Direct AccessRyan BarragreeChristian Busch

Paula MartinSarah Welch

Vision 2020“…physical therapy will be provided by physicaltherapists who are doctors of physical therapy,recognized by consumers and other health care

professionals 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

• “…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 BOD

Types of Direct Access

• Limited: access is allowed for evaluation and for certain types of treatment (Kansas is an example of this)

• Provision: No referral is required to access physical therapists examination, eval, and intervention with certain provisions

• Unrestricted: There is no requirement for a referral of any kind

Direct Access - Kansas

• Kansas Board of Healing Arts: Chapter 65 – Public Health Article 29 – Physical Therapy– “…a physical therapist may evaluate patients

without physician referral but may initiate treatment only after approval by a licensed physician, a licensed podiatrist, a licensed physician assistant or a licensed advanced practice registered nurse working pursuant to the order or direction of a licensed physician…”

Direct Access - Kansas– May treat a patient for no more than 30

consecutive days providing that:• Patient has been previously referred for PT by an

authorized party (such as those listed above)• Previous referral was within 1 year from the date a PT

initiates a treatment plan without a referral

Direct Access- Kansas

• Previous referral is for the same injury, disease, or condition

• PT sends a copy of the initial evaluation to a licensed authority within 5 days of the

evaluation• Treatment for more than 30 days is

dependent on the approval of a licensed authority

Direct Access - Kansas

– May treat special education students without a referral for services that fulfill their IEP (individual education plan) or IFSP (individualized family service plan)

– May provided services that are solely for education of preventative workplace injury procedures

– “To the public for the purpose of fitness, health promotion and education”

– Source: http://www.ksbha.org/statutes/ptact.html

States with Limited Direct Access• Only 17 states have unlimited

DA while 18 have provisions and 11 have limited access

• States with limited DA: California, Georgia, Illinois, Kansas, Louisiana, Mississippi, Missouri, New Mexico, Texas, Wisconsin, & Wyoming

• These states have specifications about the types of patients PTs can evaluate. In some states a PT can’t even have limited access until they have been practicing a certain number of years

States with Provisions

• The 18 states with provisions are: Arkansas, Connecticut, Delaware, Florida, Maine, Minnesota, New Hampshire, New Jersey, New York, North Carolina, Tennessee, Virginia, & Washington

• Provisions vary but generally impose restrictions on specific types of patients a PT can see (similar to limited DA) and on certain treatment types (such as spinal manipulation)

• All types of DA include the requirement of referral when the patient is “outside the PT scope of practice”. This seems like common sense for any health care professional.

Unlimited Direct Access

• States with unlimited DA: Alaska, Arizona, Colorado, Hawaii, Idaho, Iowa, Kentucky, Maryland, Massachusetts, Montana, Nebraska, Nevada, North Dakota, South Dakota, Utah, Vermont, & West Virginia

• The only restrictions mentioned in unlimited DA prohibits PTs from practicing things such as surgery and prescribing medicine

• The most recent addition to unlimited access was Hawaii in 2010. The most recent after that was North Dakota in 1989

• This means for 20 years only one state was able to make the change to unlimited direct access

• The good news is that Indiana is the only state that has no form of direct access

• Oklahoma and Michigan are eval only

Benefits

Patient• Convenience• Fewer visits• Quicker

intervention• Choice of

therapist

Payer

Decreased cost (eliminate doctor office visit costs)Eliminate possible unnecessary diagnostic tests of pharmaceutical costsOverall increased customer satisfaction

Myths and Misconceptions

• There are many misconceptions going around that might influence therapists to oppose DA

• 1)Insurance companies won’t pay for it– Important to verify coverage for every patient. Don’t assume insurers

won’t pay for patients without a referral. Research indicates positive growth towards reimbursement w/o referral.

• 2)Increases Liability– In all the years DA has been in practice there has been no

increase in liability claims as a result of DA

Myths and Misconceptions

• 3)Damaged relationships with referral sources– Direct access makes a huge difference for PTs in that now

PTs, instead of only being the recipient of referrals, can be a source for others

• 4)Direct access is only applicable for private practices– Wrong. There are many hospitals and other health systems

that have lifted the restrictions on DA. These places are able to treat outpatients without referrals

More Misconceptions

• 5)Direct access is only applicable to outpatients– Wrong. There are many therapists treating

patients in home health, sports venues, school systems, and through admission orders, in ICUs and inpatient settings

• Once people understand the truths about DA, hopefully patients and therapists alike will take better advantage of DA

How does Direct Access affect day-to-day practice?

• Insurance– Referrals and authorizations: • Aetna• Children’s Mercy/Kansas Healthwave/Coventry• Preferred Health Systems – depends on plan

– Preferred Plus of Kansas – always required for Physical Therapy

• Tricare/Triwest• Workman’s Compensation: Alignetworks, Universal

SmartComp

How does Direct Access affect day-to-day practice?

• Insurance vs. Self-pay– Copayment/Coinsurance

• Ranges vary per plan• $10 - $70 / 80-20

– Deductible• Individual and Family

– OOP Max– Visit limitations– Self-pay (example)

• Initial Evaluation: $100• Additional visits: $60

Self-referral pilots tomusculoskeletal physiotherapy

and the implications forimproving access to other

AHP services

• Among patients who self-referred during the pilots: • 77% were satisfied or very satisfied with being able to self-refer• 59% preferred a community setting as the location for assessment/treatment• 65% preferred to be able to make an appointment to see the physiotherapist

without having to see their GP first• 72% were confident that they knew when they needed to consult a physiotherapist• 74% thought that patients can learn a lot about how to manage their conditions

themselves• 89% would use the service again• fewer than 1% regularly used private providers• fewer than 24% had ever used a private provider

• http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_116358.pdf

Mitchell Study

• Direct access works against over-utilization– Physician referrals

generated 67% more claims and 60% more office visits

• Direct access promotes lower physical therapy costs– Cost per visit were 123%

higher when patients were seen by a physician prior to therapy

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

What are PTs saying about Direct Access?

• “I’ve been a physical therapist in California for more than 20 years where we have direct access. Despite the laws, almost no PT sees a patient without a referral because insurance companies won’t pay for it and patients will typically do what their insurance pay for.”

• “I wish more PTs had positive experiences with Direct access. I’m certified and licensed to provide direct access in Pennsylvania. I have been practicing as a direct access PT for about 2 years and have found no problems with reimbursement.”

• http://www.ergoweb.com/forum/index.cfm?page=topic&topicID=3718

References• http://www.wcpt.org/node/34062• http://apta.org• http://www.ergoweb.com/forum/index.cfm?

page=topic&topicID=3718• http://www.dh.gov.uk/prod_consum_dh/

groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_116358.pdf

• http://www.ksbha.org/statutes/ptact.html