• Feature

    The State(s) of Direct Access

    All across the nation, consumers have "some form" of direct access to physical therapist services. What does that mean? What work remains?

    Feature - Direct Access

    The quantity's there. The quality keeps improving. But there's still plenty of work to be done.

    That, in summary, describes the state of patient access to the services of physical therapists (PTs) in fall 2016.

    The numbers tell a story, but far from a complete one. There is "some form" of direct access, per APTA, in all 50 states, the District of Columbia, and the US Virgin Islands. (See "Levels of Patient Access to Physical Therapist Services" map on page 34.)

    Drilling down, there is "unrestricted" patient access in 18 states. That is defined by APTA as "No restrictions or limitations whatsoever for treatment absent a referral."

    "Patient access with provisions," the next level, encompasses 26 states, DC, and the US Virgin Islands. It is defined as "Access to evaluation and treatment, with some provisions, such as time or visit limits, or a referral requirement for a specific treatment intervention, such as needle EMG [electromyography] or spinal manipulation."

    "Limited patient access" applies to the fewest states—6, after Louisiana's departure from the category in June—but is the most vexing level. APTA describes it as follows: "Access to evaluation, fitness and wellness, and limited treatment only to certain patient populations or under certain circumstances (eg, treatment restricted to patients with a previous medical diagnosis or the subject of a previous physician referral)."

    The story the numbers don't tell is how the categories came to be, the history and ongoing work of PTs across the country to make direct access a reality in the face of stiff opposition, and why APTA's focus has shifted from the quantity of states and localities with direct access to the quality of those jurisdictions' direct access laws.

    "While the ultimate objective is unrestricted direct access in every state and locality, the immediate goal," APTA's Angela Shuman says, "is to remove those barriers to access that are causing the biggest problems for patients." (See "Directly Benefiting Patients" on page 34.) The priority, in other words, is "to have direct access laws in place in every jurisdiction that work for patients and PTs in those locations." Shuman is director of state affairs at APTA.

    The profession is getting there, Shuman emphasizes. But that isn't to say that the road to date has been smooth, or that the stretch ahead is obstacle-free.

    Two Not-So-Little Words

    The multi-decade struggle to achieve direct access in every state and locality was all about celebrating successes, conveying momentum, and encouraging chapters' efforts to fight access restrictions. Given fierce opposition from physician groups, chiropractors, and others, every win—however large or small—was considered important.

    In some cases, the first step was getting a proverbial foot in the door via legislation seeking limited direct access. Thus, for example, when Texas PTs in 1991 won the right to evaluate patients without referral, and to treat them for conditions or injuries that had been the subject of a physical therapy referral within the previous year, the state was added to the "direct access" list. Period. In those days, when physician referral was the norm and patients in some states lacked direct access even to evaluation by a PT, there were no "levels" of direct access.

    This would become significant later. Twenty-five years ago, however, both APTA and the Texas Physical Therapy Association (TPTA) were thrilled to tout a victory that in today's context seems "perhaps minor in the grand scheme of things," Shuman says—one that current TPTA president Mike Connors, PT, DPT, is hesitant now even to characterize as direct access.

    In 1991, however, Connors concedes, "securing evaluation without referral was a huge landmark."

    Time marched on. Victories big and small continued, with APTA supporting the chapters in their efforts and lauding their successes. The triumphs often fell far short of giving consumers unrestricted patient access to physical therapist services, and several chapters waged successful fights in the 2000s to further liberalize that access.

    Still, APTA didn't officially distinguish between states in which consumers could seek services from PTs without a referral. As Shuman puts it, "APTA's focus was on convincing state policymakers that allowing direct access was not, contrary to the opposition's rhetoric, going to create chaos. But the political process requires negotiation and compromise. This resulted in a patchwork of direct access laws across the country."

    The association's focus began to shift when Indiana—the last state that hadn't permitted even evaluation without referral—was added to the direct access list in 2013. That made Indiana direct access state number 48 by APTA's reckoning. The association knew that big news was looming.

