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  • Study: Even in States That Limit Direct Access, Getting PT First for LBP Makes a Big Difference

    A recent analysis of private insurance data adds more weight to the argument that seeing a physical therapist (PT) first for low back pain (LBP) produces a host of positive results, including lower costs, reduced probability of an emergency department (ED) visit, and lower rates of opioid prescription. But according to the study's authors, definitive answers can still be difficult to come by when it comes to the question of whether those positives further increase when a state eliminates all restrictions on direct access.

    In a study sponsored through a grant from the Health Care Cost Institute (.pdf), researchers from the University of Washington and George Washington University looked at private insurance claims data of 159,777 beneficiaries with LBP between 2009 and 2013. Researchers focused on beneficiaries from 6 western states—Alaska, Idaho, Montana, Oregon, Washington, and Wyoming.

    The study divided patients between states that offer unrestricted direct access (the law in Alaska, Idaho, and Montana) and states that impose certain restrictions on treatment—specifically, special training requirements for the PT (Washington), "degree and referral requirements" (Wyoming), and a 60-day restriction on treatment time (Oregon, although this restriction was eliminated in 2013, after the study period). Patient groups were further divided into 3 categories: those who saw a PT on the initial date of diagnosis of LBP ("PT first"), those who saw another provider initially but accessed a PT at a later date ("PT later"), and patients who saw another provider initially and never saw a PT ("no PT").

    Consistent with previous studies, authors found that regardless of the type of direct access provision, patients who saw a PT first for LBP experienced significantly lower total costs for care compared with both the no-PT and PT-later groups, including lower out-of-pocket expenditures. The PT-first cost differences were most dramatic in relation to outpatient costs and to a lesser extent to physician costs. Also unsurprising were the authors' findings that the PT-first patients had significantly lower rates for ED visits, imaging, and opioid prescriptions compared with the other groups.

    But the particular focus of the research—the differences in costs and other factors depending on the level of restriction to direct access—yielded some more complicated results. Among them:

    • In restricted states, 20.8% of all patients eventually saw a PT, compared with 13.5% in unrestricted states.
    • Among PT-later patients, those who eventually saw a PT in a restricted state averaged 69 days before seeing the PT, compared with 75 days in unrestricted states.
    • Among the no-PT groups, imaging and opioid prescriptions tended to be higher in restricted states than in unrestricted states—but ED visits were lower.
    • Across all groups, overall costs of care were lower for patients in restricted states compared with unrestricted states, a difference that authors tied to lower outpatient and hospital costs.

    Authors write that while more research is needed, there are possible explanations for the seemingly lower costs associated with restricted direct access, some of which might have something to do with the states used in the study.

    "The lower cost could be associated with prescribing restrictions and/or greater use of lower cost providers in restricted states," authors write. "Alternatively, the lower cost could be associated with access to care differences such that restricted states are more urban than unrestricted states, which are more rural."

    Also worth further exploration, according to authors, are the advantages of unrestricted direct access when it comes to rates for imaging services and opioid prescriptions, which were lower when a state had no restrictions on access. "These results suggest that removing restrictions on access to [physical therapy] may result in better imaging outcomes among select populations, but may not benefit ED visit rates," they write.

    Authors of the study include Kenneth Harwood, PT, PhD, CIE.

    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.


    • Excellent points made here. I'm glad there's a study showing the importance of PT for people with LBP. It being such a sadly common problem, people need to know how effective PT can be.

      Posted by Jordan on 3/1/2016 10:52 AM

    • I am getting therapy for lower back pain and have seen great results and all that is thanks to Phoenix

      Posted by Andrea Schott on 3/1/2016 1:12 PM

    • Physical therapist are the experts when it comes to eval and treating back and neck conditions. Direct access is a no brainier to save money. It's a shame the public is not more aware of PT direct access.

      Posted by Greg on 3/2/2016 9:50 PM

    • Non-specific exercises for non-specific back pain will yield non-specific, non predictable results. If you cannot have your back pain patient free of pain in about 10-15 minutes you probably don't understand what you are treating. 15. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet. 1928. 2:1119-1122. 16. Frieberg A H, Vinke TH. Sciatica and the sacroiliac joint. J Bone & Joint Surg. 1934.16:126. 17. McConnell CP, Teall CC. The Practice of Osteopathy. Third Edition. Kirksvillle, Mo., The Journal Printing Co. 1906. 51. DonTigny RL. Evaluation, manipulation and management of anterior dysfunction of the sacroiliac joint. The D.O. 14:215-226, 1973 13. DonTigny R L. Sacroiliac 201: Dysfunction and management A biomechanical solution. J of Prolotherapy. 2011.3(2): 644-652. https://www.researchgate.net

      Posted by Richard DonTigny -> CFYZ= on 3/3/2016 10:14 AM

    • I work in a hospital based outpatient physical therapy facility in a direct access state. We bill under 1 NPI number. I have been told that in order to allow direct access at our facility, we each need our own NPI number. Does anyone know if this is true?

      Posted by Janet on 3/7/2016 10:37 PM

    • As physician extenders (think PA & NP), we provide direct access to active duty members in the Air Force. We also prescribe meds (on a limited formulary), request imaging and refer to other specialists when indicated. This makes sense as we are the musculoskeletal experts. Most of my years of practice have been in the civilian sector. It still amazes me that civilian patients can directly see a massage therapist, chiropractor, acupuncturist, etc. But NOT a doctorate-level trained PT? It's all about a strong lobby and MD, DO, DC turf wars. -The NPI question: My understanding is that if your state allows direct access (and your insurance companies reimburse for it), each evaluating therapist needs to bill under their own NPI - just like other primary care providers (DCs, MDs, etc.)

      Posted by Mark, DPT on 3/11/2016 10:53 AM

    • For the most effective method of evaluation and treatment of low back or cervical pain, I would highly recommend seeing a certified McKenzie trained physical therapist. To locate one near your area go to mckenziemdt.org

      Posted by Wayne Rice on 3/15/2016 11:31 AM

    • Direct Access in Hawaii has been met with such opposition by the primary insurance companies in the state that it has not been utilized much. Hoping that insurers will realize the ultimate cost savings and the benefits of less drug use.

      Posted by Betty Fackler on 3/25/2016 3:45 PM

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