This year, state legislation aimed at improving patient access to skilled physical therapy services has been introduced in Tennessee, Texas, California, and Michigan. All of these bills would enhance patient choice and access to treatment alternatives to surgery and medications for movement dysfunction and mechanical pain.
These pieces of legislation are being met with resistance from the medical community including orthopedic groups and state medical associations. These groups perceive direct access to physical therapy as a threat to their financial stake in managing patients with mechanical pain. The primary rationale for opposing patient access to physical therapy is based on the view that this extension of services for outpatient PT without physician involvement would lead to increased utilization of medical services and therefore would increase costs to insurers and their beneficiaries.
This is a view is completely unfounded and is not supported by the evidence from countries in which there is a mature direct access base for physical therapy. In fact, the current evidence demonstrates the opposite—where there is more imaging there will be more surgeries and greater disability rates. See HERE and HERE and HERE.
The rate of back surgery in the United States is approximately 40% higher than in any other country and more than five times those in England and Scotland. Back surgery rates increase almost linearly with the per capita supply of orthopedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy.
The truth is, if the current system of physician referral for orthopedic interventions was working well and the system was coping with the current utilization, there would not be a problem and increased scrutiny toward orthopedic groups who employ their own physical therapists by MedPAC and the media.
Direct access for physical therapy will only be of benefit to the general community if this system works cost efficiently and there is perceived to be incremental value in self-referred treatment pathways to PT.
If a patient is self-referred for rehabilitation and does not perceive value or benefit, they will not be compliant or continue treatment. Likewise, self-referred patients to physical therapists tend to be more motivated and require less treatment than physician referred patients.
In a mature patient direct access (to PT) market for musculoskeletal pain, where people in pain truly have a choice as to where they receive treatment, they will go where the product, and therefore the outcomes, are the best.
Internal medicine referral patterns to orthopedic surgeons for musculoskeletal pain has led to an overwhelming increase in imaging services, pain medication prescription and surgeries and the clinical outcomes have not improved and according to some has declined in recent years. Many orthopedic groups own their imaging equipment and also have their own PT departments and thus benefit financially from physician referral to their own facility.
While the general community has grown cynical of costly and inefficient referral practices, it is also tired and disillusioned with ordinary and ineffectual physical therapy services. Patients are more and more looking to alternative treatment paradigms. The traditional exercise based physical therapy where a PT is required to perform an evaluation but often transfers the oversight of the treatment to an ATC or technical assistant will not wash in a mature direct access market.
That is the point. In a mature direct access market, where a patient seeks the care of a physical therapist directly, only excellent physical therapy will thrive. Physical therapy will get better and more efficient in a mature direct access market as the poor rehabilitation will fail to thrive.
When profit form referral motives are removed and there is truly a choice in where to receive treatment for musculoskeletal pain, people will not return and will not refer others to inferior options. Direct access will level the playing field and thus shift the power to the health care consumer where competition drives innovation, value, and clinical excellence—not the halo effect associated with cozy physician relationship based referrals.
If orthopedic surgeons can no longer benefit financially from self-referral, they will send to the best quality PT at their disposal and they will quickly learn who is delivering the outcomes they require in the rehab of their patients.
Similarly, part of being an excellent physical therapist and one who will thrive in a direct access market, is being an expert in differential diagnosis, and one who recognizes when a patient will benefit from referral for an orthopedic or neurosurgical consultation or alternative opinion. Direct access physical therapy must be good enough to know what is not responding within a reasonable timeframe and recognize early when some diagnoses need to be cleared before conservative rehab begins. This delivers value to the system, not cost.
Two weeks of conservative management is more cost-effective than MRI for most conditions as long as there has been a full and thorough clinical evaluation to clear more significant pathology. This plays into the physical examination skills of the licensed physical therapist.
Direct access will gather momentum and the general community will benefit incrementally from the process, but physical therapy has to be good enough to become the gatekeepers for musculoskeletal pain. Current physical therapy (PT) education mandates that these skills are taught in the entry-level curriculum, but obstructive laws prohibiting patient access to quality PT limits practice of these learned skills. As in any market, the best will prevail and the rest will dwindle. We owe it to ourselves as a profession to promote patient direct access and be held responsible and accountable for the musculoskeletal wellbeing of our patients. The medical profession isn’t meeting this need.
C. Jason Richardson, PT
Greg Spurgin, PT
