Direct Access in the States

Our goalAPTA Vision Sentence for Physical Therapy 2020By 2020, physical therapy will be provided by

physicaltherapists who are doctors of physical therapy,recognized by consumers and other health careprofessionals as the practitioners of choice to whomconsumers have direct access for the diagnosis of,interventions for, and prevention of impairments, functional limitations, and disabilities related tomovement, function, and health.

Direct Access and the Professions’ Vision

Direct Access and Vision 2020

• One of the Six Elements as Developed by APTA’s House of Delegates and Board of Directors

• Prerequisite for other components of the Vision

• Controlled by policymakers (external audiences

Vision 2020

EBP

AP PoC

DA

DPT

Professionalism

Direct Access Defined

Historical Perspective• Accreditation of PT degree programs were joint effort with

AMA until 1977.

• Physician referral and prescription required.

• APTA House of Delegates address in late 1970’s (Position on evaluation and treatment without referral – 1979

• State status at passage of Association position– 2 States did not require referral in practice act

• 1979 Action kicked off Association “direct access” initiative– 31 years later: state of direct access has progressed from 2

states to 45 + DC.

What is “Direct Access”?• Direct access is the legal right of the

public to seek and receive an examination, evaluation, and interventions by a physical therapist without the referral of a physician.

APTA Board of Directors, 2000.

3 Types of Direct Access• Unrestricted: No referral language in the

physical therapy practice act.

• Provision: No referral needed to access physical therapists examination, evaluation, and intervention with certain provisions.

• Limited Direct Access: allows for access to evaluation and access for certain types of treatment.

States with Direct Access

45 States and the District of Columbia currently have some form of direct access to physical therapist examination, evaluation, and intervention. (45 of 51 jurisdictions = 88%)

Important to stress some form as negotiations from Albany to Olympia have created many different direct access animals.

Status of Direct Access States

• 16 states have unrestricted direct access - no referral language in the PT practice act.

• 29 + DC states have direct access with provisions.– 11 of the 30 have what is considered

‘limited direct access:’ CA, GA, IL, KS, LA, MS, MO, NM, TX, WI, and WY

Unrestricted Direct Access

16 States with unrestricted direct access:

Nebraska was the first in 1957Maryland – 1979 (technically CA in 1968 but overturned with AG

opinion)Massachusetts – 1983Arizona - 1983West Virginia - 1984Nevada, Utah - 1985Alaska + South Dakota – 1986Kentucky, Montana + Idaho – 1987Colorado, Iowa + Vermont – 1988North Dakota - 1989

Direct Access with provisions

Arkansas – 1997 Rhode Island - 1992Connecticut – 2006 South Carolina - 1998Delaware – 1993 Tennessee – 1999 DC – 2007 Virginia - 2001Florida – 1992 Washington - 1988Maine – 1991Minnesota – 1998New Hampshire – 1988New Jersey – 2003New York – 2006North Carolina – 1985Ohio – 2004Oregon -1993Pennsylvania – 2002

Direct Access with provisions

Referral required only for specific services:  - Arkansas (Pulmonary Hygiene, Wound Care),

- Connecticut, Maine, and North Carolina (Spinal Manipulation), - Washington (certain orthotics)

Referral required only if patient does not show progress within a specifiedperiod of time: Connecticut (30), DC (30), Maine (30), New Hampshire (25),Ohio (30). Referral required after an absolute time frame regardless of patient progress: Delaware (30), Florida (21), Maine (120) Minnesota (90), New Jersey (30), New York (30), Oregon (60), Rhode Island (90), South Carolina (30), Tennessee (30), and Virginia (14),

Provisional Direct AccessArkansas (1997) and Washington

(1988)

Spinal manipulation prohibitions in return

for direct access – NEVER AGAIN!

