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  • APTA Fact Sheets on 2018 Outpatient Payment, Home Health Now Available

    Now available to APTA members: context and details to help you understand final 2018 rules from the Centers for Medicare and Medicaid Services (CMS) on the home health (HH PPS) and outpatient (OPPS) prospective payment systems.

    The final OPPS rule includes provisions that APTA supported—particularly moves toward reimbursement for outpatient-based total knee arthroplasty (TKA) and "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical-access hospitals and rural hospitals with fewer than 100 beds. The rule also includes an overall 2% payment increase for outpatient hospitals and a 1.9% boost for ambulatory surgical centers. To access the fact sheet, visit the APTA Medicare Payment and Policies for Hospital Settings webpage. Scroll to the "Outpatient Care" area and look under "APTA Fact Sheets and Summaries."

    After receiving significant opposition from APTA, the APTA Home Health Section, and other professional and consumer advocacy organizations, CMS backed off on a proposed rule to adopt a payment system that, among other changes, would have removed therapy service-use thresholds from the payment mix. For now, CMS plans to leave the payment system as-is for the most part, but the agency will use 2018 as an opportunity to explore changes with stakeholders. In terms of payment amounts, CMS will enact an $80 million reduction in 2018, a cut mandated by the Affordable Care Act. The APTA fact sheet can be accessed on the association's Medicare Payment and Policies for Home Health webpage, under "APTA Fact Sheets and Summaries."

    Want even more information on CMS-related changes in store for 2018? Don't miss the December 13 Insider Intel call-in program that will include information on HH PPS and OPPS provisions. The program is available at no cost to APTA members.

    4 Things to Do Now That the 2018 Fee Schedule Is Out

    By now, most physical therapists (PTs) have heard the news: the final 2018 Medicare Physician Fee Schedule (PFS) released in early November by the US Centers for Medicare and Medicaid Services (CMS) included some significant variations from the PFS proposed in July. Instead of finalizing CPT code values that were the same as—and occasionally larger than—current values, CMS opted to offer up a more complicated combination of cuts and increases that could affect PTs in different ways, depending on their case-mix and billing patterns.

    So what should PTs do in the wake of the new PFS? Here are APTA's top 4 suggestions.

    1. Know the design process for the fee schedule.
    It's important to understand what led to the changes to provide context, a slight sense of relief, and a reminder of why payment needs to move toward value-based models and away from fee-for-service.

    The PFS now set to debut January 1, 2018, is the CMS response to an American Medical Association (AMA) committee's recommendation on potentially "misvalued" codes associated with a wide range of professions, not just physical therapy. When the process began in early 2016, many predicted that the final outcome would be deep cuts to nearly all valuations—as much as 10% or more overall. APTA and its members fought hard to substantiate the validity of the current valuations, and even the need for increases in some areas. The end result was a significant improvement from where things were headed at the start of the process.

    That's not to say it's been an entirely satisfying process from start to finish. This recent PT in Motion News story goes into more detail about the sometimes-frustrating journey from points A to B.

    2. Understand what's being changed.
    Just about everything that happens at CMS is complicated, and the process that led to the new CPT code valuations is no exception. Still, a working knowledge of how CPT codes are valued is helpful in understanding why the PFS contains such a mix of positives and negatives.

    One important thing to understand is that code valuation is actually a stew of 3 separate elements, known as relative value units (RVUs). These are estimations of the labor, expense, and possible professional liability involved in performing any given treatment or evaluation task associated with a CPT code. The 3 types of RVUs are known as "work," "practice expense" (PE), and "professional liability." The coding valuation differences between the proposed and final PFS were due to changes to the PE RVUs only.

    This wasn't part of the proposed rule. While the AMA Relative Value Scale Update Committee Health Care Professions Advisory Committee did recommend changes to PE RVUs, CMS initially opted to not adopt those suggestions. When the final rule was released 3 months later, CMS—without seeking input from APTA or any other stakeholders—did an about-face and adopted the changes to PE RVUs.

