Physical Therapy Journal of
Policy, Administration and
Leadership
August 2014 | Vol. 14 | No. 3
Physical Therapy Direct Patient Access Versus Physician
Patient-Referred Episodes of Care: Comparisons of Cost,
Resource Utilization & Outcomes
by Mary Beth Badke, PT, PhD1 / Julie Sherry, PT, MS, DPT2 / Marc Sherry, PT, DPT2 / Sean Jindrich, MBA2 / Kip Schick, PT, DPT2
/ Sijian Wang, PhD3 / William G.Boissonnault, PT, DHSc1
1
Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison,
Wisconsin
2
Department of Orthopedics & Rehabilitation, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
3
Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health,
Madison, Wisconsin
Continued on page 3 »
IN THIS ISSUE: HPA RESOURCE
25
Community-Based Rehabilitation in Southern Belize
37
HPA The Catalyst Recognizes Members
31
A Changing Landscape for Science and Technology:
Potential Impact on PT Practice and Health Policy
38
HPA 2014 Research Awards
35
Candidates for Election
Section Special Interest Groups:
33
Global Health (GHISIG)
42
Technology SIG
Official Publication of the Section on Health Policy & Administration of the American Physical Therapy Association
Continued from page 1 »
Study Design: Retrospective
Objective: Evaluation of a hospital-based direct access (DA) program for outpatient spine and sport physical
therapy.
Background: Considering the challenges facing health care delivery, patient DA to physical therapy services may
result in reduced health care costs without compromise to outcomes. Few studies exist that describe the potential
impact of DA practice models.
Methods and Measures: Using hospital outpatient billing from November 2007 to December 2009, episodes
of care for patients with spinal and sports conditions were categorized as DA (n = 252) or Physician Referred (PR)
(n =169). Retrospective analyses were conducted, adjusting for age, gender, chronicity, and health care utilization
during the previous six months. Resource utilization, functional outcomes, and overall cost were compared between
subject groups.
Conclusions: After adjusting for key variables, DA episodes were less costly than PR episodes. The reduced costs
along with no apparent compromise of function support the DA model as a potential strategy addressing one
current health care system challenge.
Address correspondence to:
William Boissonnault, PT, DHSc, Physical Therapy Program, 1300 University Avenue, Rm 5190
Medical Science Center, Madison, WI, 53706, Phone (608) 263-5095, Fax (608) 262-7809, email:
boiss@pt.wisc.edu
Introduction
Musculoskeletal conditions, including arthritis, chronic
joint pain, and low back pain, represent the most common self-reported medical conditions in the United
States (107 million adults in 2005).1 The estimated annual direct cost for musculoskeletal care for the years
2002-2004 (in 2004 adjusted dollars), was $510 billion
or 4.6% of national gross domestic product. This was
attributed, in part, to the rapidly increasing rates of diagnostic imaging, opioid analgesic prescriptions, spinal
injections, and surgeries.1 Indirect costs (primarily lost
work days and wage loss), related to musculoskeletal
conditions for people between 18 and 64 years with a
work history for the period 2002-2004, accounted for
an additional $339 billion (3.1% national gross domestic product).2
Martin et al.3 reported that national health care expenditures for adults in the United States with spinal
problems increased by 82% between 1997-2006 ($19.4
billion to $35.1 billion). The increased expenditures
were primarily related to spine-related inpatient care
(spinal surgery), prescription medications (which represented the largest increase in per-user expenditures), and
emergency services. Despite the increased expenditures
and advancing technology, the US Medical Expenditure
Panel Survey found worse self-reported functional limi-
tations, mental health, work limitations, and social limitations among patients with spinal conditions in 2005
compared to 1997.4
Suggested strategies to reduce health care costs without
compromising health status, quality of care, or innovation include direct patient access (DA) to physical
therapy services, defined as accessing physical therapy
services without the requirement of physician referral.5
The Institute of Medicine’s (IOM) report titled, The
Healthcare Imperative: Lowering Costs and Improving
Outcomes provides the observation; “…for patients with
low back pain-substituting an initial physician evaluation
with an initial evaluation performed by a physical therapist … would achieve cost savings while simultaneously improving access, patient satisfaction and the patient’s return
to function”.2(p.18)
Several studies provide initial confirmation of IOM’s
observation. In 2005, Virginia Mason Medical Center
(Seattle, WA) initiated a DA model for patients with
