What Direct Access in Florida means
According to Florida's 21-day Direct Access statute if you want to see a Physical Therapist without a prescription or referral you are allowed to receive care for 21 calendar days. If your condition requires treatment beyond 21 days then there must be a "practitioner of record" who reviews and signs the Plan of Care (POC). This practitioner must be one of the following professionals:
- Medical physician
- Osteopathic physician
- Dental Hygenist
That last one may raise some eyebrows, but it is technically legal as Hygenists are licensed and regulated under Chapter 466 which is one of the professionals allowed to oversee the POC.
Direct Access to Physical Therapy (PT) services in Florida should be unrestricted. Let me show you why.
As the U.S. healthcare “debate” spirals into a blur of misinformation, media posturing and propagandized rhetoric the facts of the matter remain unchanged: $3.0 trillion spent on healthcare in 2014(18), 47 million uninsured Americans(7), 37th international ranking in World Health Organization statistics for healthcare performance(23) and #1 in cost per capita(20).
One effort to contain some of the costs of healthcare and contribute a higher quality of service is embodied in the push for direct access to health care professionals, namely physical therapists. Here in Florida, while a limited form of direct access to PT has been around since 1992, the continued restrictions place an unnecessary burden on an already strained system that lacks sufficient primary care providers. The Association of American Medical Colleges (AAMC) estimates there will be a nationwide shortage of 46,000 primary care physicians (37% of overall physician shortage) by 2025(8). I will provide an argument for the elimination of legislative barriers to direct access to PT in Florida as a positive change for improving quality of care, protecting patient safety and reducing overall costs.
In 1992 the Florida Legislature granted state licensed physical therapists the privilege of direct access for 21 days, subject to the approval of a practitioner of record beyond this timeframe (FL Statutes, Ch. 486.021). Practitioners of record are stipulated as being professionals regulated under the Statute chapters of Medicine, Osteopathy, Chiropractic, Podiatry and Dentistry. Other qualified professionals, such as Advanced Registered Nurse Practitioners (ARNP), are prohibited from such authorization. These provisions were put into place as a compromise with groups that opposed this legislation.
Currently all 50 states, the District of Columbia and the U.S. Virgin Islands enjoy some form of direct access, whether unlimited or provisional(1). These privileges have been enacted because the vast majority of the country understands that physical therapists are well-qualified, both through formal education and clinical training, to evaluate a patient's condition, assess his or her physical therapy needs and, if appropriate, safely and effectively treat the patient or refer out if beyond the scope of practice.
Obstacles to Direct Access
Threats to Patient Safety: The ability to provide primary care services has been opposed by special interest groups that fear that giving this authority to physical therapists would translate into a threat to patient safety. For example, the Florida Orthopaedic Society (FOS) successfully prevented the filing of legislation to grant physical therapists direct access to patients during the 2009 legislative session. Advocacy efforts conducted by the FOS to educate lawmakers on the dangers to patients direct access poses were successfully received by legislative leadership(22). In 2006 the New York State Society of Orthopaedic Surgeons (NYSSOS) ran a smear ad in The Legislative Gazette, campaigning that physical therapists are not “trained to recognize” bone tumors in the lower back because of “limited expertise” and the goal of going to PT is “to receive treatment, not a diagnosis”(19).
Competition: The Institute for Alternative Futures (IAF), in their report “The Future of Chiropractic Revisited” described PT as the chiropractor’s “biggest competitive threat” due to expansion of direct access and “restructuring their educational programs so most of them are Doctor of Physical Therapy programs”(13).
Referral-for-Profit: The existence of physician-owned physical therapy services (POPTS) has posed a threat to the professional autonomy of PT since the 1970’s when it was first identified in the journal Physical Therapy(12). Physicians have claimed improved communication with therapists, lower patient costs, seamless integration of care and higher quality of care as potential benefits to this arrangement. A 2007 article in Podiatry Today described the process of incorporating a physical therapy service as an ancillary revenue stream under the pretense of expanding patients’ options (15).
Benefits of Direct Access
According to the American Physical Therapy Association’s (APTA) Vision Statement for Physical Therapy, by 2020 “Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services.” The organization envisions that treatment will be provided by “doctors of physical therapy … who may be board-certified specialists”(2).
High Standards of Training: As of October 2015 there are 258 accredited and developing Doctor of Physical Therapy (DPT) programs in existence(3). The Commission on Accreditation in Physical Therapy Education (CAPTE) requires these programs to include doctoral-level tutelage in the biological, behavioral and clinical sciences as well as professional education and expanded clinical experience over Master’s-degree programs4. The addition of coursework in differential diagnoses, medical imaging and pharmacology, for example, help prepare the therapist to undertake the responsibilities of a primary care provider. To this end, experienced physical therapists have been found to have higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopedists6.
