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  • UnitedHealthcare Announces New Pilot Program to Increase Access to Physical Therapy Services as Result of Collaboration With APTA

    This week, UnitedHealthcare (UHC) announced a pilot program in 5 states that will waive the cost of copays and deductibles for 3 physical therapy sessions for patients with low back pain (LBP) living in Connecticut, Florida, Georgia, North Carolina, and New York. The pilot, which could affect as many as 1 million enrollees, goes into effect July 1, 2019. Other states will join the program in 2020 and 2021.

    Specifically, the pilot will be available to UHC enrollees with new onset of LBP when receiving care from an outpatient in-network provider. This benefit change will not extend the enrollee’s physical therapy or chiropractic benefit maximum, and will apply only to services related to treating back pain. Enrollees must have physical therapy or chiropractic benefits remaining in order to use this benefit.

    UHC will send emails about the benefit change on a quarterly basis to enrollees in the 5 states as they gain access to the benefit. Information also will be included on myuhc.com in the enrollee’s benefit information under Rehabilitation Services - Outpatient Therapy and Chiropractic (Manipulative) Treatment.

    This pilot follows a multiyear collaboration between APTA, OptumLabs, and UHC that included publication of a study in the American Journal of Managed Care (subscription required). This study affirms that higher copays and payer restrictions on provider access may steer patients away from more conservative treatments for LBP, including physical therapy and chiropractic services. "Innovative modifications to insurance benefits," authors write, "offer an opportunity for increased alignment with clinical practice guidelines and greater value."

    "This type of collaboration between a professional association and a private insurer is key to advancing the essential role of the physical therapy profession in improving outcomes for patients," says Carmen Elliott, MS, APTA's vice president of payment and practice management. "APTA continues to advocate for benefit design that is validated by data and meets the needs of patients, providers, and payers.”

    The study's authors, which include APTA member Christine M. McDonough, PT, PhD, hypothesized that patients with LBP who had easier access to a wider array of providers and lower out-of-pocket costs would be more likely to first seek out conservative approaches such as physical therapist (PT) or chiropractic services.

    Researchers looked at 5 years of claims data from OptumLabs Data Warehouse for 117,448 adult patients to determine the relationship between health plan benefit design and patient choice of primary care physician (PCP) versus a physical therapist or chiropractor as the first-line provider for new-onset LBP.

    Patients were excluded if they were not enrolled 2 years before and after the onset of LBP with no prior diagnosis of LBP or back procedures, or if they had filled opioid prescriptions within a year of LBP onset. Included patients could not have had any neoplasm diagnosis in the previous year or recent LBP-related diagnoses, such as spinal fractures, that would require more intensive treatment.

    For the analysis, authors divided the patients into 2 groups: those who first sought treatment from either a PCP or a PT, and those who first sought treatment from either a PCP or chiropractor.

    Their findings include:

    Only 2.8% of the 82,052 patients in the PCP-versus-physical therapist group chose to see a PT first, while 31% of the 115,144 patients in the PCP-versus-chiropractor group chose to see a chiropractor first. The majority of patients had a point-of-service (POS) health plan, and approximately 30% had no copayment or deductible to meet.

    Fewer restrictions on provider access was associated with higher likelihood of seeking out physical therapy or chiropractic treatment. Compared with patients with a POS plan, patients enrolled in a preferred provider organization (PPO) plan—the least restrictive option—were 32% more likely to see a physical therapist first. Patients in exclusive provider organization (EPO) plans were 16% less likely than POS patients to see a physical therapist first. These findings were similar for choosing a chiropractor versus a PCP.

    Higher copayments decreased the likelihood of a patient seeing a physical therapist as first provider. Patients with a copayment over $30 were 29% less likely to see a physical therapist first than were patients with no copayment. This association was not evident for chiropractic.

    As deductibles increased, the odds of a patient seeing a PT first declined; this association was not consistent for chiropractic. Patients with a deductible between $1,001 and $1,500 were 19% less likely to see a PT first (as opposed to seeing a PCP) than were those who had no deductible, while patients in this level were more likely to see a chiropractor first. Patients with a deductible of $1,500 or more were 11% less likely to see a PT first and 7% less likely to see a chiropractor first.

