Download - Direct Access in the States
Direct Access in the States
Our goalAPTA Vision Sentence for Physical Therapy 2020By 2020, physical therapy will be provided by
physicaltherapists who are doctors of physical therapy,recognized by consumers and other health careprofessionals as the practitioners of choice to whomconsumers have direct access for the diagnosis of,interventions for, and prevention of impairments, functional limitations, and disabilities related tomovement, function, and health.
Direct Access and the Professions’ Vision
Direct Access and Vision 2020
• One of the Six Elements as Developed by APTA’s House of Delegates and Board of Directors
• Prerequisite for other components of the Vision
• Controlled by policymakers (external audiences
Vision 2020
EBP
AP PoC
DA
DPT
Professionalism
Direct Access Defined
Historical Perspective• Accreditation of PT degree programs were joint effort with
AMA until 1977.
• Physician referral and prescription required.
• APTA House of Delegates address in late 1970’s (Position on evaluation and treatment without referral – 1979
• State status at passage of Association position– 2 States did not require referral in practice act
• 1979 Action kicked off Association “direct access” initiative– 31 years later: state of direct access has progressed from 2
states to 45 + DC.
What is “Direct Access”?• Direct access is the legal right of the
public to seek and receive an examination, evaluation, and interventions by a physical therapist without the referral of a physician.
APTA Board of Directors, 2000.
3 Types of Direct Access• Unrestricted: No referral language in the
physical therapy practice act.
• Provision: No referral needed to access physical therapists examination, evaluation, and intervention with certain provisions.
• Limited Direct Access: allows for access to evaluation and access for certain types of treatment.
States with Direct Access
45 States and the District of Columbia currently have some form of direct access to physical therapist examination, evaluation, and intervention. (45 of 51 jurisdictions = 88%)
Important to stress some form as negotiations from Albany to Olympia have created many different direct access animals.
Status of Direct Access States
• 16 states have unrestricted direct access - no referral language in the PT practice act.
• 29 + DC states have direct access with provisions.– 11 of the 30 have what is considered
‘limited direct access:’ CA, GA, IL, KS, LA, MS, MO, NM, TX, WI, and WY
Unrestricted Direct Access
16 States with unrestricted direct access:
Nebraska was the first in 1957Maryland – 1979 (technically CA in 1968 but overturned with AG
opinion)Massachusetts – 1983Arizona - 1983West Virginia - 1984Nevada, Utah - 1985Alaska + South Dakota – 1986Kentucky, Montana + Idaho – 1987Colorado, Iowa + Vermont – 1988North Dakota - 1989
Direct Access with provisions
Arkansas – 1997 Rhode Island - 1992Connecticut – 2006 South Carolina - 1998Delaware – 1993 Tennessee – 1999 DC – 2007 Virginia - 2001Florida – 1992 Washington - 1988Maine – 1991Minnesota – 1998New Hampshire – 1988New Jersey – 2003New York – 2006North Carolina – 1985Ohio – 2004Oregon -1993Pennsylvania – 2002
Direct Access with provisions
Referral required only for specific services: - Arkansas (Pulmonary Hygiene, Wound Care),
- Connecticut, Maine, and North Carolina (Spinal Manipulation), - Washington (certain orthotics)
Referral required only if patient does not show progress within a specifiedperiod of time: Connecticut (30), DC (30), Maine (30), New Hampshire (25),Ohio (30). Referral required after an absolute time frame regardless of patient progress: Delaware (30), Florida (21), Maine (120) Minnesota (90), New Jersey (30), New York (30), Oregon (60), Rhode Island (90), South Carolina (30), Tennessee (30), and Virginia (14),
Provisional Direct AccessArkansas (1997) and Washington
(1988)
Spinal manipulation prohibitions in return
for direct access – NEVER AGAIN!
