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  • Study: Direct Access to Physical Therapy Safe, Effective, and Cheaper Than Referral-Based Care

    In brief:

    • Researchers analyzed claims and outcomes data for 447 patients receiving physical therapy for back or neck pain either via direct access or medical referral
    • Patients in both groups received the same guideline-based care using the same outcome measures
    • Improvement in pain and disability was similar, but direct access patients with neck or back pain incurred $1,543 lower average costs than those who chose referral from a physician, with no adverse events
    • Authors suggest physical therapy direct access as 1 way to decrease cost of care in this population

    While opponents of direct access to physical therapy often cite patient safety as a concern, a new study comparing direct access and traditional access to care identified similar outcomes, no adverse events, and lower cost of care. Patients who obtained physical therapy via direct access had significantly lower medical costs—an average of $1,543 less per patient than those who chose referral from a physician. The study was e-published ahead of print in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free).

    Using a clinical registry, researchers compared 2 years' worth of claims data and patient outcomes for 447 patients who received physical therapy for back or neck pain in a “physical therapy-led spine management program” via medical referral versus patients who accessed physical therapist care without a referral. Outcome measures used for the study were the numeric pain rating scale, Oswestry low back pain index or neck disability index (as appropriate), the patient health questionnaire for anxiety and depression (PHQ-4), and the EQ-5D, a standardized overall health status measurement instrument.

    The 276 patients who chose direct access had “significantly fewer” physical therapy sessions (mean = 0.9) and days in care (mean = 10.5). The average cost per direct access patient was $260 less for physical therapy, $169 less for radiology, and $53 less in “other costs” such as medications compared with individuals who accessed physical therapy after physician referral. Total cost savings for the entire direct access group equaled $400,000.

    “These findings are pragmatic and reflect the impact of patient choice to access care for neck and back pain in a real clinical environment,” say authors. “Our results suggest who sees a patient with neck and back pain first influences downstream costs over the next year.”

    This is significant, according to the researchers, because “spine-oriented conditions” cost $85 billion every year, not including costs of workplace productivity. And these costs continue to rise—the average cost per patient has increased 49% between 1997 and 2006.

    Authors note that the increase in costs has not led to improved outcomes, hypothesizing that 1 possible reason is the delay in care due to the process of medical referral. They believe direct access to physical therapy would lead to lower costs and outcomes similar to traditional medical referral avenues.

    Researchers merged clinical data from the ATI Patient Outcomes Registry with claims data from Blue Cross Blue Shield of South Carolina. All participants were adult employees or employee dependents of the Greenville Health System in South Carolina. The program included access to 8 physical therapy clinics in 3 counties. During the program, BCBS actively encouraged patients to seek physical therapy care first, rather than seek physician care first for low back or neck pain. BCBS plan benefits were the same for both groups.

    All patients received the same type of care based on clinical practice guidelines with progression criteria and were evaluated using the same outcome measures for pain, disability, psychosocial factors, and overall health. In a few cases, direct access patients were referred to a physician for consultation.

    “When patients chose to see a physical therapist first, there were no identified incidents of missed diagnosis or delays in care as a result of physical therapists’ clinical decision making," authors write. "This suggests that physical therapists utilizing a standardized, evidence based screening questionnaire can adequately determine appropriateness of physical therapist intervention. This is an important finding, as patient safety is often noted as a counter argument to direct access to physical therapy.”

    Authors of the study include APTA members Thomas R. Denninger, PT, DPT, Chad E. Cook, PT, PhD, and Charles A. Thigpen, PT, PhD, ATC.

    The study did have some limitations: The majority of the patients chose traditional referral. Patients in that group were younger, more likely to have acute onset of symptoms, and more likely to have widespread pain. The study also was potentially biased by “unmeasured factors” influencing patients’ choice of first provider, lack of prior health utilization data, and exclusion of patients who did not complete physical therapy.

    However, authors say the results “suggest that the availability of the choice to pursue direct access to physical therapy for back and neck pain is safe and provides similar outcomes with cost savings comparing to traditional medical referral.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • Direct access is the law in Ohio since 2004 and it has been useless because 95% of insurers including Medicaid require a physician referral. So after 40 years of struggle to get this we are right back where we started. In addition POPTS has ballooned because of the need for a referral for the insurers. Making professional practice a big joke. The children just want to stay infantile.

      Posted by Ray Aschettino on 11/10/2017 7:14 PM

    • The major limitation of this study is that no POPTs were considered: the discrepancy would be larger in that case. And physician referral would likely result in a referral to a POPT practice. So while the data favors self-referral/direct access, the data set is still skewed.

      Posted by Nechama Karman on 11/13/2017 9:50 AM

    • Please get this data into the hands of every Government Affairs Committee Chair across the country to present to Insurance Payers in the legislative body. Getting direct access is one thing- demonstrating cost savings to payers is the real change that is necessary. They will always require physician referal unless we demonstrate that it will cost THEM less. Clinicians- you want this to change? Advocate locally with state chapters, and get your legislators involved in medical resource utilization!!

      Posted by Sarah H Stuhr on 11/16/2017 11:38 AM

    • Maybe it is more clearly explained in the full study, but $260+ $169+$53= $482 in saving, not $1543.

      Posted by Brian Lambert PT on 11/16/2017 2:16 PM

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