    There were mixed results for consumer-driven health plans (CDHPs) such as health reimbursement accounts (HRAs) and health savings accounts (HSAs). Patients with HRAs were 16% less likely to see a PT first compared with patients without CDHPs, but they were slightly more likely to see a chiropractor first. Patients with HSAs were 25% more likely to see a PT first compared with patients without CDHPs. HSAs had no effect on the chiropractic group.

    "Our study has demonstrated that patients experiencing LBP are moderately responsive to network restrictions and cost sharing in their choice of entry-point provider," authors write. "Reductions in spending are not necessarily accompanied by improvement in value, particularly if patients bypass routine care that would prevent higher downstream costs."

    [Editor's note: McDonough is also the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant as well as a recipient of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    News From NEXT: 2018-2019 Marquette Challenge Raises Over $266,000 for the Foundation

    Students from across the country were recognized June 13 during the Foundation for Physical Therapy Research (Foundation) awards luncheon for their participation in the 31st annual Marquette Challenge—which for 2019-2020 will be called the VCU-Marquette Challenge. Virginia Commonwealth University (VCU) was recognized as the top fundraising school, raising $34,327. The challenge now takes on VCU’s name along with host Marquette University as part of the contest's tradition.

    Earning second place was the University of Pittsburgh ($22,648), and coming in third was the University of Delaware ($18,323). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising $25,000.

    The annual challenge is a grassroots fundraising effort coordinated and carried out by student physical therapists and physical therapist assistants across the country.

    This year, more than 150 schools nationwide participated in creative efforts to support the Foundation, raising a total of $266,019.

    Funds raised through the challenge go toward physical therapy research grants and scholarships and support the rigorous scientific review process that helps the Foundation identify the most promising new investigators. Since 2002, 27 research grants and scholarships have been awarded in the name of the challenge. Funds from the challenge also supported a recent high-priority research grant to look at physical therapist interventions for older adults who have multiple chronic conditions.

    To view the complete list of participating schools visit the Foundation's webpage.

    The Good Stuff: Members and the Profession in the Media, June 2019

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Feeling the beat of pain management: Don Walsh, PT, DPT, MS, associate professor of physical therapy at North Georgia University, has teamed with professors from the school's music department to offer a drum circle as part of a pain management program—an idea funded in part by Move Together's Pro Bono Incubator. (Gainesville, Georgia, Times)

    Helping to shape health care policy: Alan Meade PT, ScDPT, MPH, has been appointed to the US Centers for Medicare and Medicaid Services Advisory Panel on Outreach and Education. (CMS announcement)

    Assistant coach/PT: Maral Javadifar, PT, DPT, talks about the path that led her to her position as an assistant coach for the Tampa Bay Buccaneers. (ESPN)

    Foam roller risks: Danielle Weis, PT, DPT, has a few words of warning for foam roller fanatics. (wellandgood.com)

    I like big putts and I cannot lie: Morgan Lemos, PT, DPT, describes how physical therapy can keep golfers on the course. (NBC2 News, Fort Meyers, Florida)

    Quotable: “Physical therapy and occupational therapy are important to him because he’s trying to gain the strength to stand from his chair for his badge pinning and salute for the national anthem." -Jessica Greenfield, whose 11-year-old son Miller aspires to become a police officer as he struggles with the challenges of a neurodegenerative disease. Miller was recently accepted as a cadet in the Sacramento, California, police department. (CBS13 News, Sacramento)

    Strength, courage, and inspiration in fighting cancer: Michelle Masterson, PT, PhD, delivered a moving speech at a cancer survivor celebration held by the Eleanor N. Dana Cancer Center at the University of Toledo Medical Center. (Toledo, Ohio, Blade)

    Bringing a PT perspective to CMS: Carmen Cooper-Orguz, PT, DPT, MBA, has been named to the US Centers for Medicare and Medicaid's annual advisory panel on hospital outpatient payment. (Federal Register)

    Sculpting a PT vision: Richard Smith PT, MS, has retired from his clinic position and is now making his mark as a sculptor. (Fairfield, Montana, Sun-Times)

    Getting in the swim of things: Laura Diamond, PT, MSPT, MS, leads a swim team of patients, family, and friends that competes in local fundraising events for cancer research. (Lincoln, Massachusetts Wicked Local)