    "By the end of 2013, the Oklahoma and Michigan chapters were well-positioned to help achieve passage of legislation the following year to become the 49th and 50th states on the direct access list," Shuman recounts. When that day came, the achievement would need to be recognized and hailed as the culmination of the thousands of PTs' hard work on behalf of patients. "But we also recognized that significant and onerous barriers to patient access remained in place in many states," Shuman says. "We needed to acknowledge in our messaging that a lot of work remained to be done."

    Hence the addition, in 2014, of those aforementioned words "some form" to the direct access characterization. As in a July 2014 PT in Motion News item telling visitors to APTA.org that "all 50 states and the District of Columbia [now] allow for some form of direct access to PTs for evaluation and treatment." As in a notation on the consumer website MoveForwardPT.com that "All 50 states and the District of Columbia allow some form of direct access to physical therapist services without a referral."

    "We knew there needed to be some nuance to our messaging," Shuman says, "because there has been and continues to be the need to go back into many of those practice acts and make improvements—to remove barriers and lessen restrictions to patient access to physical therapist services in states and localities where they still exist."

    The APTA chart "Levels of Patient Access to Physical Therapist Services in the States"—referenced in "Resources" on page 40—classifies states and localities by category: unrestricted patient access, patient access with provisions, and limited patient access. The listings describe any access restrictions within a given practice act. The document illustrates a couple of important points, Shuman says.

    "One is, laws literally are all over the map when it comes to those 'forms' of direct access—what direct access looks like for patients and PTs across the country," she says. "The other takeaway from the chart is that within the 'patient access with provisions' category there's a broad spectrum. Patient access is pretty open in some states and much more limited in others." In some of the "provisions" states, she notes, "what we're hearing from chapter leaders and individual PTs is, 'We're good with where were are. Our laws on patient access to our services are working for us, so we're channeling our advocacy efforts in other directions right now.'"

    In localities in which significant patient access restrictions remain, efforts continue at both the chapter and national level to eliminate or ease them. This year, for example, a practice act revision was won in Florida that lengthened from 21 to 30 days the period within which consumers can see a PT without referral. Last year, other access improvements were secured in Georgia, New Mexico, and Virginia.

    "In each case, APTA staff work with the chapter's leadership, legislative chair, and lobbyists to develop legislative strategies, bill and amendment language, talking points for legislators, supporting information, and answers to opposition arguments," Shuman says. "We also help chapters develop grassroots campaigns and mobilize their members to communicate with lawmakers. We offer messaging assistance and guidance, as well."

    The association also has a state advocacy grant program that awards funds to chapters to advance a variety of legislative priorities, including those related to direct access.

    Adding the "some form" language and highlighting on the tiered chart all the unfinished business in the states reflects what Shuman calls a "pivot in the conversation," recognizing the "evolution" of the nationwide fight for patient access to the services of PTs.

    "We've got the numbers now—some form of direct access in all 50 states, DC, and the US Virgin Islands—but it isn't as if we've checked off that box and said, 'We're done,'" Shuman emphasizes. "The focus now is on removing the barriers that are the most prohibitive to consumers and the PTs who seek to serve them."

    Testing The Limits

    Connors, in Texas, applauds APTA's adoption of the "some form" language—calling it a "great clarification." But those 2 qualifying words, he notes, demonstrate that not all direct access laws are created equal. This inequality is acutely felt in the Lone Star State. Connors is pleased that diehard opponents of direct access in his state no longer can "throw in his face" the seeming suggestion that Texans already have acceptable access to physical therapist services. APTA's shift in focus to the quality of access acknowledges that, in Texas and elsewhere, much work remains undone.

    Connors and APTA staff agree that the reason Texas remains 1 of only 6 states at the limited patient access level is the heated opposition and deep pockets of physician groups.

    "The Texas Medical Association is the largest physician lobby in the country, with about 47,000 members," Connors observes. "The TPTA, by contrast, has about 7,000 members. That gives you some idea what we're up against."

