Direct Access in the States

1. Direct Access in the States

2. Our goal APTA Vision Sentence for Physical Therapy 2020 By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.

3. Direct Access and the Professions’ Vision

4. 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

5. Vision 2020

6. Direct Access Defined

7. 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.

8. 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.

9. 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.

10. 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.

11. Status of Direct Access States • 16states have unrestricted direct access - no referral language in the PT practice act. • 29 + DCstates 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

12. Unrestricted Direct Access 16 States with unrestricted direct access: Nebraska was the first in 1957 Maryland – 1979 (technically CA in 1968 but overturned with AG opinion) Massachusetts – 1983 Arizona - 1983 West Virginia - 1984 Nevada, Utah - 1985 Alaska + South Dakota – 1986 Kentucky, Montana + Idaho – 1987 Colorado, Iowa + Vermont – 1988 North Dakota - 1989

13. Direct Access with provisions Arkansas – 1997 Rhode Island - 1992 Connecticut – 2006 South Carolina - 1998 Delaware – 1993 Tennessee – 1999 DC – 2007 Virginia - 2001 Florida – 1992 Washington - 1988 Maine – 1991 Minnesota – 1998 New Hampshire – 1988 New Jersey – 2003 New York – 2006 North Carolina – 1985 Ohio – 2004 Oregon -1993 Pennsylvania – 2002

14. 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 specified period 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),

15. Provisional Direct Access Arkansas (1997) and Washington (1988) Spinal manipulation prohibitions in return for direct access – NEVERAGAIN!

16. Limited Direct Access California - 1968 Georgia - 2006 Kansas - 2007 Illinois - 1988 Louisiana - 2003 Mississippi - 2006 Missouri - 1999 New Mexico - 1989 Texas - 1991 Wisconsin - 1989 Wyoming - 2003

17. 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.

18. Direct Access States without direct access to evaluation: Alabama and Indiana States without direct access to treatment: Hawaii, Michigan, Oklahoma

19. Creating a New Paradigm in Health Care with Direct Access MD/DO PT NP RD PA OD DPM DC DDS MD(specialists) OD DPM DC PT MD MD PT NP RD PA

20. The 3 D’s of Direct Access • Denied Access • Delayed Access • Disparities in Access

21. The Benefits of Direct Access • The Benefits to the Patient • The Benefits to the Payer or taxpayer

22. The Benefits to the Patient Improved Access Improved Choice Eliminate delays Faster return to work

23. Benefits of Direct Accessfor the Patient • Choice of provider • Less visits • Convenience/flexibility • Earlier intervention • Decreased out-of-pocket expense (copays, pharmacy)

24. The Benefits to the Payer Cost Effectiveness Consumer Choice

25. Benefits of Direct Accessfor the Payer • Decreased costs when referral not required • Physician visit costs • Combats referral for profit (over-utilization)

26. Benefits of Direct Accessfor the Payer • Decreased costs when referral not required • Possible unnecessary diagnostic or pharmaceutical costs

27. Benefits of Direct Accessfor the Payer • Decreased number of claims to process • Physician visits • Diagnostics • Pharmacy • Appeals

28. Benefits of Direct Accessfor the Payer • Increased customer satisfaction • Less out-of-pocket expense • Faster access to help • Faster return to work

29. Research: Mitchell Study Direct Access DOES NOT promote over-utilization3: • Physician referral episodes of care generated 67% more claims and 60% more office visits

30. 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.

31. 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”

32. 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”

33. So what’s the beef? • Malpractice • Diagnosis • MedPAC • Loss of collaboration/team approach?? • Mandate on all PTs and patients to practice via direct access.

34. 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.

35. 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.)

36. 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.

37. 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

38. 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

40. Diagnosis: the politics of fear “Allowing unlimited physical therapy without a doctor’s assessment ..requires a PT to step beyond their training to make 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

41. 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…

42. Diagnosis: the politics of fear CANCER! And the fracture complicates care and the child must undergo amputation! ALL OF THIS BECAUSE OF DIRECT ACCESS!

43. 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 Rotenberg Minnesota Orthopaedic Society

44. 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 Matson Minnesota Medical Association

45. MedPAC The 2004 MedPAC report was to determine the feasibility of removing the referral requirement for the Medicare program and does 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.

46. MedPAC In the same report MedPAC Commissioners and staff fully acknowledged 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.

47. 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. .

48. 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

49. 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.

50. Contact Information Justin Elliott Associate Director, State Government Affairs American Physical Therapy Association (APTA) 1111 North Fairfax Street Alexandria VA 22314 justinelliott@apta.org