    A PT's testimony on serving in the military as a transgender woman: Army Capt. Alivia Stehlik, PT, DPT, testified to congress about the contributions made to national defense by her and other transgender individuals in the military. (NBC News)

    When discomfort takes off: Blake Dircksen PT,DPT, offers tips on the best way to sit on a long flight. (lifehacker.com)

    Get some rest: Alika Antone, PT, DPT, discusses the importance of adequate sleep to good health. (South Sound Magazine)

    Don't stand for sitting: Kasey Kruse PT, DPT, outlines the risks of too much sitting, and what can be done to address them. (CBS News11/21, Dallas-Fort Worth, Texas)

    Quotable: "We physical therapists hope that people will begin to see physical therapy as a necessary and tremendously helpful part of maintaining a healthy lifestyle. Eventually, we hope people will come to physical therapy for an annual check up, so that we can spot dysfunction before it becomes painful and problematic." –Rena Eleazar, PT, DPT, on helping people to understand when they should see a PT. (Self)

    Helping heroes regain independence: Whitney Anderson, PT, DPT, shares her pride in being part of a rehab team that helped a wounded warrior gain independence through use of an exoskeleton. (KFOR News 4, Oklahoma City, Oklahoma)

    Easing plantar fasciitis pain: Chris Wilson, PT, outlines ways to manage plantar fasciitis at home. (Frontiersman)

    Got the (tummy) time? Tricia Catalino, PT, DSc, and Jill Heathcock, PT, MPT, PhD, discuss the importance of "tummy time" for infants. (New York Times)

    Worth the weight: Keaton Ray PT, DPT, ATC, provides pointers on how to start weight training the right way. (nextavenue.org)

    The Lakers' PT advantage: Judy Seto, PT, DPT, has been named director of sports performance for the Los Angeles Lakers. (lakersnation.com)

    The keys to more years in the driver's seat: Heidi Piccione PT, DPT, recommends movements that can build flexibility to help older adults keep driving. (Tampa Bay, Florida, Times)

    Journal-publishing how-tos: Christopher Kevin Wong PT, PhD, and Jean Fitzpatrick Timmerberg PT, MHS, PhD, share what they've learned about starting up an academic journal (they're cofounders of the Journal of Clinical Education in Physical Therapy). (Columbia University Medical Center newsletter)

    Let's dance: Michelle Reilly PT, DPT, explains how dancing can be an effective alternative to the gym when it comes to staying physically fit and active. (Omaha, Nebraska, World-Herald)

    Quotable: “There are times where somebody else has the knowledge that a physician doesn’t have to be the leader. A good example would be if physical therapy or some other modality is more important to the patient progressing. In those instances, the physician shouldn’t be necessarily calling the shots.” – Jason Higginson, MD, chief of pediatrics at eh Brody School of Medicine at East Carolina University, and co-author of JAMA module on working in interprofessional teams. (American Medical Association newsletter)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    News From NEXT: Oxford Debaters Argue: Is Social Media Hazardous?

    The verdict is in: social media is hazardous to the physical therapy profession. At least some of the time.

    That was the outcome of the 12th annual Oxford Debate, during APTA's NEXT Conference and Exposition in Chicago, which in traditional style-over-substance fashion included the pro team wearing hazmat suits while the con team adopted a Blues Brothers theme.

    "Our job isn't to say that social media is good or evil but that it's hazardous," Karen Litzy, PT, DPT, said in her opening remarks for the pro team. "People [complain], sell pseudoscience, and attack others. This is where social media becomes hazardous."

    Litzy was joined on the pro team by Jimmy McKay, PT, DPT (team captain), and Jarod Hall, PT, DPT. Taking the opposing position were Ben Fung, PT, DPT, MBA (team captain), Jodi Pfeiffer, PTA, and Rich Severin, PT, DPT. (Positions in the Oxford Debate are assigned, and may not reflect the personal opinions of the participants.)

    News From NEXT: Debaters Argue: Is Social Media Hazardous?

     

    Pfeiffer, dressed as Sister Mary Stigmata, led off for the con team, arguing, "Social media is vital. It's how we communicate with each other. Some people disseminate misinformation on social media. How do we correct it? On social media! We will use it to get rid of the misinformation."