    So what? The answer is twofold: first, the tweaks to PE RVUs mean it's difficult to make many sweeping generalizations about how the new PFS will affect individual practices and clinics; second, it's worth noting that individual work RVUs either remained unchanged or increased.

    A more detailed explanation of how the codes were affected is available in an APTA fact sheet on the 2018 PFS (listed under "APTA Summaries and Fact Sheets"). For a more complete explanation of RVUs and the differences between the 3 types, check out this APTA podcast on the CPT valuation process.

    3. Get a sense of how you might be affected.
    A sense of history and understanding of detail are all well and good, but the bottom line is your bottom line.

    Here's the complication with the 2018 PFS: because of the wide variation in upward and downward adjustments, it's hard to make statements about how PTs in general will be affected. CMS estimates the overall impact at a 1%-2% reduction, but a lot depends on the types of patients a PT or clinic typically sees and what interventions are commonly used. Some providers could see increases.

    In an effort to clear up some of the uncertainty, APTA offers a calculator than can help you see how your typical case-mix would fare in the new PFS. The calculator, offered in Microsoft Excel, allows you to enter different codes to see what changes to expect, given your Medicare service area.

    4. Keep learning.
    There's much more to understand about the PFS—not just in terms of the details of how the new rule will work, but in terms of APTA's work to safeguard CPT codes throughout the misvalued codes review process.

    One great way to learn more about what to expect is coming up in December, when the association hosts a free webinar on Medicare changes for 2018 on December 6 from 1:00 pm to 2:00 pm ET. The webinar will be presented in a "flipped" format, meaning that when you register, you'll be provided with a prerecorded presentation to listen to in advance. That way, more of the actual session can be devoted to live interaction with the presenters. Be sure to sign up—and listen up—soon.

    Another opportunity is available December 13, when APTA hosts an "Insider Intel" phone-in session that will cover many of the same topics, albeit in a pared-down 30-minute session, from 2:00 pm to 2:30 pm ET. Instructions for signing up for this session are on APTA's Insider Intel webpage.

    Innovation 2.0 Learning Lab to Focus on PTs as Key Players in PCMHs to Address Childhood Obesity

    Managing childhood obesity in a patient-centered medical home setting is the fourth and final installment of APTA’s online Learning Labs series based on the Innovation 2.0 initiative. Interested members are invited to register for the interactive session, scheduled for December 15, 1:00 pm–4:00 pm.

    Like the first 3 labs, the January 18 event will enable participating APTA members to hear firsthand from the physical therapist innovators who were selected to pursue new, creative models of care. This fourth lab is your chance to hear from your colleagues about working in a patient-centered medical home (PCMH).

    In this innovative health care model, the physical therapist (PT) plays a key role in measurements of obesity-related signs and symptoms that affect the human movement system, including aerobic fitness and strength deficit, lower extremity joint pain, gait dysfunction, and motor control deficit. The PT also evaluates and monitors children's physical activity and sedentary behaviors, and is trained in behavioral strategies to enhance physical activity and parental support. The model measures cost-effectiveness by tracking incidence of disease rates and hospitalization for obesity-related conditions.

    Referrals to specialists (such as PTs when a cluster of impairments appear that indicate a movement disorder associated with obesity) are coordinated so that appropriate care is received. Regular follow-ups document progress and help the young patients and their families with self-management. This model also could provide support for including PTs in PCMHs that target other chronic health conditions that affect movement.

    The Learning Lab is a free online event intended as an advanced experience for providers who are currently active in innovative programs or ready to explore them. Participants will be expected to actively engage in the lab session, and materials will be provided beforehand to help them do so. If that’s you, visit the Innovation 2.0 webpage and scroll to the "Learning Lab" section to register.

    APTA will post a recording of the event afterward, which also will include the prerecorded presentation and downloadable template—all free to APTA members.

    Visit the Innovation 2.0 webpage to register for the PTs as Key Players in a PCMH Program for Childhood Obesity Learning Lab. For details on all of the projects selected for development, as well as projects that received honorable recognition, go to Innovation 2.0 Background. Profiles of each project were also featured in a September 2015 article in PT in Motion magazine.

