Direct Access in the States
Our goal
APTA Vision Sentence for Physical Therapy
2020
By 2020, physical therapy will be provided by physical
therapists who are doctors of physical therapy,
recognized by consumers and other health care
professionals as the practitioners of choice to whom
consumers have direct access for the diagnosis of,
interventions for, and prevention of impairments,
functional limitations, and disabilities related to
movement, 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
DPT
EBP
DA
Professionalism
AP
PoC
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 1957
Maryland – 1979 (technically CA in 1968 but overturned with AG opinion)
Massachusetts – 1983
Arizona - 1983
West Virginia - 1984
Nevada, Utah - 1985
Alaska + South Dakota – 1986
Kentucky, Montana + Idaho – 1987
Colorado, Iowa + Vermont – 1988
North Dakota - 1989
Direct Access with provisions
Arkansas – 1997
Connecticut – 2006
Delaware – 1993
DC – 2007
Florida – 1992
Maine – 1991
Minnesota – 1998
New Hampshire – 1988
New Jersey – 2003
New York – 2006
North Carolina – 1985
Ohio – 2004
Oregon -1993
Pennsylvania – 2002
Rhode Island - 1992
South Carolina - 1998
Tennessee – 1999
Virginia - 2001
Washington - 1988
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 specified
period 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 Access
Arkansas (1997) and Washington (1988)
Spinal manipulation prohibitions in return
for direct access – NEVER AGAIN!
Limited Direct Access
California - 1968
Georgia - 2006
Kansas - 2007
Illinois - 1988
Louisiana - 2003
Mississippi - 2006
Missouri - 1999
New Mexico - 1989
Texas - 1991
Wisconsin - 1989
Wyoming - 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 Access
States without direct access to evaluation:
Alabama and Indiana
States without direct access to treatment:
Hawaii, Michigan, Oklahoma
Creating a New Paradigm in
Health Care with Direct Access
MD/DO
OD
DPM
DC
DDS
MD(specialists)
PT
PA
NP
RD
PT
NP
OD
DPM
MD
PT
RD
MD
PA
DC
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 Access
Improved Choice
Eliminate delays
Faster return to work
Benefits of Direct Access
for the Patient
• Choice of provider
• Less visits
• Convenience/flexibility
• Earlier intervention
• Decreased out-of-pocket expense (copays,
pharmacy)
The Benefits to the Payer
Cost Effectiveness
Consumer Choice
Benefits of Direct Access
for the Payer

Decreased costs when referral not
required
Physician visit costs
Combats referral for profit (over-utilization)
Benefits of Direct Access
for the Payer

Decreased costs when referral not
required
Possible unnecessary diagnostic or
pharmaceutical costs
Benefits of Direct Access
for the Payer
• Decreased number of claims to process
–
–
–
–
Physician visits
Diagnostics
Pharmacy
Appeals
Benefits of Direct Access
for 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 overutilization3:
– Physician referral
episodes of care
generated 67% more
claims and 60% more
office visits
1000
900
800
700
600
500
400
300
200
100
0
Claims
MD
PT
Office
Visits
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.
MD
Refers
$14,000
DA for
PT
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Cost
Claims
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 to
make 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 child
must 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 Rotenberg
Minnesota 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 Matson
Minnesota Medical Association
MedPAC
The 2004 MedPAC report was to determine
the feasibility of removing the referral
requirement for the Medicare program and
does 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.
MedPAC
In the same report MedPAC Commissioners and staff fully
acknowledged 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 Information
Justin Elliott
Associate Director, State Government Affairs
American Physical Therapy Association (APTA)
1111 North Fairfax Street
Alexandria VA 22314
justinelliott@apta.org