    Hall responded, "One study said that, across social media, young professionals spend 116 minutes a day. Social media thrives on the misfortunes of others." Borrowing the concept of schadenfreude—defined as pleasures derived from the misfortunes of others—Hall referred to schandenFacebook. "It's where you relate the great things you said to Mrs Jones and ignore the stupid things you said to 50 others. Sometimes the grass looks greener (on the other side) because it's fake."

    Fung insisted that social media does more good than harm, asking, "Which is more hazardous to our profession: that questions are being asked or that we're not part of the conversations? One study found that only 1 in 10 people who need physical therapy will receive physical therapy. If you want to get the average person away from the screen, you have to be part of the conversation. The greater question is that when people ask questions, we're not there [on social media] in their time of need."

    Audience participation followed, with a near-even split of 7 for the pro position and 6 for the con. Among the comments:

    • Anything can be hazardous. If we're not using social media, we're missing an opportunity.
    • How many people at NEXT have met people on social media?
    • How many people have sat next to someone at NEXT who isn't paying attention because they're on social media?
    • Maybe we shouldn't be looking for evidence and research on social media.

    The attendees also made their views known by using clappers, running from one side of the room to the other as a debater made a persuasive point, and enthusiastically cheering.

    Severin summarized for the con team: "PTs are the movement experts. But people have an outdated image of physical therapy. #ChoosePT changed many views about physical therapy. The PT Day of Service, under the brand of physical therapy, has helped. Social media is key to that movement. Illinois and Texas recently adopted direct access legislation, and social media was vital in that effort. Social media has removed hazards to the profession. It's where we create communities. In addition, it's where patients and the next generation of PTs are going. We need to engage with our communities on social media."

    McKay summarized for the pro team: "My job isn't to show that social media is good or bad, just that it's hazardous. Social media leads you to do things you'd never do in person. … Social media is how the anti-vax science goes viral. This is how flat earth society thought goes around the world. Social media filters and distorts information. That's hazardous. But social media is not going away. So we must be safe when using it."

    After weighing the arguments and presentations, moderator Charles Ciccone, PT, PhD, FAPTA, found in favor of the pro team 29-23.

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    News From NEXT: For Optimal Outcomes, Look Beyond Compensation Patterns, Maley Lecturer Says

    "Any movement-related profession—personal trainers, athletic trainers, dance therapists, yoga instructors—who can observe impairments such as a weak muscle can try to fix it," said Beth Fisher, PT, PhD, FAPTA, in delivering the 24th John H. P. Maley Lecture on June 14 at Combined Sections Meeting. However, too often the "fix" involves the patient compensating with movement patterns that interfere with the ability of an affected limb to improve to its true potential. Fisher argued that with their level of education and skill, physical therapists (PTs) can and should identify and help the patient recover that capability.

    During her presentation "Beyond Limits: Unmasking Potential Through Movement Discovery,"

    Fisher said that in earlier clinician practice with patients with stroke and brain injury she continually hit ends points with her patients, but she realized "these were my endpoints and not the patient's, [because] at least 1 aspect of the movement abnormalities…were the results of compensation." Given the brain's ability to continuously alter its structure and function, and the body's ability to achieve movement goals in more than 1 way, people with an impairment tend to progress toward the movement pattern that is most efficient—achieves a goal using the least amount of energy and the fewest body parts. And while a compensatory solution may get the job done overall, this easy route that comes naturally may not lead to optimal improvement, thus denying the patient the best possible outcome. In fact, "the compensations [patients] choose may be the source of the problem—may actually predispose the problem to occur," Fisher said, by keeping the patient from exploring better ways to achieve their movement goals.

    She asked: Is this really the best we can do? "If we want to reach someone's full capacity, then we need to go beyond this limited choice that patients come up with on their own without a physical therapist," Fisher said. However, she argued, PTs have been academically trained to view movement from an impairment-driven perspective—the assumption that a patient's compensatory movement pattern results from an impairment that is masking his or her capability. And so both PT and patient expect that compensation will provide the best—or only—results.

    "If I have minimal expectations," Fisher asked, "how is that going to impact my patient's expectations? What is that going to do for recovery potential?" Instead, as professionals with the expertise to look beyond compensation approaches, PTs must encourage potentially riskier, more-difficult solutions. "With what we know about brain plasticity, it is our job to help patients realize that they have more options," she said.