low back pain (LBP) and reported decreased costs per
episode of care in the first year, in part from a reduction
in the number of MRI scans ordered (from 15.4% to
10% of patients). In addition, while previously many
patients had to wait a month to receive care, mean appointment wait times decreased to one day and only
PTJ-PAL - J3
six percent of patients lost work time.6 Mitchell and de
Lissovoy7 reviewed paid claims data for patients with
acute musculoskeletal disorders and reported 67%
more physical therapy claims and 60% more office
visits for physician referral (PR) episodes compared to
DA episodes. Total paid claims averaged $2,236 for PR
episodes and $1,004 for DA episodes. In another study,
Overman, Larson, Dickstein and Rockey8 compared
management of patients with LBP and noted fewer
patients were prescribed muscle relaxants and narcotic
analgesics when seen initially by a physical therapist
(24%) versus when seen by an internist (44%). Functional improvement for patients with the most severe
symptoms was significantly greater for the physical
therapist-managed patients and overall fewer of these
patients experienced re-occurrences of their back pain
six months following the initial visit.8 More recently,
Pendergast, Kliethermes, Freburger and Duffy9 carried
out a retrospective data analysis of private health insurance claims data. The authors noted that DA episodes
had fewer physical therapy visits and lower costs after
covariate adjustment, but did not differ in health care
utilization after PT. Given the pressing need voiced by
IOM to lower health care costs and improve patient
outcomes, more detailed data is needed on DA practice
models, particularly in previously unexamined practice
settings. The purpose of this study, therefore, was to
compare physical therapy practice when patients were
seen by physical therapists with and without a PR on a
variety of cost and utilization variables. These outcome
variables included episode of care resource utilization,
number of patient visits and duration of care, functional
outcomes for patients with spine problems, and costs associated with the delivered care.
Methods
In 2007, the University of Wisconsin Hospital & Clinics Authority (UWHCA), a large academic medical center in Madison, Wisconsin implemented an outpatient
physical therapy DA program. Through a collaborative
effort by hospital administrators, the Department of
Orthopedic and Rehabilitation physicians and physical therapists (PTs), the practice model was developed
and approved by the UWHCA Medical Board. A pilot
program was initiated and the program’s success resulted
in the DA model being adopted in all orthopedic and
sports outpatient clinics associated with this medical
center.10
Table 1. Frequencies of demographic and professional characteristics
of the seven participating physical therapy providers.
A. Sex
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Participants and Episodes of Care
Participants in this study were patients seen
in three hospital outpatient settings that are
a part of UWHCA, the academic medical
center and health system for the University
of Wisconsin. The clinics were located in the
same geographical location (within a 15 mile
radius) and were sites where the DA care was
initially provided. All sites were identically
financed and used the same billing system.
Seven physical therapists (PTs) who had
completed the DA training provided patient
care. The PTs were hourly-paid employees of
UWHCA and no patient care-related financial incentives were available to them (characteristics of the physical therapy providers
are presented in Table 1). The institution
developed a list of qualification criteria and a
required training program for PTs interested
in participating in the DA practice model.
The required training programs consisted of
assigned readings, lecture and discussion sessions, and successful completion of a patient
case-based competency assignment. The details of the qualification criteria and training
program can be found in a previous publication.10
Certification for use of a limited data set from UWHCA and an application for exemption from IRB review
were submitted. This research was determined to be
exempt under Code 45 of Federal Regulations 46.101
(b) (4), as research involving the collection of existing,
unidentifiable information.
The seven physical therapists identified participants’
referral status (PR: “evaluate and treat” or DA). Additional verification of each episode as DA or PR was
provided by electronic medical record (EMR) documentation taken from the physical therapy health history
intake form. The most frequent diagnoses for the participants are presented in Table 2 and included backache
and lumbago, joint pain and stiffness, neck pain, and
shoulder dysfunction/pain, marked by ICD-9 codes including 710-739.
