Missouri Physical Therapy Association

Legislators

General Information About Physical Therapy

(coming soon)

POPTS/Referral for Profit

American Physical Therapy Association Position
Click here for the APTA Position on Physician-Owned Physical Therapy Services (POPTS) - PDF File

Federal Trade Commission Report
Click here for the FTC Presentation - PDF file

Direct Access to Physical Therapy Services

The Problem

In many jurisdictions, the practice of physical therapy is contingent upon the prescription or referral of a physician. This requirement does not recognize the professional training and expertise of the licensed physical therapist nor does it serve the needs of those patients who require physical therapy but must first be seen by a physician.

The Solution
Amend current statutes at the state level to permit direct access to physical therapy services.

Rationale

Today's environment of health consciousness, pursuit of physical fitness, and the promotion of a concept of wellness is tempered by the need to control the escalating costs of health care. One goal of the state legislatures in the 1990s has been the reform of the burgeoning health care system. Two areas of intense legislative focus have been how to increase access while still achieving cost containment. One of the most effective tools for cost control and increased access is easily attainable yet often overlooked and underutilized by the legislatures - that of direct access to the services provided by health care professionals.

Physical therapy is the case in point. Entry into the profession and practice of the profession are stringently regulated by all states, and as highly trained health care professionals, physical therapists have a proven track record of effectively treating millions of patients. Physical therapists are well-qualified, both through formal education and clinical training, to evaluate a patient's condition, assess his or her physical therapy needs and, if appropriate, safely and effectively treat the patient. Physical therapists are also well-qualified to recognize when patients demonstrate conditions, signs and symptoms that should be evaluated by other health care professionals before therapy is instituted. Physical therapists recognize when it is appropriate to refer patients to these other health care professionals for consultation.

The professional training and expertise which characterize physical therapists has been recognized by 39 states. These states have removed the out-dated provisions requiring a referral by a physician, from their statutes. Further, these states and the insurance companies that reimburse under direct access will realize cost savings of approximately $1,200 per patient episode of care according to the results of a recent study by Dr. Jean Mitchell and Dr. Greg deLissovoy of Georgetown University and Johns Hopkins University, respectively. Just imagine what this could mean to your state's workers' compensation program or special education department!

If you represent Puerto Rico, the District of Columbia, or one of the 11 states that still contains barriers to direct patient care by physical therapists, please consider the benefits of reform. By amending the physical therapy practice act in your state, you will be providing your constituents with an additional entry point into the traditional medical system, increased choice in the selection of a health care professional, access to less expensive and more timely care, and a simple, yet, extremely effective way to meet the goals of increased access and cost containment.
For additional information on "direct access," please contact the Government Affairs Department of the American Physical Therapy Association at 703/706-8533.

Cost-Effectiveness of Direct Access to Physical Therapy

Jean Mitchell, PhD, Georgetown University, and Gregory de Lissovoy, PhD, MPH, Johns Hopkins University, December 1994

In a study conducted to determine whether direct access to physical therapy services provided by a licensed physical therapist is cost effective, it was found that:

The total paid claims for physician referral episodes to physical therapists was 123% or 2.2 times higher than the paid claims for Direct Access episodes. The total paid claims averaged $2,236 for "physician referral" episodes as compared to $1,004 for Direct Access episodes. When expressed in terms of actual reimbursements, the difference in total paid claims per episode was $1,232.
Physician referral episodes were 65% longer in duration than Direct Access episodes.
Physician referral episodes generated 67% more physical therapy claims and 60% more office visits than Direct Access episodes.

Background:

Using health insurance claims data from Blue Cross-Blue Shield of Maryland, an expert panel of physicians and physical therapists analyzed 8,920 episodes of care from 3,000 individuals from 1989 through mid-1993. The authors concluded that, "Direct Access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classified as physician referral episodes."

FAQ

Frequently Asked Questions on Physical Therapists’ Services Provided Without Referral

What does patient access to physical therapists’ services without referral mean and why is it needed?