Limited Direct AccessCalifornia - 1968Georgia - 2006Kansas - 2007Illinois - 1988Louisiana - 2003Mississippi - 2006Missouri - 1999New Mexico - 1989Texas - 1991Wisconsin - 1989Wyoming - 2003

Steps toward unrestricted direct

access• 5 states have been successful in improving their direct access statute– New Hampshire (2002)– Virginia (2007)– Tennessee (2007)– Oregon (2007)– Minnesota (2008)Able to show legislators that the “world didn’t end” because

of their initial direct access, hence justifying increased access.

Direct AccessStates without direct access to

evaluation:Alabama and Indiana

States without direct access to treatment:

Hawaii, Michigan, Oklahoma

MD/DO

PT NP RD PA

Creating a New Paradigm in Health Care with Direct Access

MD

PT NP

RD PA

OD DPM DC

PT MD

OD DPM

DC DDS MD(specialists)

The 3 D’s of Direct Access

• Denied Access

• Delayed Access

• Disparities in Access

The Benefits of Direct Access

• The Benefits to the Patient

• The Benefits to the Payer or taxpayer

The Benefits to the Patient

Improved AccessImproved ChoiceEliminate delays

Faster return to work

Benefits of Direct Accessfor the Patient

• Choice of provider

• Less visits

• Convenience/flexibility

• Earlier intervention• Decreased out-of-pocket expense

(copays, pharmacy)

The Benefits to the Payer

Cost EffectivenessConsumer Choice

Benefits of Direct Accessfor the Payer

Decreased costs when referral notrequired

Physician visit costsCombats referral for profit (over-

utilization)

Benefits of Direct Accessfor the Payer

Decreased costs when referral notrequired

Possible unnecessary diagnostic or pharmaceutical costs

Benefits of Direct Accessfor the Payer

• Decreased number of claims to process– Physician visits– Diagnostics– Pharmacy– Appeals

Benefits of Direct Accessfor the Payer

• Increased customer satisfaction– Less out-of-pocket expense– Faster access to help– Faster return to work

Research: Mitchell Study

Direct Access DOES NOT promote over-utilization3:– Physician referral

episodes of care generated 67% more claims and 60% more office visits

0100200300400500600700800900

1000

Claims OfficeVisits

MDPT

Research: Mitchell Study

Direct Access DOES NOT result in higher physical therapy costs3.– Cost per visit were

123% higher when patients were first seen by a physician prior to PT and

– Claims paid under direct access to physical therapist were $1,232 less than physician referred.

$0$2,000$4,000$6,000$8,000

$10,000$12,000$14,000

Cost Claims

MDRefersDA forPT

National Endorsements of Direct Access

• National Black Caucus of State Legislatures (NBCSL): “The NBCSL urges the adoption of state legislation that permits access to physical therapists without a physician referral”

National Endorsements of Direct Access, cont.

• American Legislative Exchange Council (ALEC): “patients should have the ability to access physical therapists' services without current professional practice restrictions regarding referral”

So what’s the beef?• Malpractice

• Diagnosis

• MedPAC

• Loss of collaboration/team approach??

• Mandate on all PTs and patients to practice via direct access.

Will Direct Access increase liability?

• Since 1994, the APTA endorsed liability carrier has not reported an increase or change in claim pattern that reflects negatively on Direct Access. The underwriter (CNA) agrees.

• Underwriter does not charge a premium in states with Direct Access.

Diagnosis/patient safety• Diagnosis is both a process and a label. The

diagnostic process performed by the physical therapist includes integrating and evaluating data that are obtained during the examination to describe the patient/client condition in terms that will guide the prognosis, the plan of care, and intervention strategies. Physical therapists use diagnostic labels that identify the impact of a condition on function at the level of the whole person. (Guide to Physical Therapist Practice. Rev 2nd Ed. Alexandria, VA: American Physical Therapy Association; 2003.)