Four hundred fifty-six unique patient episodes of care
between November 2007 and September 2009 were retrospectively reviewed. The 456 episodes of care included
187 related to spinal impairments and 269 related to
sports injuries. Exclusion criteria were: 1) inpatient
stays within the window of care (180 days prior to start
of care), 2) surgery including those requiring postoperative rehabilitation, or 3) having both PR and DA
episodes of care. Due to insurer requirements, patients
with Medicare, Medicaid, or Workers Compensation
insurance as their primary insurance were not eligible
for the study.
Participants’ billing data and EMR were accessed to
collect information regarding resource utilization.
Functional outcomes status for patients with spinal
disorders was collected via CareConnections, a patient
self-report questionnaire. CareConnecTable 2. Frequency and percentages of ICD-9 Codes by diagnosis category, and DA and PR
tions was developed by
groupings.
Schunk and Rutt11 to
evaluate outcomes in
DA
PR
ICD-9 Code identifier
orthopedic outpatient
n (%)*
n (%)*
rehabilitation patients.
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Back Pain Disability
always the same one for the entire episode of care.
Index (ODI).13 Within
each section, there are
six statements that are
A random sample of PR patient charts, relative to each
scored on a Likert scale from least functional (0) to
therapist’s DA sample size, was randomly selected by a
most functional (5). The scores for each item are added
scheduler blinded to the study’s purpose. For this PR
together and divided by the total number of points possample and the previously identified DA sample, unique
sible for a final score which represents ability to funcpatient episode of care numbers, and initiation of, and
tion on a 0-100% scale.11
end of care dates were collected by the physical therapists.
PTJ-PAL - J5
Schunk and Rutt examined the test-retest reliability of
each item of the CareConnections questionnaire using
an intraclass correlation coefficient (ICC)(3,1).11 Values
ranged from 0.69 to 0.96, with a mean ICC of 0.85.
However, validity of the questionnaire has not been examined, which is a limitation.
Table 3 provides a description of all the variables and
how they were measured for each episode of care.
group and to patient identity) who used specific criteria
to classify payments as either “likely” or “unlikely” to be
related to the reason (documented diagnosis) the patient
sought therapy. A list of billing codes and their descriptors were used to differentiate musculoskeletal versus
non-musculoskeletal charges. For example, visits to the
UWHCA Clinics for preventive cardiology, allergy, dermatology, or eye exam/services and laboratory charges
such as prostate cancer screening, thyroid hormone, or
Table 3. Description of study variables, how they were measured, and their source.
Variable
Measurement
Data Source
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Resource Utilization and Costs
UWHCA billing data were accessed for the sample 180
days prior to beginning of care dates, and up to and including end of care dates (determined by patient chart
notes). A unique episode of care was defined from the
date within the 180 day window the patient first sought
care for the relevant condition to the date of discharge.
At all three clinical sites, a PT visit was determined by
a unique service date found in the billing system; an
initial visit is typically 4 units of service (representing
60 minutes of time) and all follow-up visits were defined as 2 units of service (representing 30 minutes of
time). Billing data were reviewed by two of the seven
participating physical therapists, (blinded to DA or PR
J6 - PTJ-PAL
blood glucose testing were labeled “unlikely” and were
excluded from the analysis. Line item charges likely to
be related to the reason the patient sought therapy were
categorized as physician services, physical therapy services, plain x-ray films, advanced imaging, injections or
other.
Functional Outcomes
CareConnections was used to measure functional outcomes, pain, and perceived improvement. These data
were available for patients with spine dysfunction who
filled out initial and discharge CareConnection questionnaires. Functional indices, perceived pain, and
perceived improvement as documented by the physical
therapist were transferred by the data manager to software used to submit the data for benchmarking. Comparable clinical outcome data for the population with
sports injuries was not available.