    Furthermore, he notes, "The Texas Orthopaedic Association has taken the official stance that direct access to physical therapist services is a public safety issue. Which we know isn't true, and which we can and have definitively refuted, based on the research and evidence from other states. This is a cash-and-pocketbook issue," Connors says, "that's linked to physician-owned physical therapy practices."

    He nevertheless sees cause for optimism as TPTA looks to seek greater patient access to physical therapist services in the 2017 legislative session.

    The removal earlier this year of bordering Louisiana from the dwindling ranks of states APTA classifies as offering only limited patient access to physical therapist services will be yet another talking point in TPTA's ongoing lobbying and public relations efforts, Connors says. While TPTA long has cited the direct access freedoms enjoyed by consumers in other states, Louisiana's move, Connors says, further stigmatizes Texas as a member of a shrinking and discredited club.

    Provisional Leadership

    Many factors contributed to the passage earlier this year of a law that allows PTs in Louisiana to treat patients without a referral or previous medical diagnosis for up to 30 calendar days provided patient progress is shown—a significant improvement over what had been one of the most restrictive direct access laws in the country.

    Cristina Faucheux, PT, governmental affairs chair of the Louisiana Physical Therapy Association (LPTA) credits the efforts of its lobbying team, governmental affairs district liaisons, private practitioners, a spectrum of community leaders and activists that included media figures, former legislators, friends of current legislators, and patients. But perhaps the biggest factor, Faucheux says, was the work of a study committee authorized during the 2015 state legislative session to investigate the pros and cons of direct patient access to physical therapist services and report its findings and recommendations to the legislature.

    Among the committee's 25 members were individuals representing orthopedic physician, chiropractic, acupuncture, and athletic training groups; the Health and Welfare committees of the Louisiana House and Senate; and LPTA and APTA. Four 5-hour meetings were held in summer and fall 2015, during which all stakeholders were asked to present evidence for or against direct access.

    The panel as a whole ultimately found the weight of evidence to be firmly on PTs' side, concluding that there was a "clear and obvious benefit" to removing restrictions to direct patient access to physical therapist services. Because the Louisiana Physical Therapy Board was required to share the findings with lawmakers, meetings were set up with each legislator. LPTA was invited to participate in that process.

    "We met with 90% of the legislators before the legislative session even began," Faucheux notes. "Being able to speak with them 1-on-1 in their home districts—highlighting the evidence and answering their questions at a time when they weren't inundated with other pressing matters—was well worth the great amount of work that was required."

    The legislation was approved by wide margins in both chambers of the legislature and signed into law by Gov John Bel Edwards on June 6.

    The chapter has since been busy getting the word out to consumers, primarily via social media. These are exciting days, Faucheux says.

    The victory did not move Louisiana into the ranks of states with unrestricted patient access, because a referral is required if the patient has not made "measureable or functional progress after 30 calendar days." But this is a case in which, per APTA's objective, the direct access law that's now in place "works" for the jurisdiction.

    "Although APTA classifies our access as 'provisional,' we are very happy with the bill language," Faucheux says. "The LPTA Board of Directors and Government Affairs Committee members feel the timeline is appropriate to determine the effectiveness of physical therapy services in almost all orthopedic cases and a majority of neurological ones. Furthermore, the language is open, in that it does not state that the patient must be referred to a physician. The provision allows the physical therapist to use his or her clinical judgment to determine the most appropriate health care provider for referral. So, that may even be a physical therapist who specializes in a particular area."

    Susie Harms, PT, MHS, president of the Kansas Physical Therapy Association (KPTA) and a clinician at Via Christi Health in the town of Manhattan, expresses similar satisfaction with her state's "patient access with provisions" status in the wake of practice act revisions in 2013 that "opened things up a lot."

    Before 2013, she says, "No one could just walk in without a referral except in very limited cases." Now, however, referral is not required unless and until the patient, per the language of the practice act revision, is "not progressing toward documented treatment goals—as demonstrated by objective, measureable, or functional improvement, or any combination thereof—within 10 visits or 15 business days from the initial treatment visit following the initial evaluation visit."