Limited Direct AccessCalifornia - 1968Georgia - 2006Kansas - 2007Illinois - 1988Louisiana - 2003Mississippi - 2006Missouri - 1999New Mexico - 1989Texas - 1991Wisconsin - 1989Wyoming - 2003
Steps toward unrestricted direct
access• 5 states have been successful in improving their direct access statute– New Hampshire (2002)– Virginia (2007)– Tennessee (2007)– Oregon (2007)– Minnesota (2008)Able to show legislators that the “world didn’t end” because
of their initial direct access, hence justifying increased access.
Direct AccessStates without direct access to
evaluation:Alabama and Indiana
States without direct access to treatment:
Hawaii, Michigan, Oklahoma
MD/DO
PT NP RD PA
Creating a New Paradigm in Health Care with Direct Access
MD
PT NP
RD PA
OD DPM DC
PT MD
OD DPM
DC DDS MD(specialists)
The 3 D’s of Direct Access
• Denied Access
• Delayed Access
• Disparities in Access
The Benefits of Direct Access
• The Benefits to the Patient
• The Benefits to the Payer or taxpayer
The Benefits to the Patient
Improved AccessImproved ChoiceEliminate delays
Faster return to work
Benefits of Direct Accessfor the Patient
• Choice of provider
• Less visits
• Convenience/flexibility
• Earlier intervention• Decreased out-of-pocket expense
(copays, pharmacy)
The Benefits to the Payer
Cost EffectivenessConsumer Choice
Benefits of Direct Accessfor the Payer
Decreased costs when referral notrequired
Physician visit costsCombats referral for profit (over-
utilization)
Benefits of Direct Accessfor the Payer
Decreased costs when referral notrequired
Possible unnecessary diagnostic or pharmaceutical costs
Benefits of Direct Accessfor the Payer
• Decreased number of claims to process– Physician visits– Diagnostics– Pharmacy– Appeals
Benefits of Direct Accessfor the Payer
• Increased customer satisfaction– Less out-of-pocket expense– Faster access to help– Faster return to work
Research: Mitchell Study
Direct Access DOES NOT promote over-utilization3:– Physician referral
episodes of care generated 67% more claims and 60% more office visits
0100200300400500600700800900
1000
Claims OfficeVisits
MDPT
Research: Mitchell Study
Direct Access DOES NOT result in higher physical therapy costs3.– Cost per visit were
123% higher when patients were first seen by a physician prior to PT and
– Claims paid under direct access to physical therapist were $1,232 less than physician referred.
$0$2,000$4,000$6,000$8,000
$10,000$12,000$14,000
Cost Claims
MDRefersDA forPT
National Endorsements of Direct Access
• National Black Caucus of State Legislatures (NBCSL): “The NBCSL urges the adoption of state legislation that permits access to physical therapists without a physician referral”
National Endorsements of Direct Access, cont.
• American Legislative Exchange Council (ALEC): “patients should have the ability to access physical therapists' services without current professional practice restrictions regarding referral”
So what’s the beef?• Malpractice
• Diagnosis
• MedPAC
• Loss of collaboration/team approach??
• Mandate on all PTs and patients to practice via direct access.
Will Direct Access increase liability?
• Since 1994, the APTA endorsed liability carrier has not reported an increase or change in claim pattern that reflects negatively on Direct Access. The underwriter (CNA) agrees.
• Underwriter does not charge a premium in states with Direct Access.
Diagnosis/patient safety• Diagnosis is both a process and a label. The
diagnostic process performed by the physical therapist includes integrating and evaluating data that are obtained during the examination to describe the patient/client condition in terms that will guide the prognosis, the plan of care, and intervention strategies. Physical therapists use diagnostic labels that identify the impact of a condition on function at the level of the whole person. (Guide to Physical Therapist Practice. Rev 2nd Ed. Alexandria, VA: American Physical Therapy Association; 2003.)
