Direct Access: How It Can Change Your Practice

Achieving direct access has been a major initiative for APTA and its chapters for more than 25 years. It is hard to think of any APTA program that has demanded a greater investment of volunteer time and energy, financial commitment, and staff resources than the work that has been done to achieve direct access at the state and federal levels.

While we have had tremendous success at the chapter level and are seeing promising activity on Capitol Hill, the impact of direct access on our practice appears to be less than anticipated. Data collection efforts are under way to determine the extent to which direct access is being used and promoted by physical therapists and the reasons why it is not being used more extensively.

In the meantime, it is important to consider the potential that direct access has to enhance the practice of physical therapy and the care we give our patients. Direct access allows physical therapists to:

  • Develop more collaborative relationships with other health care professionals.
  • Compete in all markets where "referral for profit" is a problem by marketing directly to consumers.
  • Be responsible for all clinical decisions related to physical therapy patient care.
  • Soften the impact of declining insurance reimbursement by offering cash-based services in the areas of prevention, fitness, and health promotion.
  • Save patients valuable time and money otherwise spent obtaining unnecessary referrals.
  • Improve patient access to care.

Even after many years, there are myths and misconceptions that surround the topic of direct access. Let's eliminate some of them now:

1. Direct access is only relevant to private practices. This is incorrect. In fact, several major hospital and health systems recently have been able to eliminate institutional restrictions on the use of direct access and are successfully treating outpatients without referral.

2. Direct access only applies to outpatients. Physical therapists across the country are successfully using direct access in private-pay home care, in industry, on the sports field and performing arts venues, in school systems and pediatric centers, and through admission orders in ICUs and other in-patient settings.

3. Insurance companies will not pay for patients seen without a referral. While it is always important to verify individual coverage for each patient, it is a mistake to assume that all insurers require a referral. In fact, information from both payers and physical therapist providers indicate very positive trends toward reimbursement without referral.

4. Direct access will increase my liability risk. In all of the years that direct access has been available (more than 30 years in some states), there has never been a documented increase in liability claims or an increase in liability premiums resulting from direct access.

5. Direct access will destroy my relationships with referral sources. Most professionals (attorneys, dentists, physicians, accountants and others) rely upon referrals from other professionals to build and sustain their practices. Direct access laws eliminate the legal requirement for a written referral---but the need for strong referral relationships is as important as it's always been. . The difference is that now physical therapists are free to develop the type of referral relationships that exist among other professional groups by serving not only as the recipient of referrals but also as a referral source to other health care professionals.

Using direct access in practice requires both confidence and competence in clinical judgment and skills. For many, it also calls for new knowledge and expertise in marketing and relationship building. How can physical therapists begin to take advantage of the opportunities provided by direct access to the benefit of both their practices and their patients?

Start in your own backyard: Tell all of your patients about the option of coming directly to you without a referral when they or their friends and family need a physical therapist. Make sure you remind them again at their final visit. Have information in your waiting room, on your Web site, and in all your promotional materials informing patients that they can come to you directly. Offer workshops and lectures on topics of special interest to your current patients to help them become familiar with your many skills and abilities.

Work to change your employer's policies. Some hospital organizations and corporations have bylaws and policies that require a referral for a patient to see a physical therapist. Physical therapists across the country have worked successfully in several settings to get these requirements changed. Through data collection efforts, they have been able to show successful outcomes in terms of number of visits, length of treatment, and reimbursement.

Check your managed care contracts. Many managed care contracts have no requirement for a referral for physical therapy. Don't assume that there is a referral requirement unless you know for sure. Many insurance companies now recognize the cost savings and improved access to care that come with direct access and do not require a referral for payment.

Offer cash-based services. Physical therapists are well qualified to provide services that are valuable and of great interest to patients-but that may not be covered by insurance plans. Some examples include osteoporosis and balance programs for seniors, fitness assessments and personalized fitness training, weight-loss programs, sports enhancement training, and group exercise classes. These programs typically require little or no extra space, equipment, or training and can be a great way to introduce the public to physical therapy.

Think outside the box. While many physical therapists consider their patients to be their primary clients, there are many opportunities to provide physical therapy services through arrangements with corporations, self-insured employers, child development centers, urgent care centers, and health clubs, to name a few. These situations provide many opportunities to build relationships with those who are in a position to suggest physical therapy to others-and are great settings in which to use direct access.

Has direct access changed your practice? If you are successfully using direct access, consider sharing your experiences with other APTA members. The more we share our successes, the faster direct access will become an integral part of physical therapist practice. What a great day that will be for our patients!

Contact nancywhite@apta.org to share your direct access successes.

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