    "Most patients show improvement within several physical therapy visits, and, if they haven't done so within that timeframe, we likely would've sent them back to their physician even without the requirement," Harms notes. "So, while Kansas's direct access level is considered 'provisional,' we see it as good provisional status."

    A subsequent hard-won battle in Kansas to grant PTs the right to provide dry needling—combined with comments from some lawmakers that KPTA's recent victories have opened "a can of worms" that has prompted other allied health groups in the state to seek practice changes—has influenced KPTA's timetable for pursuing unrestricted patient access to physical therapist services.

    "The Kansas Board of Healing Arts, our regulatory body, has expressed concern about further expanding physical therapists' scope of practice, given the profession's recent legislative successes," Harms says. That board, she notes, has no PT members.

    KPTA followed up its direct access win 3 years ago by surveying its members on how the association should best market the news to consumers. The resulting multimedia marketing campaign (titled "Go!") employed the hashtag "#ILOVEMYPT" and ran during National Physical Therapy Month in October. In addition to blanketing the state with radio and newspaper ads, KPTA provided its membership with downloadable posters, brochures, postcards, and videos that could be used during community education events—all promoting the benefits of direct patient access to physical therapist services. Harms also sent a peacemaking letter to Kansas physicians in which she wrote, in part, that the state's PTs "look forward to even greater collaboration" with them "in our shared mission to provide excellent health care for Kansans."

    What little response Harms's letter engendered was mostly along the lines of, "You know you guys will never get paid for that, right?" she recounts. Harms refuted such statements then and continues to do so now, as they have proven to be largely untrue. (See "The Myth of Nonpayment" on page 36.)

    Unrestricted Pride

    Tim Flynn, PT, PhD, made a conscious choice to live and work in Colorado after a 20-year career as a PT in the US Army. In the military, Flynn not only enjoyed unlimited patient access, but he even could order diagnostic imaging and prescribe medications. He'd seen the many benefits to patients of unlimited access to physical therapist services and had relished the broad opportunities to meet their needs. While he did have family in Colorado, the fact that it is an unlimited patient access state played at least as big a role in his decision to relocate there.

    "I knew I'd find it very frustrating to work in a state in which patients needed a referral just to see me," he says. "To me, part being a physical therapist is about helping people without their needing to worry about jumping through hoops to get to me."

    Flynn owns Colorado in Motion, a 4-clinic Fort Collins-based practice that describes itself as "a community of mindful practitioners dedicated to empowering our patients with the skills they need to live a healthy Colorado lifestyle." That goal translates, Flynn says, to aggressively marketing physical therapy and wellness services to consumers who can directly tap them.

    Pam Duffy, PT, PhD, an assistant professor in the Department of Public Health at Des Moines University, was president of the Iowa Physical Therapy Association when unrestricted patient access to physical therapist services became law in that state in 1988. Such access is especially valuable, she says, for patients with chronic conditions—who can and do contact their PT directly whenever they feel or even suspect that additional physical therapy is merited.

    Not only does Duffy—a former member of APTA's Board of Directors and a Catherine Worthingham Fellow of the American Physical Therapy Association—feel strongly that unlimited access to physical therapist services is best for consumers, but she also has played a role in demonstrating it. She coauthored a study, published in 2012 in the journal Health Services Research and available on APTA's direct access webpage, that suggested "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases."

    The study found that patients who visited a PT directly for outpatient care had fewer visits and lower overall costs on average than did those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.

    "That large database allowed for a powerful analysis," Duffy says. "It confirmed that direct access to physical therapist services may facilitate cost-effective treatment of musculoskeletal disorders, and suggested that avoiding delays in getting physical therapy is extremely important."

    As she sees it, direct access—whether unlimited or subject to only minor provisions—also pays dividends in the way PTs are seen by and interact with payers and policymakers. "That legal status is absolutely critical," Duffy says, "to establishing our professionalism and credibility to third-party payers and lawmakers.