    The 2018 Physician Fee Schedule: Where We Are, How We Got Here, What's Ahead

    Here are a few things that can be said about the 2018 Medicare physician fee schedule (PFS) released by the US Centers for Medicare and Medicaid Services (CMS):

    1. It's a mixed bag in terms of adjustments to current procedural terminology (CPT) codes commonly used in physical therapy, with some values going up, and others being cut.
    2. Physical therapy isn't the only profession that saw CPT code reductions: otolaryngologists, nurse anesthetists, and urologists, to name a few, are also bracing for cuts.
    3. It could've been a lot worse—up to a 10% cut or more based on changes to the practice expense.
    4. Statements 1-3 aren't much consolation when you're a physical therapist (PT) facing estimated average payment reductions between 1.3% and 2% (but again, this is hard to pinpoint: there will be increases, but in other cases decreases will be even worse).

    What happened?
    Just a few months ago, the outlook was good for PTs when it came to next year's PFS. After a 2-year American Medical Association analysis of CPT codes that CMS believed may have been potentially "misvalued," the proposed rule that emerged was a clear win for the profession: no cuts to codes values, and even a few increases. From the perspective of the profession, the proposed rule adopted all of the positive recommendations from AMA—namely, no cuts and a few increases to work relative value units (RVUs)—and none of the damaging AMA recommendations, which included adjustments to practice expense (PE) inputs that would affect payment. Things were looking good, and APTA and its members advocated strongly for the rule as proposed.

    When the final rule was issued in November, things stopped looking so bright. Between release of the proposed rule and publication of the final version, CMS veered away from its typical process when it announced—without warning and without allowing opportunity for input from any stakeholders, including APTA—that it would reverse its decision and adopt the recommendations related to PE inputs. The rule change has altered the payment landscape for PTs in ways that are still being worked out by APTA. The association has published a summary of the rule on its website (listed under "APTA Summaries and Fact Sheets").

    Mapping the landscape
    While it's true that the final rule will result in increases in some areas, some of the payment reductions that will go into effect next year will hit home for some PTs. What is known for certain is that a few of the most commonly used codes in physical therapy will see a drop, including manual therapy, therapeutic exercise, mechanical traction therapy, and aquatic therapy.

    At the same time, other codes will increase—some significantly. Gait training therapy values will increase, as will neuromuscular reeducation, and therapeutic activities. Values for the 3-tiered evaluation codes adopted by CMS in 2016 also will rise (although the single value for all 3 tiers is maintained), in addition to orthotic management and training (first encounter), and prosthetic training (first encounter).

    APTA is putting final touches on a calculator that will help members get a more precise estimate of the potential impact of the new rule, given their particular practice circumstances. The calculator is set to be released early next week.

    "While it's clear that the CMS reversal from its proposed rule will result in drops to some of the codes used frequently by PTs, the bottom line effects of the new rule will vary depending on case mix and billing patterns," said Carmen Elliott, MS, APTA vice president of payment and practice management. "The overall 2% drop estimated by CMS doesn't take that variation into account. There will be some providers who will see reductions in payment of anywhere from 1% to 2%, but we anticipate that others could see overall increases."

    How we got here
    "This is frustrating, both in terms of the payment reductions as well as the way CMS surprised stakeholders with its reversal from the proposed rule. The cuts will be hard on some physical therapist practices," said APTA Vice President of Government Affairs Justin Elliott (no relation to Carmen Elliott). "It’s also true that the initial projections, long before the initial proposed rule, were far more bleak."

    Justin Elliott is referring to the way CMS handles codes that it believes may be "misvalued"—often read as a euphemism for "overpaid." It's a complex, multi-year process overseen by the AMA's Relative Value Scale Update Committee (known as RUC) Health Care Professions Advisory Committee (HCPAC). The RUC HCPAC engages in dialogue with stakeholder groups, including APTA, and conducts surveys of individual providers before issuing recommendations on how codes should be valued. The survey of PTs was conducted in October 2016.