Patient Safety: A 2006 study of 50,799 patient visits to PT via direct access found no incidences of injury or adverse events resulting from PT diagnoses or management(17). Another study looking at the clinical diagnostic accuracy between PTs and orthopedic surgeons found no difference in accuracy when evaluating patients with musculoskeletal injuries(16). In fact, when looking at patient safety one must ask how appropriate is it NOT to see a physical therapist? Two studies by Freedman and Bernstein study revealed 82% of the recent medical school graduates failed to demonstrate basic competency in musculoskeletal medicine(9,10).
Reduced Costs: Multiple studies have demonstrated that physical therapists can provide safe and cost-effective care for patients with musculoskeletal conditions in direct access practice settings, supporting the expansion of direct access physical therapy services(7,14,21). For example, physician referral episodes of care reportedly increased physical therapy claims by 67%, office visits by 60%, and costs by 123% than when patients directly accessed physical therapy without physician referral(14). A 2007 Wall Street Journal article highlighted the cost savings of providing PT on the front-end of care for patients experiencing back pain, reducing the number of costly MRIs from 35% to less than 5%, with improved outcomes as well(11).
The longstanding barriers to unrestricted direct access highlighted here bear no weight when it comes to the issues of competency, patient safety, and reduced costs. Opposition has primarily been from groups who see Physical Therapy as competition and ancillary. They fail to respect the profession for its autonomy, high level of education, reliance on evidence-based standards and effectiveness with outcomes. The appropriate utilization of PT for musculoskeletal conditions has the potential to save employers, insurers and ultimately patients considerable amounts of money and positively contribute to the reform of a healthcare system in desperate need of quality and efficiency.
1. APTAa. “Direct Access at the State Level.” APTA Web site. Available at: http://www.apta.org/StateIssues/DirectAccess/
2. APTAb. “Vision 2020”. APTA Web site. Available at: http://www.apta.org/Vision2020/
3. ATPAc. “Number of PT and PTA Programs”. APTA Web site. Available at: http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Aggregate_Program_Data/NumberofPTPTAPrograms.pdf#search=%22number%20of%20pt%20pta%20programs%22
4. CAPTE. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. APTA Web site. Available at: http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Accreditation_Handbook/EvaluativeCriteria_PTA.pdf
5. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32-38.
6. Daker-White G, Carr AJ, Harvey I, Woolhead G, Bannister G, Nelson I, Kammerling M. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health. 1999;53:643–650.
7. DeNavas-Walt C, Proctor B, Smith J. Income, Poverty, and Health Insurance Coverage in the United States: 2006. Washington DC: U.S. Census Bureau; 2007.
8. Dill, MJ, Salsberg ES. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington DC: Assoc of Amer Medical Colleges: 2008.
9. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002;84:604-608.
10. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80:1421-1427.
11. Furhmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. Wall Street Journal. January 12, 2007. Available at: http://www.wsj.com/articles/SB116857143155174786
12. Hiltz DL. Hiring of physical therapists. [Letter to the editor]. Phys Ther. 1976;56:1061.
13. Institute for Alternative Futures, The Future of Chiropractic Revisited: 2005-2015. Alexandria: Institute for Alternative Futures; 2005. Available at: http://www.altfutures.org/pubs/health/Future%20of%20Chiropractic%20Revisted%20v1.pdf
14. Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10–18.
15. Moore J. How To Provide Physical Therapy As An Ancillary Service. Podiatry Today. 2007;20(2). Available at: http://www.podiatrytoday.com/article/6695.
16. Moore JH, et al. Clinical Diagnostic Accuracy and Magnetic Resonance Imaging of Patients Referred by Physical Therapists, Orthopaedic Surgeons, and Nonorthopaedic Providers. J Orthop Sports Phys Ther. 2005;35:67-71.
17. Moore JH, MacMillian DG, Rosenthal MD, Weishaar MD. Risk Determination for Patients With Direct Access to Physical Therapy in Military Health Care Facilities. J Orthop Sports Phys Ther. 2005;35:674-678.
18. National Health Expenditure Projections 2014 Highlights. CMS Web site. Available at: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf
19. NYSSOS. Are you trained to recognize the bone tumor in this lower back? The Legislative Gazette. May 22, 2006.
20. Organization for Economic Cooperation & Development (OECD), OECD Health Data 2000: A Comparative Analysis of Twenty-nine Countries. OECD: 2000.
21. Overman SS, Larson JW, Dickstein DA, Rockey PH. Physical therapy care for low back pain. Monitored program of first-contact nonphysician care. Phys Ther. 1988;68:199–207.
22. Strzlecki W. Advocacy in the States. AAOS in the States Newsletter. Washington DC: Amer Assoc of Ortho Surgeons; August, 2009.
23. World Health Organization. The World Health Report 2000 – Health Systems: Improving Performance. Geneva: WHO; 2000.