FAQ: Direct Access at the State Level

What does patient access to physical therapists' services without referral mean and why is it needed?

Patient access to physical therapists' services without referral means the removal of the physician referral mandated by state law to access physical therapists' services for evaluation and treatment. Forty-eight (48) states and the District of Columbia allow for evaluation and some form of treatment without physician referral. (Please note - some states have time or visit limits or provisions tied to treatment without a referral. Be sure to check out a summary of the various state direct access laws (.pdf).) Currently, a referral is required by state law to initiate treatment by a licensed physical therapist in 2 states: Michigan and Oklahoma. Michigan and Oklahoma allow for evaluation without referral, but not treatment.

This referral mandate causes delays in the provision of physical therapists' services to individuals who would benefit from treatment by a physical therapist. Delays in care result in higher cost, decreased functional outcomes, and frustration to patients seeking physical therapy treatment. Eliminating the referral mandate results in timely, and thus more effective, physical therapists' services.

Are physical therapists qualified to deliver physical therapists' services independent of referral?

Absolutely. Physical therapists are educated at the post-baccalaureate level and receive extensive education and clinical training in the examination, evaluation, diagnosis, prognosis, and intervention of patient/clients with functional limitations, impairments and disabilities. As of January 1, 2002, all physical therapy programs were required to be accredited at the masters level. Physical therapists are qualified to recognize when a patient presents with signs and symptoms inconsistent or outside the scope and expertise of the physical therapist and when the patient should be referred to a physician. APTA's Guide of Professional Conduct advocates that physical therapists should assist patients in receiving appropriate medical care when the physical therapist's examination and evaluation reveals signs and symptoms inconsistent with a condition that can be appropriately treated with physical therapy or needs a physician's care and expertise.

Liability insurers and the Federation of State Boards of Physical Therapy affirm that physical therapists' services provided without referral does not jeopardize the health, safety, or welfare of the patient/clients seeking physical therapists' care and services without referral. Health Providers Service Organization (HPSO), the leading liability insurer of physical therapists in the United States, states in a January 10, 2013, letter, "Direct access is not a risk factor that we specifically screen for in the underwriting of our program nor do we charge a premium differential for physical therapists in direct access states. We currently have no specific underwriting concerns with respect to direct access for physical therapists."

Is there a concern that if a physical therapist initiates treatment without a referral that they will miss a patient's underlying medical conditions?

The risk of a health care provider missing underlying conditions is always present. However, physical therapists have an extremely low rate of malpractice and a low incident of claims or complaints filed against them. The rate of malpractice insurance has been shown to be no higher in states where physical therapists practice without a referral versus states where physical therapists practice with referral. Physical therapists actually assist patients to get appropriate care when they recognize signs and symptoms that are inconsistent or outside the scope of physical therapists' practice.

There is evidence from the Federation of State Boards of Physical Therapy and a leading liability carrier, the Health Providers Service Organization (HPSO), that there is no increased risk to patients in states that do not mandate referral before the provision of physical therapists' services. HPSO does not rate a physical therapist as a higher risk because they practice without referral. There has been no increase in claims against physical therapists in states without the referral mandate. Most importantly, physical therapists consider their role in protecting the public's health, safety, and welfare as extremely important.

Physician groups argue that physical therapists cannot diagnose. How can you respond to such a charge?

Diagnosis is a fundamental part of physical therapists' practice. Physical therapists practice according to the disablement model. This model of practice is recognized by the World Health Organization, the National Center for Medial Rehabilitation Research, and the Institute of Medicine. Physical therapists diagnose with respect to physical therapist practice as authorized by state law. In diagnosing a patient's condition in accord with such law, physical therapists are not in conflict with the diagnosis provisions of state laws governing the practice of medicine. No states prohibit a physical therapist from performing a diagnosis. Diagnosis by a physical therapist is essential for the physical therapist to be able to provide the proper interventions. Diagnosis is a label for a cluster of signs and symptoms gathered by examination and evaluation that is essential to guide the selection of appropriate interventions in physical therapy practice.

Why should policymakers be concerned with this issue?

Allowing individuals to make decisions regarding their health care is good policy. Eliminating the referral requirement is one step to making health care more accessible to more people.

Physical therapist education supports practice without referral. Physical therapist practice in the states that allow treatment without referral has proven that it is safe. Yet consumers in four states do not have access to these services unless another health care provider refers them to a physical therapist.

Patient access without the current professional practice restrictions regarding referral is about individual choice in health care decisions. Elimination of the referral mandate does away with an unnecessary and burdensome regulation.

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