    When the process began in early 2016, indications were that, overall, CPT codes commonly associated with physical therapy could see a double-digit cut. APTA staff and CPT advisors worked with the RUC HCPAC to move recommendations away from that potentially catastrophic change, and survey responses from PTs helped to reinforce the notion that current code values were not far off—at least in terms of averages across all codes.

    Given where things seemed to be headed in 2016, the release of the final rule, though far less than ideal, does amount to a win—of sorts. And context is important: physical therapy wasn't alone in professions with codes on the CMS chopping block, with otolaryngologists, anesthesiologists, nurse anesthetists, urologists, and vascular surgeons all seeing overall code reductions between 1% and 2%, according to CMS estimates.

    What's next?
    According to Justin Elliott, "APTA is exploring all avenues to advocate against these cuts before they take effect on January 1, 2018." He added, "All options are on the table and every path is being evaluated for our response to the final rule."

    Those advocacy efforts will require APTA and its members to have a solid understanding of just how the CPT changes impact them during the coming year, according to Carmen Elliott, who said that the key to getting insight on the effects is for PTs to continue to code and document appropriately while they evaluate their case mixes and other factors. "The only way to truly understand the effects of these changes is for our coding efforts to remain consistent," she said.

    At the same time, APTA President Sharon Dunn, PT, PhD, thinks there's an even bigger picture to be considered.

    "We can't yet say what the overall impact will be as a result of these code value changes, and we know that the effects will vary from provider to provider," Dunn said. "What we can say for sure is that these kinds of adjustments and recalculations truly underscore the need for health care providers to move toward value-based payment models that truly reflect the value of physical therapist services’ triple aim—improving the experience of care, improving population health, and reducing costs. The CPT code structure has 1 foot firmly planted in the outmoded fee-for-service world. That needs to change."

    Bill Allowing PTAs in TRICARE Ready for President's Signature

    Well, that was quick: a week after an agreement was reached on legislation that would allow physical therapist assistants (PTAs) to participate in the TRICARE payment system used throughout the US Department of Defense health care system, both the US Senate and House of Representatives have passed the bill. It's now ready to be signed by the president.

    The PTA provisions are part of the National Defense Authorization Act (NDAA) that includes language proposed by APTA to add PTAs and occupational therapy assistants to the TRICARE program.

    "This is a significant win for PTAs, but an even bigger win for patients in the TRICARE program," said Michael Hurlbut, APTA senior congressional affairs specialist. "The important services PTAs provide should be as accessible as possible, regardless of payer."

    The Good Stuff: Members and the Profession in Local News, November 2017

    "The Good Stuff," is an occasional series that highlights recent, mostly local 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!

    According to a recent survey, PTs have the sixth lowest divorce rate compared with other professions. (MentalFloss)

    Marika Molnar, PT, director of physical therapy for the New York City Ballet and the School of American Ballet, received national recognition for her work. (Dance magazine)

    Robert Gillanders, PT, shares tips on exercising without a gym or equipment while traveling. (The Washington Post)

    Joey Cadena, PT, DPT, explains the importance of maintaining muscle balance in runners. (McAllen, TX, Monitor)

    Julie Fritz, PT, PhD, and Steven George, PT, PhD, discuss a study on the effects of exercise on low back pain. (Reuters news service)

    Kelly Hutto, PT, is the subject of a feature story highlighting PlayBig Therapy & Learning Center, a local facility that uses play therapy and other methods to help children with autism, developmental delays, and social, emotional, and behavioral issues. Hutto is a co-owner. (Tallahassee Democrat)

    Gregory Massie, PT, DPT, offers advice on staying motivated to exercise during dark and cold winter months. (Stroudsburg, PA, Pocono Valley Record)

    Sasha Cyrelson, PT, DPT, provides suggestions for yoga poses that can help relieve low back pain. (Self magazine)

    The APTA Hawaii Chapter comes to the rescue for Global Physical Therapy Day of Service by delivering flip-flops and sandals to a local school. (Lihue, HI, Garden Island)

    Nicola Owen, PT, discusses her work with a young athlete experiencing Ewing sarcoma. (Atlantic City, NJ, Press)

    "Our existing health care system is designed to treat pain through easily delivered products, like opioids, injections, and surgery. Its inability to adjust to the inherent individual nature of pain has caused tremendous societal problems." - Steven George, PT, PhD, writing in The Hill

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

    Choosing Wisely at 5: Is It Making a Difference (And What About the Next 5 Years)?

