beginning the transfer with a greater amount of hip flexion compared to controls.

The significance of this is that physical therapists must be aware that, even in the face of normalized muscle strength, patients after TKA may need to be specifically trained in the transfer in order to perform it correctly.  I wonder why the body doesn’t use the quad in the pre-injury manner on it’s own? Are we only wired once?  Is there some inhibition of the quads that persists for a good reason?  Is it related to TKA, or is this phenomenon present after all knee surgery?

Personally, I find I use my hip extensors most of the time in my very injured knee.  I notice this while climbing stairs and, especially, while cycling on my road bike where the smallest movement of the seat completely saps my power. 

By the way, this study has been getting nice pick-up by the press, even earning a feature in the LA Times.

 

Farquhar, S.J., Reisman, D.S., Snyder-Mackler, L. (2008). Persistence of Altered Movement Patterns During a Sit-to-Stand Task 1 Year Following Unilateral Total Knee Arthroplasty. Physical Therapy DOI: 10.2522/ptj.20070045