Functional improvement was defined as the difference
between the functional score at the initial visit and the
functional score at discharge. Functional outcome was
= perceived improvement x10. The test-retest reliability
and validity of the VAS has been established.14,15
Due to a lack of an appropriate standardized outcome
assessment tool, functional outcome data for the participants with sports injuries was not available.
Statistical Analysis
The sample was first summarized numerically with descriptive statistics.
Table 4. Definitions of regression analysis dependent and independent
Sample size calculation was based on
variables.
the primary outcome of total cost.
Based on previous research,7 the total
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groups was expected to be $1,000
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alpha error rate and 80% power, the
required sample size was determined
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# defined as the functional score at discharge. Perceived
pain and perceived improvement were measured with
a ruler on separate 10 cm visual analogue scales (VAS).
The pain index ranged from no pain to worst pain
imaginable and the period of time considered was in the
last 24 hours. The improvement index ranged between
no improvement and complete recovery since the beginning of therapy treatment. The pain index raw score was
the measurement in centimeters of marks on the VAS,
which patients had made. The improvement and pain
raw scores were converted into percentages with the
following formulas: percent decrease in pain = (initial
pain – final pain)/initial pain and percent improvement
The Kolmogorov-Smirnov test was
conducted to test the normality of
data. For all data used in two-group
comparisons, the normality of data
was rejected. Therefore, the KruskalWallis test was used for the two-group
comparisons. It must be noted that
since multiple tests were conducted,
the Type-1 error could be inflated.
However, based on Bonferroni’s correction, use of the threshold 0.004 for
the p-value, the overall Type-1 error
was controlled at the 0.05 level. In
other words, if the p-value for a given
comparison was smaller than 0.004,
the difference was declared significant
even though multiple tests were conducted on the same data.
Because simple comparisons do not
control for confounding factors, multivariate linear regression was used
to compare DA and PR episodes with respect to total
physical therapy visits and total episode costs. Natural
logarithm transformation was used on these variables to
deal with positive skewness of data typical of medical
utilization and expenditure data.7 Table 4 contains definitions of variables used in the regression analysis. A dichotomous variable was constructed to identify episodes
that did and did not have diagnostic imaging (x-ray,
MRI, CT and ultrasonography). To further distinguish
episodes involving imaging by referral status an interactive term was constructed identifying DA episodes that
involved charges for imaging procedures (direct access
– radiology).7 This variable was used to determine if the
PTJ-PAL - J7
difference between DA and PR was different for episodes with imaging and episodes without imaging. To
adjust for potential differences in morbidity burden, additional variables controlled for were age, gender, chronicity (symptom duration in weeks as noted in patient
chart), and health care use unrelated to physical therapy
conditions and management in the previous six months.
The Wald test was used to evaluate the significance of
independent variables.
For the outcome data gathered from the participants
in the spine clinic, a two-tailed t-test was used to compare DA and PR patient groups evaluating functional
outcome, functional improvement, pain, and perceived
improvement. Unless otherwise stated, a criterion level
of p < .05 was used for all analyses. Data analyses were
performed using SAS1 and Microsoft Excel2 software.
Results
Sample characteristics
Of the 456 unique episodes of care, 35 were excluded:
22 DA and 13 PR patient episodes, leaving a sample
size of 421 episodes. Twenty-four of the 35 removed
episodes were due to 1) inpatient stays within the window of care (n = 4), 2) referral requested post-operative
rehabilitation (n = 2), and 3) having both PR and DA
episodes of care (n = 18). Of the remaining 11 excluded
episodes (2.4% of study population) seven were lost to
follow-up (patient discontinued treatment), two had
missing charge details, and two had coding errors. Subjects’ age, sex, chronicity, and number and duration of
treatments are provided in Table 5 along with the associated probability associated with tests of difference
between the DA and PR groups.
Resource Utilization and
Costs
The number of visits (p
< .0001) and mean treatDA
PR
ment duration (p = .03)
Variable
p
(n = 252)
(n = 169)
were significantly less for
DA patients. Tables 6 and
'
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in DA episodes versus PR
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1
Release 9.2; SAS Institute Inc, 100 SAS Campus Drive, Cary, NC
different (p = .28).
