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Some form of direct access to physical therapist (PT) services has been a reality in all 50 states since early 2015. But just how much of a reality is it? That’s another question.

A recent report from APTA analyzed data from a 2015 survey of nearly 6,000 PTs from all states and the District of Columbia to get a sense of how direct access was being implemented—or not implemented—and what might be standing in the way of broadest possible use. Analyses found that while direct access is happening to some degree across the country, a combination of institutional barriers, state-level restrictions, and varying levels of understanding of the concept among PTs may be hindering its growth.

According to the report, 1 of the biggest impediments to widespread use of direct access is the fact that some states restrict the practice through provisions that include limiting the number of sessions that can be provided without a referral, only allowing for a certain number of days to pass between startup of physical therapy and obtaining a referral, and placing special requirements on PTs who want to engage in direct access. Not surprisingly, PTs in states with unrestricted direct access tend to have higher engagement levels than those working under restrictions.

But that’s not the only thing standing in the way of more widespread use of direct access. The report points out that the barriers most often cited by PTs in the survey had to do with the policies of supervisors or facilities requiring referral even when the state allows direct access. Nearly 2 out of 3 respondents said that their employment setting required referrals regardless of state law.

In addition to those very real restrictions, direct access also may face a perception problem among some PTs, with 60% of respondents reporting that concerns about reimbursement were among the biggest barriers to increased direct access use—a number at odds with the fact that “claims for direct access are not routinely denied” by payers, according to the report. And that low rate of denial is in line with respondents’ estimates that only 7.5% of their direct access claims were denied (though 41% said they didn’t know for certain that their claims were denied due to lack of referral).

The good news is that even with those real and perceived barriers, direct access is being used widely among PTs, with 50% of respondents reporting some use of direct access. In states with unrestricted direct access, the rate climbs to 65.5%. Most of the use (69%) is occurring in private and hospital-based outpatient clinics and group practices.

Among other details from the report:

  • The most frequently cited services associated with direct access include “traditional patient and client management,” with 93.3% of users listing those services. Fitness, prevention, wellness, and health promotion was listed by 43.8% of PTs who engaged in direct access, and 39.3% of users listed screenings as an associated activity.
  • Of the 73% of direct access-using PTs who market direct access, 69.7% do so through direct marketing to patients, with 53.1% listing participation in community events, and 48% reporting that they provided education on direct access to referral sources.
  • Respondents reported self-pay patients as the highest users of direct access, at 44.1%. Patients with commercial coverage were estimated at 25.3%.

“This report provides a snapshot of direct access use and perceptions at a particular point in time,” said Elise Latawiec, PT, MPH, APTA senior practice management specialist. “We anticipate that its use has increased since 2015, and we will continue to advocate for states to drop restrictions, to increase patient access. At the same time, it’s important for PTs to gain a solid understanding of direct access and promote its benefits to the institutions and facilities that are imposing restrictions that aren’t required by state law and regulation. As we move to a value-based environment, direct and early access to therapy services will play a critical role in the profession’s ability to deliver on lowering overall health care costs.”

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