    Eric Ries is the associate editor of PT in Motion.

    Directly Benefiting Patients

    "Direct access means the removal of the physician referral mandated by state law to access physical therapists' services for evaluation and treatment. Every state, the District of Columbia, and the US Virgin Islands allow for evaluation and some form of treatment without physician referral. However, many of those states continue to impose arbitrary restrictions on direct access, or only allow for treatment without referral under very limited circumstances. These restrictions cause 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 costs, decreased functional outcomes, and frustration to patients seeking physical therapy treatment. Eliminating arbitrary barriers results in timely, more effective care."

    (From "FAQ: Direct Access at the State Level, available at www.apta.org/StateIssues/DirectAccess/FAQs/)

    The Myth of Nonpayment

    Legal direct access to the services of PTs doesn't guarantee payment for services provided in the absence of a referral. Payment policy is determined by the insurer and is highly variable, with many insurers silent on the issue. But the "pervasive perception" among some PTs that legal access is of limited value because most insurance companies won't pay for services so rendered is "inaccurate," says Carmen Elliott, vice president of payment and practice management at APTA.

    APTA has conducted 2 surveys in the past 7 years to better determine how direct access is being used by members and what obstacles still exist. The 2009 survey (summary at www.apta.org/DirectAccess/UtilizationSurvey/) questioned PTs in 9 states and drew nearly 1,800 respondents. Seventy-four percent of the responding PTs who provided direct access services reported that no third-party payments were denied because of the lack of a referral, and PTs who had experienced denials reported few of them.

    In a broader survey conducted in spring 2015 that netted nearly 6,000 responses from PTs in all 50 states and the District of Columbia, less than a quarter of respondents cited lack of referral as a cause for claims denial. (The full survey results are being reviewed and also will be available online.)

    The notion that insurance companies will not pay for the physical therapy visits of patients seen without a referral is among the "myths and misconceptions" cited in the APTA document "Direct Access: How It Can Change Your Practice" (see "Resources" on page 40). The document advises in part, "While it is always important to verify individual coverage for each patient, it is a mistake to assume that all insurers require a referral. In fact, information from both payers and physical therapist providers indicate very positive trends toward reimbursement without referral."

    In Colorado, where consumers have had unrestricted patient access to the services of PTs since 1988, "we don't see many carriers requiring physician referral for payment," reports Tim Flynn, PT, PhD, owner of Colorado in Motion, based in Fort Collins.

    "We've had very little resistance from insurance companies to payment without referral," echoes Susie Harms, PT, MHS, president of the Kansas Physical Therapy Association. PTs in that state have faced few referral requirements since passage of liberalizing practice act revisions in 2013.

    Louisianans secured the legal right to see PTs without referral this June. Cristina Faucheux, PT, government affairs committee chair of the Louisiana Physical Therapy Association (LPTA), says payers closely followed that debate, in which LPTA and supporters of physical therapy produced a stack of evidence attesting to the efficacy, safety, and cost-effectiveness of patient access without referral. LPTA has leveraged that testimony, and has parlayed its longtime outreach to and dialogue with payers, to good effect, she says. "Our initial discussions with payers have been very positive," Faucheux reports.

    APTA, Elliott notes, continuously works with payment chairs and other chapter leaders to provide third-party payers with "information and messaging" about the benefits to patients, and to health care providers' own bottom lines, of direct consumer access to physical therapy services.

    She cites, for example, "The Value of Physical Therapy," a 3-page document (see "Resources" on page 40) that encapsulates the demonstrated value to consumers and cost-effectiveness to the health care system of broadening consumer access to the services of PTs.

    As for the remaining holdouts among payers, Harms believes their days of resistance are numbered.

    "The longer we provide quality services with increased direct access across the United States," she says, "the more research we will accumulate demonstrating the effectiveness of physical therapy. It just won't make economic sense not to pay for our services."