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Table 5. Comparison of subject demographic and diagnosis-related variables by
referral status with associated probabilities.
2
Microsoft Corporation, One Microsoft Way, Redmond WA
98052
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Table 6. Mean values for resource utilization in DA versus PR episodes.
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Table 8 displays the regression analyses results where
outcome variables included the number of physical
therapy visits and total charges per episode of care. Each
outcome variable was transformed and expressed as its
natural logarithm. In each model, with significance
level set at p <.05, the coefficient for the variable DA
was negative indicating that episodes classified as DA
involved fewer visits and lower costs relative to PR episodes; these differences were statistically significant. The
adjusted R2 values indicate the models account for 29%
of the variation in the log of physical therapy visits and
for 45% in the logarithm of the variation of total costs.
The positive coefficient for radiology implies that PR
episodes with charges for diagnostic imaging procedures
J10 - PTJ-PAL
are characterized by significantly more physical therapy
visits and higher total costs per episode relative to PR
episodes not involving imaging procedures. The interaction term that identified DA episodes involving radiology was associated with higher total episode charges.
Controlling for age and gender accounted for negligible
variance in physical therapy visits and total costs. The
duration of the health problem (chronicity) was associated with higher total episode charges but not a greater
number of physical therapy visits. The coefficients for
non-related charges were both positive implying that
greater health care use during the six months prior to
physical therapy intervention was associated with a
greater number of physical therapy visits
and higher total episode charges.
Since log-transformed results cannot be
interpreted directly, the coefficients for the
DA variables have been converted to percentages. Relative to PR episodes, those episodes classified as DA involved 52% fewer
physical therapy visits. When measured in
terms of total charges, DA episodes were
67% less expensive than those classified as
PR.
Functional Outcomes
Table 9 summarizes mean functional outcome scores and mean functional improvement from the start of care to discharge
for the participants with spinal impairments. No significant differences in initial
function, functional outcome scores, or
functional improvement existed between
the DA and PR groups. Table 10 presents
median percentage improvement scores for
pain and perceived recovery. No significant
differences for decrease in pain or median
percentage improvement score for perceived recovery were noted between the DA
and PR groups.
Table 9. Mean assessment measure values for participants with spine
dysfunction.
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Discussion
This project’s purpose was to assess resource utilization, overall costs, and functional outcomes for physical therapy outpatients in the areas of spine and sports
rehabilitation and compare them across two groups: DA
and PR. Using hospital billing data and controlling for
symptom duration (chronicity) of the health care problem and previous health care use, significant differences
between the two groups were found for resource utilization and costs.
Resource Utilization
Direct Access episodes utilized fewer physical therapy
and physician services, fewer imaging procedures, and
were shorter than PR episodes. Total visits for DA episodes were, on average, 72.2% of total visits for PR
episodes. This is comparable to 62.2% of total visits for
PR episodes in the Mitchell and de Lissovoy study,7 to
Leemrijse, Swinkels and Veenoff,16 who found total DA
episodes to be 77% of PR episodes, and to the 86.2%
that Pendergast et al.9 reported.
Comparison of the DA and PR patient episodes also
revealed 92% more plain film radiography and 193%
more advanced imaging procedures in the PR episodes.
These findings are consistent with previous reports that
MRI use dropped by approximately one-third when pa-
tients were initially seen by a physical therapist.6 Mitchell and de Lissovoy7 also reported fewer claims for radiology with DA episodes in comparison to PR episodes.
Our findings differ from Overman et al.,8 who noted
similar rates of patients undergoing diagnostic imaging between physical therapist and physician-managed
patients. In that study, however, both groups of practitioners were trained to use a standardized algorithm
to determine whether imaging was indicated. It seems
likely that this standardization may have accounted for
the parity between practitioners.
Costs
An average cost savings of $1,455 was noted with DA
episodes of care as compared to PR episodes. Although
these findings are consistent with Mitchell and de Lissovoy’s7 findings, the studies are not directly comparable.