    By modifying that implicit choice, the PT can help patients discover a capability they may not have even realized they have. "The most rewarding moments I have had in my career have come when I hear ‘I didn't know my leg (or arm) could do that,'" Fisher said.

    She noted that PTs can't ignore impairment, "but if we are only viewing the problem from that perspective then we and our patients will reach a plateau-minimizing capacity."

    Instead, every student and every therapist should include the perspective of looking at how a movement choice can mask capacity. "We need to start from the bottom up," Fisher said, "and teach students to observe movement and hypothesize how implicit choices—not just impairments—may be driving movement faults." Otherwise, "we have limited patients and their potential to discover other options for movement by a perspective that does not consider the choices they make."

    News From NEXT: McMillan Lecturer Outlines Keys to Excellence in the Physical Therapy Profession

    Tom McPoil, PT, PhD, FAPTA, said he intentionally structured the title of the 50th McMillan Lecture—"Is Excellence in the Cards?" as a question "to raise an element of doubt or uncertainty in our quest to achieve excellence." After all, he said during his delivery of the lecture on June 13 as part of the APTA NEXT Conference and Exposition in Chicago, he has several concerns regarding the profession's ability to achieve excellence.

    Before describing the reasons for his uncertainty, McPoil did recognize some of the profession's remarkable accomplishments since he began his career in 1973. "We no longer serve as a subservient technician in the health care system, our students now obtain an exceptional education and are granted a doctoral degree, we can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services," he noted.

    But he said there still is room for improvement from both clinical and academic perspectives, and the remainder of his lecture outlined those perspectives. From the clinical standpoint, he described 3 areas.

    First, McPoil questioned continued acceptance of examination and management methods that may have been proven to have no evidence to support their use. As an example, he identified what is known as the podiatric model, which classifies foot types based on the concept of subtalar joint neutral position. McPoil said that subsequent studies—including those he and colleagues conducted—showed that "subtalar joint neutral position had no relevance to the typical pattern of rearfoot motion. In short, our results challenged the validity of the podiatric model." Yet, he continued, many physical therapist education programs and postprofessional continuing education courses still teach the model. McPoil expressed his hope that the profession will continue to stress the importance of using methods that have been validated with basic science and clinical evidence, especially at entry-level and in education programs, "as it is our new doctor of physical therapy graduates who must serve as our profession's change agents."

    Second, McPoil expressed concern over a lack of acknowledgment of historical research studies that provide evidence for a practice's continue use. He quoted a 2009 article by Mary Halefi ("Forget This Article: On Scholarly Oblivion, Institutional Amnesia, and Erasure of Research History," Studies in Art Education) that "recurring themes, issues, and concerns are part of any field" and failing to cite them along with more contemporary studies risks the loss of past scholarly endeavors upon which current research may be based. "Hopefully," McPoil said, "our professional journals will always perform their due diligence" to retain the contributions of past scholars and researchers in the profession.

    Inconsistence in the level of care was McPoil's third area of needed improvement. He noted some probable causes for inadequate care, such as limited patient time resulting from low payment rates, some highly specialized areas of practice that not all PTs are familiar with, and lack of clinical practice guidelines (CPGs) that address needed services. As for specialized areas of practice, he said that physical therapist-to-physical therapist referral was "rare," and the need for intraprofessional referral needs more emphasis during entry-level education. Concerning CPGs, McPoil argued that while important, they cannot always guide the clinician to an appropriate decision and "cannot replace the need for clinical reasoning and practice knowledge." He continued that such knowledge "can be achieved only through residency or fellowship training."

    To that end, McPoil said that it may no longer be feasible to train a generalist at the entry-level, and the profession must consider allowing specialization to begin before graduation. He identified challenges to developing residency and fellowship programs, such as student loan debt, salaries not commensurate with advanced clinical specialization, and a lack of federally funded support. He expressed his hope that the profession will prioritize development of these programs, as needed funding for them won't occur until they are the expected route following professional graduation. "Our pathway to excellence demands no less!" he said.

    McPoil followed up with his thoughts on achieving academic excellence, specifically the need for every faculty member to have "a personal agenda for scholarship that includes publication."

