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  • APTA Report: Use of Direct Access Among PTs Is Widespread, but Barriers Need to Be Addressed

    Some form of direct access to physical therapist (PT) services has been a reality in all 50 states since early 2015. But just how much of a reality is it? That’s another question.

    A recent report from APTA analyzed data from a 2015 survey of nearly 6,000 PTs from all states and the District of Columbia to get a sense of how direct access was being implemented—or not implemented—and what might be standing in the way of broadest possible use. Analyses found that while direct access is happening to some degree across the country, a combination of institutional barriers, state-level restrictions, and varying levels of understanding of the concept among PTs may be hindering its growth.

    According to the report, 1 of the biggest impediments to widespread use of direct access is the fact that some states restrict the practice through provisions that include limiting the number of sessions that can be provided without a referral, only allowing for a certain number of days to pass between startup of physical therapy and obtaining a referral, and placing special requirements on PTs who want to engage in direct access. Not surprisingly, PTs in states with unrestricted direct access tend to have higher engagement levels than those working under restrictions.

    But that’s not the only thing standing in the way of more widespread use of direct access. The report points out that the barriers most often cited by PTs in the survey had to do with the policies of supervisors or facilities requiring referral even when the state allows direct access. Nearly 2 out of 3 respondents said that their employment setting required referrals regardless of state law.

    In addition to those very real restrictions, direct access also may face a perception problem among some PTs, with 60% of respondents reporting that concerns about reimbursement were among the biggest barriers to increased direct access use—a number at odds with the fact that “claims for direct access are not routinely denied” by payers, according to the report. And that low rate of denial is in line with respondents’ estimates that only 7.5% of their direct access claims were denied (though 41% said they didn’t know for certain that their claims were denied due to lack of referral).

    good news is that even with those real and perceived barriers, direct access is being used widely among PTs, with 50% of respondents reporting some use of direct access. In states with unrestricted direct access, the rate climbs to 65.5%. Most of the use (69%) is occurring in private and hospital-based outpatient clinics and group practices.

    Among other details from the report:

    • The most frequently cited services associated with direct access include “traditional patient and client management,” with 93.3% of users listing those services. Fitness, prevention, wellness, and health promotion was listed by 43.8% of PTs who engaged in direct access, and 39.3% of users listed screenings as an associated activity.
    • Of the 73% of direct access-using PTs who market direct access, 69.7% do so through direct marketing to patients, with 53.1% listing participation in community events, and 48% reporting that they provided education on direct access to referral sources.
    • Respondents reported self-pay patients as the highest users of direct access, at 44.1%. Patients with commercial coverage were estimated at 25.3%.

    “This report provides a snapshot of direct access use and perceptions at a particular point in time,” said Elise Latawiec, PT, MPH, APTA senior practice management specialist. “We anticipate that its use has increased since 2015, and we will continue to advocate for states to drop restrictions, to increase patient access. At the same time, it’s important for PTs to gain a solid understanding of direct access and promote its benefits to the institutions and facilities that are imposing restrictions that aren’t required by state law and regulation. As we move to a value-based environment, direct and early access to therapy services will play a critical role in the profession’s ability to deliver on lowering overall health care costs.”

    Want to learn more about direct access? Check out APTA’s “Direct Access in Practice” webpage for a wide range of resources from podcasts and videos to tips on preparing for direct access in your practice setting.


    • It is my belief that direct access is also held back by insurance companies requiring a referral for payment to made.

      Posted by Andrea Evans -> >JV[DJ on 10/24/2017 10:50 AM

    • We were utilizing direct access more until the healthcare exchange came into place. What we have run into is the fact that our state mandates that insurance companies have to reimburse for our services without a physician order, but the trust plans on the exchange do not have to follow our state regulations, and thus their plans require a physician order for our services. Frustrating!!

      Posted by Christy Zimmer on 10/25/2017 6:34 PM

    • While we believe it is good to communicate with other providers for best continuum of care: MD, ND, FNP, PA, DO, DC, Acupuncturist, Massage therapist etc, we never ask for referral for our private payers who do not require it. If we as a profession are too lazy (Like setting Blanket policy for all payers) or fearful (fear of denial) of making changes, then our profession will continue to be viewed an ancillary service rather than being the primary practitioners that we should be with the DPT and our knowledge based of the musculoskeletal and neurological systems. Melinda Halford, PT, CLT, Cert. MDT

      Posted by Melinda Halford on 10/25/2017 7:47 PM

    • Our role in healthcare has slowly evolved, but that role is not always embraced by Physical Therapists. I still witness PT's baking cookies for MD's and engaging in other subservient roles that perpetuate a type of class distinction. In discussions with some of these PT's, they express an attitude consistent with anxiety over being an autonomous practitioner. Many also fear financial failure so they cling to MD ownership for security. They know these anxieties wouldn't be viewed as professional attitudes by their peers, so I suspect they choose to answer surveys in ways that place the responsibility of their actions on other individuals or systems. There are likely many causes for these anxieties, but the lack of mandated residency training is among the causes.

      Posted by Brian D'Orazio on 10/26/2017 3:38 PM

    • "Direct access" in Hawaii is very limited by our 2 primary insurance providers. Unlike Medicare, BC/BS and Kaiser will not even allow an initial evaluation without a referral. Interested in knowing how to begin "establishing a blanket policy for all payers". Would this be a state by state policy?

      Posted by Betty Fackler on 10/26/2017 7:40 PM

    • In reference to the comment from Betty Fackler. There is a write up of the efforts of the Hawaii Chapter with the BC/BS affiliate (HMSA) in the HAPTA website. In the Kaiser system, all members have direct access to PT, have had since 2003. It appears it will be by individual insurers rather than a blanket policy. To get a "blanket policy" by legislation we'd probably have to demonstrate a true restraint of access by the insurers practice of requiring a physician referral. As patients are eventually seen anyway and not critically or adversely affected by the delay, I'm not sure this will fly. I'm not aware if any jurisdiction has tried this approach. Per the aforementioned report the Chapter is continuing it's efforts.

      Posted by Herbert Yee on 11/17/2017 1:59 AM

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