The former study was based on health insurance claims
data and included claims for drugs and inpatient services. The actual cost-savings amount in the current
study may also not be representative of potential savings
in other practice settings.17 Despite this, our results support the IOM’s claim that adoption of a DA model for
patient populations with low back pain could result in
considerable savings of health care dollars.5
PTJ-PAL - J11
Functional Outcomes
Regarding functional outcomes and change in disability
for the episodes of care related to spinal dysfunction, the
change in degree of disability following physical therapy
intervention did not appear to be associated with how
patients accessed physical therapy services. The functional change scores also are consistent with other
studies that assessed changes in disability following PR
physical therapy services for patients with cervical disorders and low back pain.18,19 This may refute critics of
DA who argue that independent practitioner status for
physical therapists may result in improper diagnosis,
overutilization of services, and inappropriate care.20 This
might imply that physical therapists were equally competent as the referring physicians in regards to generating patient diagnoses.
Limitations
This study was a retrospective clinical report that precludes any conclusions related to potential under/over
utilization of services. Several possible biases related to
the utilized databases include 1) missing observations,
2) selection bias related to severity or chronicity of
the medical conditions in the two groups, 3) database
lacked information on drug charges and other charges
for services seen outside of UWHC, and 4) validity of
episode construction (e.g. start, end and transactions).
Although missing episode observations were noted, they
represent a very small percentage of our potential sample (n = 11, 2.4%), which were judged not enough to
impact the data analysis. Only seven patients were lost
to follow-up and the other missing values were random
and considered not germane to the study. To minimize
selection bias, patients with inpatient stays (e.g. more
severe injuries such as fractures, trauma) and/or seeking post-operative care were excluded from the study.
These patients typically would be under direct care of a
physician and require more frequent physician followup visits and expensive diagnostic imaging, potentially
inflating total cost of care for the PR group.
Selection bias may also be a result of chronicity of the
medical conditions in the two groups. Although Leemrijse et al.16 found PR patients had greater chronicity
of pain symptoms, our analysis showed the two groups
were similar with respect to chronicity. In addition,
participants’ age, gender, and health care history (nonphysical therapy condition-related costs) of the previous
six months was used to adjust for the persistence and severity of health care needs and use. The disadvantage of
this method for assessing medical care is that a patient’s
health history and clinical status must be inferred from
the pattern of prior utilization rather than auditing
medical records.
J12 - PTJ-PAL
While an average cost-savings of $1,455 was noted with
the DA episodes of care, the total costs were potentially
underestimated given they did not contain medication
charges. Overman et al.8 noted that physician-managed
patients were prescribed minor analgesics (non-steroidal
anti-inflammatory drugs) twice as often as for the physical therapist-managed patients, and muscle relaxants
and major analgesics were prescribed 3-6 times as often.
Martin et al.3 reported that prescription medication
expenditures associated with spine-related care rose
139% between 1997-2006. During UWHC’s DA pilot
program, physical therapists referred patients to their
primary care physician for pain medications in less than
4% of the cases.10
Because our study examined cost data, an administrative rather than clinical method was used to identify
the start of unique episodes of care. Error may have
occurred from either the inclusion of irrelevant transactions or the exclusion of transactions actually related to
the condition of interest. Similar to conclusions reached
by Pendergast et al.,9 while our findings indicate that a
DA episode of care is less expensive than a PR episode
of care, we do not know whether this is indicative of
differences in illness severity. Although we controlled for
important patient characteristics and information that
was available in the cost data, we only had functional
outcome data for the participants with spine dysfunction.
Despite these limitations, our results provide valuable
information that the costs and resource utilization (diagnostic imaging referral and physician consultation)
were reduced for DA patients compared to PR patients.
Conclusions
After adjusting for key demographic variables, chronicity, and non-PT related health care utilization in the
previous six months, we found that DA episodes had
fewer physical therapy visits and were less costly than
PR episodes. We also found that DA episodes had
shorter physical therapy durations, fewer numbers of
office visits and other services, and same quality functional outcomes for those with spinal dysfunction.
References
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