     

     

    News From NEXT: Building Wellness Programs in the Least Likely Places

    Sometimes, basic assumptions beg to be questioned. Just ask physical therapists (PTs) in the oncology rehabilitation department of Froedtert Hospital and Medical College of Wisconsin, who wondered why prevention and wellness couldn't be a part of the patient experience from the moment they entered the facility's doors.

    That questioning led to the development of an innovative group exercise program for patients checked in to the hospital for chemotherapy and other treatments primarily related to blood cancers—and so far, the program seems to be allowing many patients to leave as mobile, if not more so, than when they arrived. On June 13, the PTs shared their story of how they established and grew the program, known as the "Strength in Numbers" exercise class, as part of APTA's NEXT Conference and Exhibition in Chicago.

    The idea behind the program was based on a reality check of the typical path of an oncology patient visiting the hospital for treatment, explained Kelly Colgrove, PT. Unlike patients who arrive with other conditions such as congestive heart failure, "our patients walk in strong and independently." During the course of treatment, however, they often experience decreased muscle strength, challenging PTs to play catch-up before the patient is discharged.

    The Froedert PTs wanted to "Strength in Numbers" change that. As it now operates, the program—known as "SIN" to the amusement of patients—offers a 1-hour group circuit training class 2 times a week. Colgrove describe SIN as "a fun environment based on camaraderie and music, but all within the acute care setting."

    Patients are selected for the voluntary program based on their health at the time of check-in, Colgrove explained. Those whose condition is more fragile receive more typical 1-on-1 physical therapy. But the patients who qualify for SIN are assessed, given goals, and scheduled to participate in the group. Once the SIN group, patients still can choose to return to the more traditional therapy program.

    Besides the direct physical benefits to patients, the SIN program has helped to reinforce what the presenters call a "culture of mobility" at the hospital.

    The presenters led attendees through their process of developing and maintaining the program, encouraging audience members to think about similar possibilities in their own practice settings. They explained the importance of a solid basis in research, careful consideration of stakeholder concerns, evaluation of current and needed resources, and program metrics to evaluate outcomes, among other areas.

    Through their recaps, the presenters demonstrated how flexibility and creativity are key elements in all areas of development, implementation, and evaluation. "Being able to adapt and evolve is going to be key," explained Alyssa Kelsey, PT, DPT. For the SIN program, that means seeking ongoing input from patients and staff, as well as monthly check-in meetings to monitor operations and identify future goals.

    That flexibility should also include the capacity to question your own assumptions and evaluative measures, explained Colgrove. "Sometimes, the questions you think you want to answer at the beginning of the program may not be the questions you want to answer after a year," she said.

    One question has been consistent throughout the SIN program: Does it work? So far, the answer seems to be yes. Outcome measures for patients with a length of stay longer than 20 days and more than 50% participation in SIN found that 72% maintained or improved their 5-time sit-to-stand scores, 64% maintained or improved on Functional Gait Assessment, and 53% maintained or bettered their scores related to self-perceived deficits at discharge.

    And if patient enthusiasm for the program is any measure, the SIN program also seems to be doing well: according to the presenters, patients frequently have the same criticism of the offering—that the classes only occur 2 days a week.

    News From NEXT: How One Hospital Implemented Direct Access

    A panel of PTs from the Hospital for Special Surgery (HSS) in New York explained how that institution implemented direct access (DA) to physical therapist services during a June 13 session at APTA's 2019 NEXT Conference and Exposition. They then advised attendees how to operationalize DA at their own institutions.

    Presenters from HSS were Carol Page, PT, DPT; Mary Murray-Weir, PT, MBA; Robert Turner, PT, DPT; and Jaime Edelstein, PT, DScPT. Also presenting was Aaron Keil, PT, DPT, from the University of Illinois at Chicago.

    Keil noted that DA was achieved in all 50 states and the District of Columbia in 2015, but only 18 states have unrestricted access. The others include limiting or restrictive provisions, meaning there still are barriers to DA.

    He cited a 2015 APTA survey for which nearly 65% of respondents said the major administrative barrier to DA implementation was "My supervisor/facility requires all patients to have a referral." Keil noted that this is especially true in hospital-based inpatient and outpatient facilities, as hospitals tend to be more risk averse and "may be more restrictive than state law."