    Five years into the American Board of Internal Medicine (ABIM) Foundation's "Choosing Wisely" campaign, most health care providers and consumers who've heard about it agree that the initiative has something important to say about avoiding unnecessary tests and procedures, including some associated with physical therapy. But has that awareness increased significantly, and does it translate into changes in behavior? Some say no—or at least not yet.

    ABIM's recently released special report on the first 5 years of the Choosing Wisely program characterizes the initiative as a sorely needed effort that is gaining momentum. Since its beginnings in 2012, the collection of ineffective and overused treatments and tests has expanded to 525 recommendations from more than 80 specialty society partners, according to ABIM. In 2014, APTA became the first nonphysician organization to contribute to Choosing Wisely when it released its list of "5 Things Physical Therapists and Patients Should Question."

    The initiative, which partnered with Consumer Reports, has received wide media attention during the past 5 years and has even expanded to 19 other countries around the world. "Clinicians and patients all across the United States—and now the world—are engaging in conversations about avoiding unnecessary care thanks to the efforts of medical specialty societies, health systems, clinical practices, consumer groups, and community collaborations to advance Choosing Wisely," the report states.

    But has the program gained traction? And more to the point, are the Choosing Wisely recommendations being followed on a wide scale? Answers to those questions may not be as positive, say researchers writing in Health Affairs.

    To find out the extent of Choosing Wisely's impact, researchers followed up on an ABIM survey of 600 practicing physicians conducted in 2014 with a survey of their own, conducted this year. Authors of the study wanted to find out if knowledge of the program has grown since 2014, and whether physicians were actually following Choosing Wisely recommendations.

    The results of the 2017 survey are based on an underwhelming response rate—just 5.5%—but the researchers pressed ahead, asserting that the low response rate may, if anything, skew results in favor of physicians who know and support Choosing Wisely and were thus more willing to participate.

    Authors of the study found that the percentage of physicians aware of the campaign in 2017 (42%) had not grown significantly since 2014 (39%), nor had the percentage of physicians who believe campaign is valuable, from 91% in 2014 to 93% in 2017.

    When asked for their opinions on what is driving the continued use of low-value care identified in Choosing Wisely, 87% of the 2017 respondents cited malpractice concerns (87%), followed by physicians' desire for more information (84%) and "just to be safe" (78%). As for changes to health care that would help to decrease use of low-value care, most physicians surveyed pointed to malpractice reform (92%), followed by spending more time with patients (88%) and financial rewards (72%).

    Authors were skeptical that malpractice concerns are truly a driver of use of low-value care, citing research that estimates "defensive medicine" adds roughly 3% to overall health care spending. Similarly, the argument that patient demand drives the use of low-value care is also not supported by research, according to the study's authors.

    The relatively slow decline in the use of unnecessary care since Choosing Wisely's debut points to a need to develop a "roadmap" for the next 5 years, 1 that will lead to a greater impact on care, say authors of a separate analysis and commentary that also appeared in Health Affairs. They stress the need for more robust efforts at almost all levels, from stronger recommendations from societies to the use of more rigorous study designs to evaluate barriers and outcomes.

    Authors cite 4 major areas that they believe need to be strengthened if the Choosing Wisely campaign wants to make a real difference in usage of low-value care:

    Strong methods for developing recommendations. Authors assert that early on, societies tended to select tests and treatments that were fairly safe bets among their members—low-value, to be sure, but also not necessarily widely practiced. Recommendations now need to move into areas that have wider prevalence and potential impact, they write.

    Innovative intervention methods. More thinking needs to go into why providers and patients are not opting out of low-value services, including looking into behavioral science frameworks that shed light on decision-making, and investigating ways to pursue cultural change among clinicians and patients.

