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Increased Utilization of Direct Access to Physical Therapy

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Increased Utilization of Direct Access to Physical Therapy

  1. 1. INCREASED UTILIZATION OF DIRECT ACCESS TO PHYSICAL THERAPY: A MODEL FOR REDUCING HEALTHCARE EXPENDITURES Adam W. Walker, Washburn University, Student Physical Therapist Assistant Zach Frank, Washburn University, PTA Program Director ABSTRACT 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. Adam Walker 900 SW Robinson Ave #508 Topeka, KS 66606 (785) 418-6852 Zach Frank 1700 SW College Ave Topeka, KS 66621 (785) 670-1406
  2. 2. APTA, 2011 Introduction 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 access. 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).
  3. 3. 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
  4. 4. 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). Safety 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
  5. 5. 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.
  6. 6. REFERENCES American Health Information Management Association [AHIMA] Personal Health Record Practice Council. Helping consumers select PHRs: Questions and considerations for navigating an emerging market. Journal of AHIMA. 77(10): 50-56. American Physical Therapy Association [APTA]. (2011). Direct access to physical therapy services. Retrieved July 09, 2011 from American Physical Therapy Association [APTA]. (2011). FAQs: Direct access at the state level. Retrieved July 09, 2011 from Childs, J.D., Whitman, J.M., Sizer, P.S., Pugia, M.L., Flynn, T.W., & Delitto, A. (2005). A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskeletal Disorders. 6:32. Crout, K.L., Tweedie, J.H., Miller, D.J. (1998). Physical therapists' opinions and practices regarding direct access. Physical Therapy. 78(1): 52- 61. Deyle, G. (2006). Direct access physical therapy and diagnostic responsibility: The risk-to-benefit ratio. Journal of Orthopaedic & Sports Physical Therapy. 36(9): 632-634. Domholdt, E. & Durchholz, A.G. (1992). Direct access use by experienced therapists in states with direct access. Physical Therapy. 72(8):569-574. Jette, D.U., Ardleigh, K., Chandler, K., & McShea, L. (2006). Decision-making ability of physical therapists: Physical therapy intervention or medical referral. Physical Therapy. 86(12): 1619-1629. Leemrijse, C.J., Swinkels, I.C.S., Veenhof, C. (2008). Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy. Physical Therapy. 88(8): 936-946. Mielenz, T.J., Carey, T.S., Dyrek, D.A., Harris, B.A., Garrett, J.M., & Darter, J.D. (1997). Physical therapy utilization by patients with acute low back pain. Physical Therapy. 77(10): 1040-1051. Mitchell, J.M., & deLissovy, G. (1997). A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Physical Therapy. 77(1): 10-18. Moore, J.H., McMillian, D.J., Rosenthal, M.D., & Weishaar, M.D. (2005). Risk determination for patients with direct access to physical therapy in military health care facilities. Journal of Orthopaedic & Sports Physical Therapy. 35(10): 674-678. Pendergast, J., Kliethermes, S.A., Fregurger, J.K., & Duffy, P.A. (2011). A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Services Research. DOI: 10.1111/j.1475-6773.2011.01324.x. Sandstrom, R. (2007). Malpractice by physical therapists: Descriptive analysis of reports in the National Practicioner Data Bank Public Use Data File, 1991-2004. Journal of Allied Health. 36(4): 201-208. Sandstrom, R., Lohman, H., & Bramble, J. (2009). Health Services: Policy and Systems for Therapists (2nd ed. pp. 33-36). New Jersey: Pearson Ed Snow, B.L., Shamus, E., & Hill, C. (2001). Physical Therapy as primary health care: public perceptions. Journal of Allied Health. 30(1):35-38.