    Page said that an essential first step to achieving DA was getting buy-in. One key group was physicians—particularly surgeons—who were concerned that their patient levels would drop. Page explained, "We showed that direct access would 'widen the funnel' and actually provide them more patients," while at the same time screening to avoid sending inappropriate patients to the surgeons.

    Administrative staff was taught how to screen patients and schedule them with appropriate PTs. They also were made responsible for tracking timing and number of permissible visits for adherence to state provisions, building on an HSS foundation of training and competency programs it conducts for all staff.

    The hospital established criteria for DA PTs that were more stringent than required by the state. For example, while New York requires 3 years of clinical experience, HSS required that experience to be at outpatient facilities. It also required CEUs in certain areas, such as spine, manual therapy, and differential diagnosis.

    Turner described the development of a written exam for aspiring DA PTs. Questions were developed following the same item-writing guidelines used by the American Board of Physical Therapy Specialties. A score of 80% is required to pass the test.

    HSS also developed a practical examination involving an actual patient. The primary question to be answered is: "Can you take this patient and treat him or her? Or do you refer to a physician?"

    The program was made voluntary for PTs since some didn't initially feel comfortable with it. "Not everyone fits the mold," Turner said.

    Page addressed operationalizing DA, which she divided into 4 categories. The first was resources. She said, "APTA has amazing resources." She advised those in the audience to search APTA's website for "direct access" and browse the resources. The second category is billing, which she made clear "is different in a hospital setting" from a private practice and requires a hospital-wide effort. The team leading the DA program at HSS made a conscious decision not to contact insurance companies in advance and announce their intentions. "We did a soft launch with a small number of patients. We let them know that their interventions might or might not be covered," Page said, but he found that most insurers did cover the services, and HSS now contacts insurers in advance.

    The other elements of operationalizing DA were documentation and marketing. These included developing specific policies and procedures, providing notice of advice for patients, identifying common ICD-10 codes, and developing tip sheets for patients and physicians.

    The panel listed a series of lessons learned—things to do and things not to do. For example, don't:

    • Assume people understand what DA is.
    • Give up.
    • Be mean, defense, argumentative, or otherwise difficult to deal with.

    On the other hand, do:

    • Assume some people will think DA is illegal and/or unsafe.
    • Highlight improved patient access and patient care.

    Ask "How can we?" rather than "Can we?"

    News From NEXT: A Moving Account of a Journey Out of Pain and Addiction—And a PT's Crucial Role

    "I failed my marriage. I failed as a father. I failed my career. And I didn't even know it was happening."

    That's how Justin Minyard describes the lowest point in his life, when, after experiencing 2 spine fractures and receiving multiple surgeries, he became addicted to the opioids prescribed to him. He found himself consumed by his pain and his meds—how many he had on hand, when he could take the next one, where he needed to go to get refills. His addiction led to a suicide attempt and 2 accidental overdoses. But most devastating for Minyard was that his addiction hurt the people he loved the most.

    "I let them down," Minyard said. "You didn't want to be around me at that time."

    Now things are different. With the help of an interdisciplinary care team that included a physical therapist (PT), Minyard said he learned how to "make pain a footnote, not the header" of his life and defeat his addiction. He'll be 8 years' clean in July.

    Minyard's moving story was delivered as the keynote address at the opening event for APTA's NEXT Conference and Exposition, held June 12-15 in Chicago. The retired Army Master Sergeant recounted the injuries he received—first during a rescue attempt at the Pentagon during the 9-11 attacks and then while on a mission in Afghanistan—but focused more on what happened afterward: the multiple fusion and other surgeries, the intense pain, and his eventual slide into addiction.

    "I didn't wake up one day and say, 'this sounds great,'" Minyard said of his use of opioids; however, he believes his passive approach to exploring treatment options played a role in his use of drugs.

    "I was not an educated patient; I didn't ask questions," he told the audience.

    After more than 2 years of attempting to manage his pain through opioids and other medications—and becoming addicted along the way—Minyard began to see options for change.

    His last fusion surgery kept him in the hospital for 3 months. Then a physician who called Minyard a "hot mess" offered him another avenue: a pain management program that involved 9 different professionals including a psychologist, psychiatrist, a pharmacologist—and a PT. Minyard took him up on the offer, and moved from what he describes as a "pain-centric to a patient-centric model of care."

