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The entire concept of reimbursement for healthcare services is vast and complicated.  But, examining costs for healthcare is not so complicated.  Certain services are expensive, others less so.  For example, orthopaedic surgeons are expensive with certain procedures like spinal fusion costing $40,000 or more.  Pharmaceuticals, which are the tool of choice in primary care, and needless radiological imaging are also expensive.  Very few of these expensive items are effective, yet reimbursement for them is provided all the time. 

Conversely, direct access to physical therapists is not expensive and can produce outcomes superior to the expensive options noted above, yet coverage for this by payors is rare.  When it does occur, costs go down.

Yet reimbursement for direct access to physical therapists is rare, despite a large transition of state practice acts to allow for this.  Some in the profession think it is a matter of time before payers realize the potential savings and alter their policy, others are taking a more active approach through the legislature.  Up next, a guest post furthering this discussion of reimbursement for direct access.

 
• Direct Access:  An Overview
• Direct Access:  Is it safe?
• Direct Access:  Reimbursement, also see Part II
• Direct Access:  The Netherlands
• Direct Access:  Making it Work
• Direct Access:  The Future

Image by TWCollins

Yes!  Okay, I will expand.

One of the central arguments brought forth by groups opposing direct access to physical therapists is that of safety. This argument implies that the only safe way for those with musculoskeletal dysfunction to receive care is to have all complaints first checked by a physician. This is in line with the traditional role of physicians as gatekeepers. But, does this argument hold water, and is there any evidence that can guide us as to the safety of physical therapists in a direct access role?  Before you read on, you may want to check out yesterday’s NYT article about the public’s eroding confidence in physicians.

Examining the Logic

Before we get to any review of evidence, let’s first bring up a point of logic and examine the reality of physicians and musculoskeletal dysfunction.  In medical school, students spend very little time learning orthopaedic examination, and rightly so.  The skill of physicians lies in managing the integrated, complex patients, with medical problems responsive to pharmaceutical management.  This takes time to learn.  So much time, that by the time medical students become residents, they are good at a lot of things, but only have basic knowledge of musculoskeletal complaints.  This lack of orthopaedic knowledge is routinely supported by research (such as 7% of Harvard medical students passing a competency exam).  By the time students are in residency, the specialized nature of their learning effectively precludes further development of these skills for all but orthopaedic residents. 

Alternatively, physical therapists almost singularly specialize in musculoskeletal dysfunction and movement.  As a biased “consumer,” I would want to see the professional with the most training in the area of my problem.  The anti-direct access safety argument does not dispute this variation in training.  It lies more central to the ability of physical therapists to detect serious medical problems, such as when that low back pain is cancer, or when that shoulder pain is a cardiac problem.  No doubt, physicians are good at this.  But, are physical therapists?  If evidence can show that physical therapists are competent diagnosticians, then the logic behind the safety argument falls apart, right?

Examining the Evidence

Conveniently, physical therapists in military settings have been seeing patients via direct access for years, and can provide a case to study safety in this setting.  This 2005 study by Moore et al. examined over 50,000 patients seen through direct access over 4 years and concluded that patients are at minimal risk for negligent care, with no adverse events resulting from PT management.  Granted, some evidence exists that those in uniformed services may be above average in musculoskeletal management, but this could be offset by the complex and varied conditions seen in military clinics, as I can attest to first-hand.  When physical therapists in a general private practice population were studied, correct decisions differentiating between patients with musculoskeletal vs. medical conditions were high, and even higher when the physical therapist was a board-certified clinical specialist.  When directly comparing physical therapist competency in musculoskeletal management with physicians, the results speak for themselves:

 

“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. Physical therapist students enrolled in doctoral degree educational programs achieved significantly higher scores than their peers enrolled in master’s degree programs. Furthermore, experienced physical therapists who were board-certified in orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than their non board-certified colleagues.”

I hope that I have at least provided enough evidence to support my enthusiastic “Yes!” that I began this post with.  Perhaps, I have also provided enough evidence to suggest that some risk exists when seeking general physician care for musculoskeletal complaints, given their lower levels of training and competency compared to orthopaedists and physical therapists. 

Now that we have concluded that direct access can be done safely, perhaps more safely by physical therapists who are board-certified specialists and have clinical doctorates, we can move on and examine some other issues central to direct access.  Next up:  reimbursement.

 
• Direct Access:  An Overview
• Direct Access:  Is it safe?
• Direct Access:  Reimbursement, also see Part II
• Direct Access:  The Netherlands
• Direct Access:  Making it Work
• Direct Access:  The Future

Photo by harryalverson.

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.

• Direct Access:  An Overview
• Direct Access:  Is it safe?
• Direct Access:  Reimbursement, also see Part II
• Direct Access:  The Netherlands
• Direct Access:  Making it Work
• Direct Access:  The Future

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