    Meaningful evaluation techniques. Rigorous research should be applied to studying the barriers to and facilitators of success, authors write, including measurement of clinically meaningful outcomes.

    Collaborative dissemination. Authors believe that states, communities, patients, payers, health systems, and academic partners need to be brought together in a more coordinated way to "test and disseminate successful approaches."

    "Clearly, [Choosing Wisely] has been changing the conversation and is beginning to influence culture, thus setting the foundation for the next 10 years," authors write, citing "a convergence of activities" for realizing the campaign's potential already exists, including support from organizations, increased use of accountable care organizations and value-based payment models, and the pressure patients face through higher health insurance deductibles.

    "Choosing Wisely has created a principal pathway through which patients and their doctors can discuss when health care services may not be needed," authors write. "As we have outlined, several important steps still remain to fulfill the promise of Choosing Wisely. It is now time to take those steps."

    To get a better sense of how the Choosing Wisely campaign intersects with APTA's efforts to help PTs and PTAs understand their role in reducing fraud, abuse, and waste, visit the association's online Center for Integrity in Practice.

    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.

    Review: Sport Specialization at an Early Age Can Increase Injury Risk

    Parents and coaches need to be educated on the risks and signs of overuse injuries common in children who specialize in a single sport at a young age, say authors of a recent research review published in theAmerican Journal of Sports Medicine. Surgery, they concur, should not be the first-line treatment for such injuries.

    An increasing number of children are focusing on 1 sport early, often because parents and coaches are enticed by the possibility of scholarships and professional participation, “increasing emphasis on sports accomplishment,” and perceived value of elite competition, authors note. But the evidence, say authors, suggests that children who wait until age 12 or older to specialize in 1 sport or begin intense training reach higher levels of athletic achievement than those who specialize at a younger age.

    In general, say authors, young athletes’ “underdeveloped musculature” and still-growing bones make them prone to overuse injuries such as rotator cuff tendinitis, shoulder instability, humeral epiphysiolysis, knee and elbow ligament injuries, hip impingement, and stress fractures, among others. The strain to a developing body also may increase their risk of injury as adults.

    The authors write that more research needs to be done to determine early specialization risks and injury patterns for specific sports, and to identify long-term consequences. In the meantime, they urge, it is important to inform parents and coaches about general injury risk and signs of overuse injuries in children. In addition, say authors, while “operative treatment is occasionally indicated for these injuries [it] should not be taken lightly or considered the first treatment option for most overuse injuries.”

    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.

    Available through the APTA Learning Center: "Repetitive Stress Injury in Youth Athletes," an online course that explores the most recent evidence related to differential diagnosis and treatment of common repetitive stress injuries in this population.

    Defense Bill Headed for Final Votes Will Include PTAs in TRICARE

    Physical therapist assistants (PTAs) are now closer than ever to being included as accepted providers under TRICARE, the payment system used throughout the US Department of Defense (DoD) health care system.

    Last week, the Armed Services Committees for both the US House and Senate reached an agreement on a National Defense Authorization Act (NDAA) that includes language proposed by APTA to add PTAs and occupational therapy assistants to the TRICARE program. The APTA-backed amendment was introduced by Sen Thom Tillis (R-NC) in July and was included in the Senate version of the bill that passed in September. The amendment can be found on page 379 of the NDAA.

    The legislation will next advance to the House and Senate, where it is expected to pass in both chambers.

    "This is great news for PTAs and patients in the TRICARE program," said Michael Hurlbut, APTA senior congressional affairs specialist. "We hope to see a bill ready for the president to sign sometime in December. Once signed into law, the changes will probably be issued through regulation, and we could see PTAs included in the TRICARE program as early as next year." APTA will work with the DoD as the process moves forward, he added.

    That wasn't the only piece of good news in the NDAA. Legislators also included amendments to address opioid prescribing within the DoD health care system, including instructions for the Secretary of Defense to "[Develop] methods to encourage health care providers of the [DoD] to use physical therapy or alternative methods to treat acute or chronic pain."

    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.