Direct Access: What is it? Why is it relevant?

The term “direct access” has been thrown around quite a bit in regards to insurance and healthcare, but a large portion of the general public still do not know what direct access is or the many benefits it holds. In short, direct access allows patients to seek physical therapy services without a prescription or prior referral from a physician. As of January 1, 2015, all 50 states provide some form of direct access. It was the culmination of a long term effort by the national physical therapy community, and represented the next step in establishing the field as an all around medical service instead of a stage in injury recovery. Even though direct access is now legal across the country, states still have their own regulations. To date, only 18 states (Alaska, Arizona, Colorado, Hawaii, Idaho, Iowa, Kentucky, Maryland, Massachusetts, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Vermont, and West Virginia) have adopted the law without any provisions. So what type of restrictions do you face if you live in one of the remaining 32 states?

Approximately six states (Alabama, Illinois, Mississippi, Missouri, Texas, and Wyoming) have limited patient access. Residents in those states are often required to seek prior treatment from a medical doctor or have a documented medical diagnosis that warrants a prescription for physical therapy. In the remaining 26 states that allow patient access with some provisions, patients can get a physical therapy evaluation but must obtain a prescription within a certain amount of time following the their initial treatment. For some treatments, such as electromyography or spinal manipulation, a prescription is required. New Jersey falls into the category of states providing provisional access. State law mandates physical therapists licensed to practice in the state of New Jersey to inform the patient’s primary care physician within 30 days of the start of treatment. Why does any of this matter?

Direct access has proven to be cost effective for both the patient and the health care system. With outcomes comparable to traditional medical referral, direct access actually expedites the patient's access to medical care. Research showed that early physical therapy for lower back pain was associated with decreased surgery, injections, opioids, and advanced imaging. Total medical costs are estimated to be $2,736 lower on average compared to delayed physical therapy, while overall health expenses due to spine related pain were reduced by an average of $1,543. With direct access providing care at such reduced costs, the healthcare landscape is adapting to the concept of patients having more control over their care. Just this year, The New York Times published an article in which Amazon, JPMorgan, and Berkshire Hathaway were looking to partner up in order to develop an independent health care system for their employees. Why? In a world where the cost of medical coverage seems to be rising exponentially and with the consumer being at the crux, cost reductions for one of the most prevalent medical conditions is crucial. 

 


The current opioid epidemic - particularly in the state of New Jersey - is another area that physical therapists have a role. About 115 people die a day in the US from an opioid overdose. In March of 2016 the CDC released guidelines that recommended non-pharmacological treatment, such as physical therapy, to manage pain. Physical therapists provide treatment, through exercise or hands on techniques, as well as patient education to manage pain. The American Physical Therapy Association (APTA) began a campaign in June of 2016 to promote early access to physical therapy and educate the public on what role physical therapy play in the manage and prevent chronic pain.  Direct access offers a solution. Physical therapists are trained extensively in the musculoskeletal (MSK) system. Musculoskeletal ailments account for about 25% of patient complaints in an ambulatory setting and can be the primary source in restricting activities of daily living. Physical therapists are the movement specialists, but also held to standards that ensure all entry level graduates are versed in medical screening for potential red flags. BMC Musculoskeletal Disorders published an article that demonstrated physical therapists had higher levels of knowledge in managing MSK conditions than medical students, physician interns and residents, and most physician specialists - with the exception of orthopedists.

 


To be clear, physical therapists are not making medical diagnoses as this is not within their general scope of practice, and physical therapists are trained to refer out when indicated by the patient's history and exam. Similarly, patients do not appear to have poor outcomes or increase in number of visits with direct access. Again, the evidence suggests that physical therapists can provide care to patients with MSK complaints in a safe and efficient manner.  Direct access should be seen as an opportunity to decrease barriers to care, allow patients to be active in managing their health, and improve communication between multidisciplinary providers. 

 

References:

Apta.org. (2018). The State(s) of Direct Access. [online] Available at: http://www.apta.org/PTinMotion/2016/10/DirectAccess/ [Accessed 1 Jul. 2018].

Apta.org. (2018). Direct Access at the State Level. [online] Available at: http://www.apta.org/StateIssues/DirectAccess/ [Accessed 30 Jun. 2018].

Apta.org. (2018). [online] Available at: http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf [Accessed 30 Jun. 2018].

American Physical Therapy Association. (2018). CDC Recommends Physical Therapy and Other Nondrug Options for Chronic Pain. [online] Available at: https://www.moveforwardpt.com/DidYouKnow/Detail.aspx?cid=cd52bad5-f4a3-4f1f-a387-9cd4a3bc1842 [Accessed 1 Jul. 2018].

Childs, J., Whitman, J., Sizer, P., Pugia, M., Flynn, T. and Delitto, A. (2005). A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskeletal Disorders, 6(1).

Denninger, T., Cook, C., Chapman, C., McHenry, T. and Thigpen, C. (2018). The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry. Journal of Orthopaedic & Sports Physical Therapy, 48(2), pp.63-71.

Drugabuse.gov. (2018). Opioid Overdose Crisis. [online] Available at: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis [Accessed 1 Jul. 2018].

Fritz, J., Childs, J., Wainner, R. and Flynn, T. (2012). Primary Care Referral of Patients With Low Back Pain to Physical Therapy. Spine, 37(25), pp.2114-2121.

Mintken, P., Moore, J. and Flynn, T. (2018). Physical Therapists’ Role in Solving the Opioid Epidemic. Journal of Orthopaedic & Sports Physical Therapy, 48(5), pp.349-353.

Ojha, H., Snyder, R. and Davenport, T. (2013). Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review. Physical Therapy, 94(1), pp.14-30.

Wingfield, N., Thomas, K. and Abelson, R. (2018). Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care. [online] Nytimes.com. Available at: https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan-health-care.html [Accessed 30 Jun. 2018].