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INCREASED UTILIZATION OF DIRECT ACCESS TO
A MODEL FOR REDUCING HEALTHCARE
Adam W. Walker, Washburn University, Student Physical Therapist Assistant
Zach Frank, Washburn University, PTA Program Director
More states are allowing direct access to physical therapy services without the requirement of a physician referral.
Currently, 46 states and the District of Columbia allow such access to physical therapy practitioners. Research has
demonstrated the effectiveness of physical therapists in identifying musculoskeletal disorders in a direct access
setting. Not only have they proven effective in diagnosis, but research indicates direct access leads to reduced
number of visits and decreased overall costs per episode of care. This paper discusses the role direct access plays
in physical therapy and how it can serve as a model for reducing healthcare expenditures in other areas.
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Until 1957, every state required a physician’s referral for any patient needing physical therapy (Crout,
Tweedie, & Miller, 1998). Direct access to physical therapy services has been a major professional objective of
physical therapy professionals for the last 20 years. According to the American Physical Therapy Association
(APTA), currently, 46 states and the
District of Columbia have granted
consumers the freedom to seek
physical therapy treatment without a
referral (2011). This referral
mandate can cause delays in the
treatment of individuals by a
physical therapist. Delays in care
could potentially result in higher
costs, decreased functional
outcomes, and decreased satisfaction
of patients seeking physical therapy
treatment. This requirement does
not recognize the professional
training and expertise of the licensed
physical therapist and physical
therapist assistant; and, more
importantly, it does not serve the
needs of those patients who require
physical therapy but must first be seen by a physician.
Elimination of this referral mandate results in timely and more effective physical therapists' services
(APTA, 2011). This paper examines the use of direct access by individuals in the majority of states that have some
type of direct access; assesses the efficiency and effectiveness of the physical therapist to make the correct medical
decision in the direct access setting; and analyzes the cost comparison associated with direct access versus restricted
Utilization of Direct Access
As the cost of health care rises in the United States, the amount of participation individuals and families
exhibit in their own health care decision making process has similarly increased. Consumers are taking a more
active role in their healthcare. They are paying a larger portion for services, reviewing provider quality through
Web sites, and researching the increased availability of health information online (American Health Information
Management Association [AHIMA] Personal Health Record Practice Council, 2006). This readily available
information is allowing individuals to be more informed when selecting the best available health care provider for
their needs. Within the scope of this ever-changing health care system and increased freedom, we find direct access
to physical therapy. Nearly 20 years ago, Domholdt and Durchholz indicated physical therapists did not practice
with direct access because of employer policies (49.1%), lack of insurance reimbursement (43.6%), patients without
a physician's referral not presenting themselves for physical therapy (25.5%), and personal preference (23.6%)
Concerns about the potential costs associated with malpractice liability have also been investigated, but the number
of events was so low that no conclusions were reached (1992). Since this study was first published, the number of
states allowing direct access to physical therapy in some manner has increased significantly, thereby increasing the
availability of patients to consult a physical therapist without a referral from a physician. While availability has
increased, the question becomes are consumers accessing these services?
Research illustrates that the utilization of direct access to physical therapy varies widely among
populations. A study by Crout et al. of physical therapists in Massachusetts found direct access patient care
accounted for 8.8 percent of their practice (1998). A similar study revealed that 12.6 percent of 1,580 patients
presenting with lower back pain reported treatment by a physical therapist through direct access (Mielenz, Carey,
Dyrek, Harris, Garrett, & Darter, 1997). However, in a more controlled setting, Moore, McMillian, Rosenthal, and
Weishaar observed 25 military health care sites over a 40-month period and found that 45.1 percent of new patients
were seen through direct access without physician referral (2005).
Childs et al., 2005
Within the smaller community associated with military bases, the level of direct access patient care
increased four-fold compared to civilian patient care. This discrepancy in utilization rates in the public sector versus
military settings could be due to the lack of public knowledge of the availability to directly seek care from a physical
therapist. Research shows the public’s knowledge of direct access and the role of the physical therapist is limited.
Snow, Shamus, and Hill reported 67.3 percent of people have no knowledge of direct access, but 73.4 percent of
respondents would seek direct care from a physical therapist if they needed one (2001). Thus, the public’s lack of
knowledge of direct access and the role of the physical therapist limit the possible use of physical therapy as a
primary treatment option.
Efficiency & Effectiveness
One primary concern that opponents of direct access have is that of the clinical efficiency and effectiveness
of the physical therapist. However, these concerns should be deemed unwarranted as physical therapists are
educated with a post-baccalaureate degree and receive extensive training in the examination, evaluation, diagnosis,
prognosis, and intervention of patients with functional limitations, impairments and disabilities; while the physical
therapist assistant is trained with at least a 2-year degree that is highly specialized to the therapy field. Additionally,
both clinicians must pass a state board exam to be certified or licensed to practice (APTA, 2011).