Diagnosis• Diagnosis – the great link to direct access

• Currently – 17 states explicitly authorize diagnosis (diagnosis, physical therapy diagnosis, or diagnosis for physical therapy)

• Identified in The Guide, The Normative Model for Physical Therapist Education, APTA House of Delegates position, and FSBPT Model Practice Act,

• Several States prohibit PTs from making a medical diagnosis.

Can Physical Therapists make a “diagnosis”?

• Medical diagnosis: interruption of normal cellular processes

vs.• Diagnosis of impairment, functional

limitation, or disability: loss of function, restriction of ability to perform task, inability to engage in activity

Can Physical Therapists make a “diagnosis”?

• CVA vs. Hemiplegia• Rheumatoid Arthritis vs. Joint

inflammation, joint deformity, muscle weakness and inability to turn keys

• MS vs. Balance deficits, weakness and decreased sensation

Diagnosis: the politics of fear

“Allowing unlimited physical therapy without a doctor’s assessment ..requires a PT to step beyond their training

tomake a diagnosis and then initiate their treatment.”

“The list of medical conditions that can masquerade as musculoskeletal problems can fill an entire text book”

- Dr. Andy Smith Assistant Professor of Orthopaedics University of Minnesota

Diagnosis: the politics of fear

• Parents of young baseball player with shoulder pain waste critical weeks having their child receive PT until fractures occurs and an x-ray is taken and it is discovered that the child’s pain was not due to an overuse injury as suspected but due to…

Diagnosis: the politics of fear

CANCER!And the fracture complicates care and

the childmust undergo amputation!

ALL OF THIS BECAUSE OF DIRECT ACCESS!

Loss of collaboration/team approach

“Coordination of care with physicians is critical”

“If there is any change in the postoperative plan we need to need to be notified and have a discussion.”

“Collaboration with PTs can also prevent delay and the

need for surgery.”

Dr. Dan RotenbergMinnesota Orthopaedic Society

2004 MedPAC Report“The Medicare payment advisory commission concluded that physician referral was

necessary to ensure appropriate physical therapy

services for Medicare beneficiaries.”

Dr. Paul MatsonMinnesota Medical Association

MedPACThe 2004 MedPAC report was to determine the feasibility of removing the referralrequirement for the Medicare program anddoes not address the issue of direct access for private pay or out-of-pocket patients in the various states.*Since the report CMS has removed referral requirement and only requires plan of care be certified within 30 days.

MedPACIn the same report MedPAC Commissioners and staff fullyacknowledged the shortcomings of the physician referral in ensuring medical necessity.

In fact, in response to a question by MedPAC Commissioner former Senator David Durenberger, MedPAC staff could offer no evidence to support the contention that a physician

referral offers an assurance of medical necessity. The current system is ineffective, but MedPAC concluded there was insufficient evidence with the Medicare population to remove the referral requirement, against the best interest of the patients that Medicare serves.

Top issues that confuse legislators

• That this about payment (insurance code) not PT statute. Legislation mandates payment for direct access vs. removal of statutory referral requirement. Use argument about pro bono and cash-based payment.

• Most legislators know little about health care and even less about PT. (education level , state licensure, belief that there needs to be supervision by MDs, etc)

• Belief that physicians “own” diagnosis. Difference between a medical diagnosis and a diagnosis for PT.

.

Strengthening your political muscle to

overcome the politics of fear and misinformation• PTs will never beat the physicians,

medical society, orthopaedic surgeons, or chiropractors in terms of political donations and campaign cash.

• Campaign donations, while important, are not the end all be all in politics.

• Lack of political wealth can be made up by strengthening your political muscle

Political Muscle

• Lobbyist, grassroots, lobby days, key contact, etc.

• Key and vital element – the personal and trusting relationship that a person has with an elected official.

• Build a meaningful and trusting relationship with your elected official – become more than just a name. Become a friend.

Contact InformationJustin Elliott

Associate Director, State Government AffairsAmerican Physical Therapy Association (APTA)

1111 North Fairfax StreetAlexandria VA 22314justinelliott@apta.org