Diagnosis• Diagnosis – the great link to direct access
• Currently – 17 states explicitly authorize diagnosis (diagnosis, physical therapy diagnosis, or diagnosis for physical therapy)
• Identified in The Guide, The Normative Model for Physical Therapist Education, APTA House of Delegates position, and FSBPT Model Practice Act,
• Several States prohibit PTs from making a medical diagnosis.
Can Physical Therapists make a “diagnosis”?
• Medical diagnosis: interruption of normal cellular processes
vs.• Diagnosis of impairment, functional
limitation, or disability: loss of function, restriction of ability to perform task, inability to engage in activity
Can Physical Therapists make a “diagnosis”?
• CVA vs. Hemiplegia• Rheumatoid Arthritis vs. Joint
inflammation, joint deformity, muscle weakness and inability to turn keys
• MS vs. Balance deficits, weakness and decreased sensation
Diagnosis: the politics of fear
“Allowing unlimited physical therapy without a doctor’s assessment ..requires a PT to step beyond their training
tomake a diagnosis and then initiate their treatment.”
“The list of medical conditions that can masquerade as musculoskeletal problems can fill an entire text book”
- Dr. Andy Smith Assistant Professor of Orthopaedics University of Minnesota
Diagnosis: the politics of fear
• Parents of young baseball player with shoulder pain waste critical weeks having their child receive PT until fractures occurs and an x-ray is taken and it is discovered that the child’s pain was not due to an overuse injury as suspected but due to…
Diagnosis: the politics of fear
CANCER!And the fracture complicates care and
the childmust undergo amputation!
ALL OF THIS BECAUSE OF DIRECT ACCESS!
Loss of collaboration/team approach
“Coordination of care with physicians is critical”
“If there is any change in the postoperative plan we need to need to be notified and have a discussion.”
“Collaboration with PTs can also prevent delay and the
need for surgery.”
Dr. Dan RotenbergMinnesota Orthopaedic Society
2004 MedPAC Report“The Medicare payment advisory commission concluded that physician referral was
necessary to ensure appropriate physical therapy
services for Medicare beneficiaries.”
Dr. Paul MatsonMinnesota Medical Association
MedPACThe 2004 MedPAC report was to determine the feasibility of removing the referralrequirement for the Medicare program anddoes not address the issue of direct access for private pay or out-of-pocket patients in the various states.*Since the report CMS has removed referral requirement and only requires plan of care be certified within 30 days.
MedPACIn the same report MedPAC Commissioners and staff fullyacknowledged the shortcomings of the physician referral in ensuring medical necessity.
In fact, in response to a question by MedPAC Commissioner former Senator David Durenberger, MedPAC staff could offer no evidence to support the contention that a physician
referral offers an assurance of medical necessity. The current system is ineffective, but MedPAC concluded there was insufficient evidence with the Medicare population to remove the referral requirement, against the best interest of the patients that Medicare serves.
Top issues that confuse legislators
• That this about payment (insurance code) not PT statute. Legislation mandates payment for direct access vs. removal of statutory referral requirement. Use argument about pro bono and cash-based payment.
• Most legislators know little about health care and even less about PT. (education level , state licensure, belief that there needs to be supervision by MDs, etc)
• Belief that physicians “own” diagnosis. Difference between a medical diagnosis and a diagnosis for PT.
.
Strengthening your political muscle to
overcome the politics of fear and misinformation• PTs will never beat the physicians,
medical society, orthopaedic surgeons, or chiropractors in terms of political donations and campaign cash.
• Campaign donations, while important, are not the end all be all in politics.
• Lack of political wealth can be made up by strengthening your political muscle
Political Muscle
• Lobbyist, grassroots, lobby days, key contact, etc.
• Key and vital element – the personal and trusting relationship that a person has with an elected official.
• Build a meaningful and trusting relationship with your elected official – become more than just a name. Become a friend.
Contact InformationJustin Elliott
Associate Director, State Government AffairsAmerican Physical Therapy Association (APTA)
1111 North Fairfax StreetAlexandria VA [email protected]