    A Directed Attack on Opioid Abuse

    The name of APTA's broad public relations campaign to educate consumers about opioid risks and urge them instead to seek physical therapy for pain management is #Choose PT. Still, "It is one thing to say 'Choose to see a PT first,' but quite another thing for the patient to actually be able to access a physical therapist first," notes Angela Shuman, director of state affairs at APTA.

    The distinction is not lost on Tim Flynn, PT, PhD, a passionate voice for the power of physical therapy in this arena who practices in Colorado, where patient access to the services of PTs is unrestricted. Flynn calls America's opioid addiction epidemic a "medical disgrace." He welcomes the public relations help to steer Coloradans in pain toward physical therapy as their option of first resort.

    "This campaign is a good step," says Flynn, owner of Colorado in Motion, which has 4 clinics and is based in Fort Collins. "A high-profile effort is needed to promote the vital importance of consumers choosing PT over pharmaceutical approaches to pain management."

    APTA's campaign, announced in June and housed at MoveForwardPT.com/ChoosePT, will continue unfolding through the end of this year and includes national online advertising, television and radio public service announcements, and other targeted advertising and media outreach. The #ChoosePT website features facts about pain and the opioid epidemic, tips for avoiding chronic pain, and a toolkit with downloadable graphics and other materials designed to extend the campaign's reach. The association is collaborating with chapters to determine the best ways to coordinate resources and messaging in each state and locality.

    "I am thrilled that APTA has undertaken this campaign," says Cristina Faucheux, government affairs committee chair for the Louisiana Physical Therapy Association. For PTs and consumers in that state, which gained direct consumer access to the treatment services of PTs in June, the timing, she says, "couldn't be better." Louisiana, Faucheux notes, "has one of the highest uses of opioids prescribed in the workers' compensation system. So, to get the word out that physical therapy is a great option for pain relief and management—and that Louisianans now can come to PTs first—is huge."

    "This campaign is a great opportunity for PTs to have a major impact on reducing opioid use and addiction," agrees Susie Harms, president of the Kansas Physical Therapy Association and a clinician at Via Christi Health in the town of Manhattan. "I've worked with substance abuse and chronic pain patients who have been able to get off pain medications because of physical therapy, and they are grateful. Anything that helps spread the word about physical therapy's effectiveness in relieving acute and chronic pain is extremely valuable."

    Even in Texas, where patient access to the services of PTs is limited, Texas Physical Therapy Association President Mike Connors, PT, DPT, says he's "really excited" about the #ChoosePT campaign and its message that "you don't have to go to a physician and get drugs for chronic pain." Connors envisions his chapter leveraging and in many ways emulating the campaign in its next big "PR push" on the direct access front.

    APTA Web Resources

    Direct Access in Practice (www.apta.org/DirectAccess)

    Highlights include:

    • Research supporting direct access
    • Podcasts and videos
    • Marketing materials
    • Advocacy materials
    • Information on preparing for direct access in your practice setting
    • Articles "Direct Access: How It Can Change Your Practice" and "Direct Access: Exploring New Opportunities"

    Direct Access at the State Level (www.apta.org/StateIssues/DirectAccess)

    Highlights include:

    • Overview of advantages of direct access to physical therapist services
    • "Levels of Patient Access to Physical Therapist Services in the States" chart classifying states and localities (District of Columbia and US Virgin Islands) by category and summarizing practice act language that spells out access restrictions, if any
    • FAQ
    • Studies in support of direct access

    The Value of Physical Therapy (http://policy.apta.org/About/Value)

    Highlights include:

    • PDF document "The Value of Physical Therapy," encapsulating its demonstrated value and cost-effectiveness
    • News stories about physical therapy's effectiveness treating various conditions


    I have recently run into some insurance issues with direct access to PT where the trust plans do not reimburse without a physician order for PT services even though Montana's state insurance commissioners mandate that private insurance companies have to reimburse for direct access in this state. I feel like there are loopholes in the whole process and new forms of insurance companies with the Affordable Care Act are able to get around paying for direct access to PT's even though it was established in your state.
    Posted by Christy Zimmer on 10/3/2016 12:30:34 PM

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