Patient access to physical therapists’ services without referral means the removal of the physician referral mandated by state law to access physical therapists’ services. Thirty-nine (39) states have granted consumers the freedom to seek physical therapy treatment without a referral. Currently, a referral is required by state law to initiate treatment by a licensed physical therapist in 11 states.
This referral mandate causes delays in the provision of physical therapists' services to individuals who would benefit from treatment by a physical therapist. Delays in care result in higher cost, decreased functional outcomes, and frustration to patients seeking physical therapy treatment. Eliminating the referral mandate results in timely, and thus more effective, physical therapists’ services.

Are physical therapists qualified to deliver physical therapists’ services independent of referral?

Absolutely. Physical therapists are educated at the post-baccalaureate level and receive extensive education and clinical training in the examination, evaluation, diagnosis, prognosis, and intervention of patient/clients with functional limitations, impairments and disabilities. As of January 1, 2002 all physical therapy programs are required to be accredited at the masters level. Physical therapists are qualified to recognize when a patient presents with signs and symptoms inconsistent or outside the scope and expertise of the physical therapist and when the patient should be referred to a physician. APTA’s Guide of Professional Conduct advocates that physical therapists should assist patients in receiving appropriate medical care when the physical therapists’ examination and evaluation reveals signs and symptoms inconsistent with a condition that can be appropriately treated with physical therapy or needs a physician’s care and expertise.
Liability insurers and the Federation of State Boards of Physical Therapy affirm that physical therapists’ services provided without referral does not jeopardize the health, safety, or welfare of the patient/clients seeking physical therapists’ care and services without referral. Health Providers Service Organization (HPSO), the leading liability insurer of physical therapists in the United States, states in a January 3, 2006 letter, "Direct access is not a risk factor that we specifically screen for in the underwriting of our program nor do we charge a premium differential for physical therapists in direct access states. We currently have no specific underwriting concerns with respect to direct access for physical therapists."

Is there a concern that if a physical therapist initiates treatment without a referral that they will miss a patient’s underlying medical conditions?

The risk of a health care provider missing underlying conditions is always present. However, physical therapists have an extremely low rate of malpractice and a low incident of claims or complaints filed against them. The rate of malpractice insurance has been shown to be no higher in states where physical therapists practice without a referral versus states where physical therapists practice with referral. Physical therapists actually assist patients to get appropriate care when they recognize signs and symptoms that are inconsistent or outside the scope of physical therapists’ practice.

There is evidence from the Federation of State Boards of Physical Therapy and a leading liability carrier, the Health Providers Service Organization (HPSO), that there is no increased risk to patients in states that do not mandate referral before the provision of physical therapists’ services. HPSO does not rate a physical therapist as a higher risk because they practice without referral. There has been no increase in claims against physical therapists in states without the referral mandate. Most importantly, physical therapists consider their role in protecting the public’s health, safety and welfare as extremely important.

Physician groups argue that physical therapists cannot diagnose. How can you respond to such a charge?

Diagnosis is a fundamental part of physical therapists’ practice. Physical therapists practice according to the disablement model. This model of practice is recognized by the World Health Organization, the National Center for Medial Rehabilitation Research, and the Institute of Medicine. Physical therapists diagnose with respect to physical therapist practice as authorized by state law. In diagnosing a patient's condition in accord with such law, physical therapists are not in conflict with the diagnosis provisions of state laws governing the practice of medicine. No states prohibit a physical therapist from performing a diagnosis. Diagnosis by a physical therapist is essential for the physical therapist to be able to provide the proper interventions. Diagnosis is a label for a cluster of signs and symptoms gathered by examination and evaluation that is essential to guide the selection of appropriate interventions in physical therapy practice.

Why should policymakers be concerned with this issue?

Allowing individuals to make decisions regarding their health care is good policy. Individuals in 11 states are prohibited by state law from seeking physical therapists’ services unless they are referred by another health care provider. Eliminating the referral requirement is one step to making health care more accessible to more people.
Physical therapist education supports practice without referral. Physical therapist practice in the 39 states that allow treatment without referral has proven that it is safe. Yet consumers in 11 states do not have access to these services unless another health care provider refers them to a physical therapist.
Patient access without the current professional practice restrictions regarding referral is about individual choice in health care decisions. Elimination of the referral mandate does away with an unnecessary and burdensome regulation.