    Minyard credits his PT as helping him to accept the idea that, yes, he may be in pain for the rest of his life, but he could work to find ways to manage the pain to make it "more of a footnote, less of a header." Now Minyard says that on most days his pain level is moderate but manageable, around a 3 on the pain scale.

    Minyard also feels that it wasn't just about the physical therapy itself. He thinks his relationship with his PT was also a major factor in his recovery.

    "She wasn't just my PT, but my psychologist, my sounding board, my marriage counselor, my educator of my options, and my kick in the ass," Minyard said. "She was all of those things."

    That recovery included taking his PT up on a suggestion that he try handcycling. He liked it—so much so that he wound up medaling in traditional upright cycling at the Invictus games.

    Even more important for Minyard is how the changed approach to pain management gave him back his life with his family.

    "I am my 11-year-old daughter's soccer coach," Minyard said. "I get to be her coach. I don't know a damn thing about soccer, but I get to be her coach. But I almost lost that. I was this close, multiple times."

    While Minyard credits a single PT with a major role in his own recovery, he told the NEXT audience that the entire profession should be proud of the life-changing work they do.

    "You're going to continue to make such a tremendous impact on countless other patients," Minyard said. "Choose PT."

    Vision in Action: 2019 House of Delegates Sees Important Role for APTA in Host of Professional, Societal Issues

    APTA's outward-facing, forward-leaning vision continues to guide APTA’s House of Delegates. The policy-making body considered 70 motions during the 75th House session addressing a wide range of issues, yet 1 overarching theme was clear: the House believes APTA has the potential to be a change agent for the profession and society at large.

    APTA as Advocate
    Delegates approved multiple motions aimed at positioning the association as an advocate for a more diverse, equitable, and inclusive profession, beginning with a general statement that APTA "supports efforts to increase diversity, equity, and inclusion to better serve the association, profession, and society." The House also unanimously adopted stronger language around the association's commitment to nondiscrimination on the basis of race, creed, color, sex, gender, gender identity, gender expression, age, national or ethnic origin, sexual orientation, disability, or health status; as well as a charge directing APTA to work with stakeholders to advance diversity, equity, and inclusion in all areas of physical therapy, including clinical, educational, and research settings.

    The House also voted to add language to the Code of Ethics for the Physical Therapist (PT) and Standards of Ethical Conduct for the Physical Therapist Assistant (PTA) that more clearly describes the duty of PTs and PTAs to report verbal, physical, emotional, or sexual harassment. In addition, delegates approved revisions to the Standards of Practice for Physical Therapy that better align the document with the APTA vision statement and more explicitly reflect the role of PTs in population health and community engagement. In addition, the House created a single set of core values for both the PT and PTA to replace separate versions for each, noting in discussion that core values are common to PTs and PTAs but discrete from behaviors, which continue to be appropriately described in the separate ethics documents.

    Other profession-focused House actions included unanimous approval of the definition of the movement system as "the integration of body systems that generate and maintain movement at all levels of bodily function," further describing human movement as "a complex behavior within a specific context…influenced by social, environmental, and personal factors." The definition will further strengthen APTA's efforts to promote the movement system as a critical component of the physical therapy profession's identity.

    Societal Issues and population health
    The House passed multiple motions related to the ways both the association and individual PTs and PTAs are connected to larger societal issues. In addition to updating positions on the association's role in advocacy for prevention, fitness, wellness, health promotion, and population health, delegates voted to broaden APTA's ability to respond to health and social issues. The House provided examples of what those broader efforts will entail, approving motions that support taking a public health approach to gun violence, promoting public participation in vaccination schedules, improving health literacy, and supporting the availability in physical therapy settings of the drug naloxone to reverse the effects of an opiate overdose.

    A new area of specialization: wound management physical therapy
    Making it the 10th area of physical therapist clinical specialization, delegates approved the creation of a wound management specialty area for certification by the American Board of Physical Therapy Specialties, a proposal developed by the APTA Academy of Clinical Electrophysiology and Wound Management.

    Finally, in keeping with APTA’s ongoing efforts to follow best practices in governance, the motions deliberated at the House included the second phase of a complete review of all House-generated documents. The review, conducted by a special committee of the House over the course of 2 years, focused on updating, consolidating, and sometimes rescinding documents, resulting in recommendations for changes to more than 100 House policies, positions, directives, and other guidance.