The diagnosis and clinical decision-making ability of the physical therapist has always been an important
aspect of the practice. Differential diagnosis and screening for medical disease is commonly taught in physical
therapy programs and is a regular topic for physical therapy journals, continuing education, state conferences, home
study courses, and the APTA Advanced Clinical Practice Series (Deyle, 2006). Furthermore, the APTA's Guide of
Professional Conduct advocates that physical therapists should assist patients in receiving appropriate medical care
when the physical therapist's examination and evaluation reveals signs and symptoms consistent with a condition
that cannot be appropriately treated with physical therapy or that needs a physician's care and expertise (APTA,
2011). In regards to patient management, Jette, Ardleigh, Chandler, and McShea reported that physical therapists
made these correct decisions 88 percent of the time when faced with non-critical medical conditions and 79 percent
of the time for critical medical conditions (2006).
Physical therapists are musculoskeletal specialists. The physical therapist is trained in and has extensive
knowledge in the musculoskeletal system with many physical therapists expanding their knowledge base even
further to specialize in specific areas such as: women’s health, pediatrics, geriatrics, orthopedics, or the neurological
or integumentary system. Musculoskeletal conditions account for roughly 25 percent of patient complaints in
primary care settings. However, primary care physicians have been shown to lack confidence in their own
evaluation and treatment skills with these patients (Childs, Whitman, Sizer, Pugia, Flynn, & Delitto, 2005).
Conversely, musculoskeletal conditions account for approximately 90 percent of physical therapy episodes
(Pendergast, Kliethermes, Fregurger, and Duffy, 2011).
A study by Jette et al. found that physical therapists made the right decision 87 percent of the time
regarding musculoskeletal conditions and that those decision-making percentages increased for physical therapists
with orthopedic specialist certifications (2006). Childs et al. also found that both licensed physical therapists, with
or without orthopedic or sport specialist certifications, and physical therapist students tended to have higher levels of
knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all
physician specialists except for orthopedists (2005).
When evaluating change in health care policies, one of the first items that must be addressed is the safety of
the patient. One indicator to judge the relative safety of a treatment is the volume of malpractice suits initiated. It
has been reported there is no difference between physical therapist malpractice suits in states allowing direct access
compared with states where it is prohibited (Sandstrom, 2007). Additionally, Moore et al. found that greater than
50,000 patients seen through military health care facilities are at minimal risk for gross negligent care when
evaluated and managed by PT’s, with or without physician referral. Furthermore, the authors reported no adverse
events resulting from physical therapists’ diagnosis or management (2005). These results indicate no adverse effects
are present, in regards to patient safety, when comparing a system with direct access to physical therapy to a system
that requires physician referral.
The Cost Comparison
With direct access, there is a potential argument that the cost and usage of physical therapy services
increase when there is no physician to act as the gatekeeper for referral (Sandstrom, 2009). This does not seem to be
true in regards to utilization rates or overall cost of services. Mitchell and deLissovy showed that direct access
involved 65 percent fewer physical therapy visits and 68 percent lower paid claims for services (1997). A more
recent and comprehensive study also found that self-referred physical therapy episodes of care were less than those
for physician-referred episodes (Pendergast, et al., 2011). Furthermore, Leemrijse, Swinkels, Veenhof, found that
patients utilizing direct access resulted in an average of 2.3 fewer physical therapy treatment sessions than patients
who were referred by their physician (2008).
A reduction in visits does not necessarily result in a decrease in overall costs as the cost per visit can
potentially be inflated. However, Mitchell & deLissovy reported a 57 percent reduction in paid claims compared to
physician referral physical therapy (1997). They reported total paid claims were reduced from $2,236 per episode
of care to $1,004 for direct access episodes (Mitchell & deLissovy, 1997).
A Model for Cost Reduction
The public policy objective for direct access statutes is to give the consumer the ability to select the most
appropriate source of care. Freedom of choice, which was seen as an important advantage of direct access satisfies a
need (Leemrijse, et al., 2008). Allowing individuals to make decisions regarding their health care is not only good
policy but also cost effective. Direct access allows educated consumers to take a more active role when making
decisions regarding their health care. In an age of consumer-directed health plans designed to educate the consumer
and provide substantial cost cutting measures for companies, increased usage of direct access to physical therapy can
prove beneficial. Eliminating the physician referral requirement is one step to making health care more accessible to
more people and reducing overall healthcare costs.
Effectiveness and efficiencies are used as evaluative criteria for health care policies. Childs et al.
demonstrate physical therapists are more effective than typical first contact health care providers, such as family
practice physicians, when diagnosing musculoskeletal dysfunctions (2006). Use of these health care providers as
frontline contacts for diagnosing and treating musculoskeletal dysfunctions could serve to improve access to care for
those suffering from common ailments.
Direct access to physical therapy services has not only proven effective but also efficient. The reduction in
number of visits and overall costs associated with each episode of care associated with direct access (Mitchell &
deLissovy, 1997, Leemrijse, et al., 2008, & Pendergast, et al., 2011) prove this system can serve as one method of
reducing overall health care costs. Direct access to physical therapy services can serve as a model of how increasing
timely access to effective and efficient care helps manage the ever inflating costs of health care.
The direct access to physical therapy model serves as an example of how increasing accessibility to
services can actually result in decreased expenditures and improved outcomes with no increase in risk to the patient.
It can serve as a model for other programs wanting to not only reduce costs but ensure quality.
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