This month I would like to discuss a topic that is a favorite of Physical Therapists everywhere in the United States, and that, as the title may have given away, is Direct Access.  This topic is very important to the survival and autonomy of Physical Therapy as a profession, and there is some form of it in all 50 states.  Direct Access is defined at a state level, therefore not all states will have the same level of access to Physical Therapy as other states.  As of 2020, 20 states have unrestricted Direct Access to Physical Therapists, such as West Virginia and Colorado.  27 states have Direct Access with provisions, such as Arkansas and Pennsylvania.  Only 3 states have very limited Direct Access to Physical Therapy, which are Missouri, Alabama and Mississippi.  Direct Access is a time saver and a money saver for many people, but unfortunately is not very well understood by the general population.  This is what I am hoping to change with this month’s blog post.  So, let’s dive in!

What is Direct Access?

  Direct Access is anyone’s ability to self-refer to a Physical Therapist for evaluation and treatment.  It allows a person to go to a Physical Therapist for help with their problem just as a person can go to a doctor for a problem.  The question Physical Therapists and people seeking Physical Therapy in states with strong provisions or very restricted access are asking is, “Why is there a gatekeeper for Physical Therapy?  Nobody needs to be referred to a Primary Care Doctor to establish care, so why should those who specialize in movement-based rehabilitation be any different?”  These are the questions that need to be asked to State Senators and Representatives for laws to change.  Of note, the American Physical Therapy Association (APTA) supports the removal of arbitrary restrictions on direct access to Physical Therapy.

Why is Direct Access Important?

  As you may have deduced from the previous section, referrals being required to attend Physical Therapy is not uncommon in many states.  Notwithstanding the 27 states with provisions allowing greater access to Physical Therapy than the 3 states who impose very great restrictions, 17 of those states require a referral after a certain number of days or visits for Physical Therapy to continue, and an additional 7 require referral if no progress is made within a certain time frame.  With healthcare costs continuing to rise, it is no wonder that insurance companies are trying to control spending.  However, it is antithetical to their cause (which really is to spend as little as possible) to require a Physician referral at any point in time, and also difficult for the person seeking assistance to justify a trip to their Primary Care Physician who will likely say, “Go get Physical Therapy.”  The person already knows this, and it is disrespectful to that person to require them to spend time and money on a doctor visit only to be told something they already know.  Unrestricted, or very few provisions on Direct Access to Physical Therapy provide the most cost-effective and time-conscious options for people seeking Physical Therapy. 

Is Direct Access Safe?

  Now that you know there are requirements in many states to get a referral from a Physician after a certain amount of time, you might be wondering if it is safe to utilize Direct Access.  “Why not just go to the Physician first?” you might be thinking.  Cost-effective and time-conscious interventions are key for most people.  Some people feel safer going to a Physician first, and this is no knock to those people.  If they need that security, I stand behind them.  However, in February, 2005, the Journal of Orthopedic and Sports Physical Therapy printed an article by Moore, et. al. that showed Physical Therapist’s ability to provide a clinically accurate diagnosis is not only on par with Orthopedic Surgeons, but it is more than double that of Non-Orthopedic Providers, who rely mainly on imaging to assist in diagnosis.  This provides great reassurance that your Physical Therapist can provide a very accurate diagnosis that is appropriate to establish a basis of your care.  An article by D Piscitelli, et al. in 2018, and another article by Ojha et. al. in 2014, discovered those who took advantage of Direct Access required fewer PT visits, fewer physician visits, fewer imaging tests performed and fewer non-steroidal anti-inflammatory drugs and secondary care, in addition to being more satisfied than those referred by a doctor and less cost per individual. Going directly to your Physical Therapist cuts out an unnecessary middle-man, potentially cuts out expensive and unnecessary imaging (x-ray, MRI, CT) and saves all the time and money otherwise spent on those things.  According to an article by Health Services Research in December, 2015, the average cost of healthcare for those who received an MRI before being sent to Physical Therapy was $4,793 more than those who went to their Physical Therapist first.  Your Physical Therapist knows what they are capable of treating and what they are not capable of treating.  If they have concerns about your presentation and are confused about your symptoms, they will send you to your doctor or a specialist for further testing to determine what exactly is going on before continuing treatment.

OK, I’m convinced.  Can I utilize Direct Access?

  A look at the APTA Direct Access by state map will inform you of any restrictions placed on going directly to a Physical Therapist by your state’s Practice Act.  The other consideration for many people is insurance.  Most people want to know “Will insurance pay for Physical Therapy if I use Direct Access?”  The answer to that question is more complicated than those we have attempted to answer thus far.  Insurance sets their own rules on what they will pay for as regards health care.  Insurance companies are big lobbyists, as we all know, and they help keep restrictions in place to Direct Access to Physical Therapy, whether by lobbying against it, or by company and plan policy.  Some insurance plans will allow you to go to a Physical Therapist directly and they will pay for it.  Other companies will pay for it, but at the Out Of Network (OON) rate.  Others still will decline to pay for PT until you have been referred by a Physician.  You will have to contact your insurance company to find your policy details.  You can see the barriers to proper healthcare access that this creates, if nowhere else than in the individual’s mind.

Who is the right candidate to use Direct Access?

  The question for many then becomes, “Why would I use Direct Access if my insurance isn’t going to pay for it?”  Or it might just be a statement, “I am not going to use Direct Access if my insurance won’t pay for it.”  I would like to rephrase this question or statement, if you will allow me, “What is the cost-value ratio of utilizing Direct Access if insurance is declining to pay or only partially paying for PT without a Physician referral?”  This is ultimately a decision that each individual will have to make on their own, but I can offer some guidance on how to get the best value for the cost. 

Perceived Value vs Actual Value

• Physical Therapists are THE movement specialists.  Our time is valuable, which is why people seek it out.  However, the perceived value of our time and the actual value do not always match up in terms of dollars.  The perceived value by many people is their co-pay.  Depending on your insurance plan, that co-pay may be $10-$75 per visit.  If you have a high-deductible plan you might be paying the full cost out of pocket until you meet your deductible.  In that case your out-of-pocket cost could range from $50-$350 per visit depending on where you live in the country and which provider you choose.  For those with low deductibles and plenty of extra time, paying $10/visit is reasonable and acceptable compared to the out-of-pocket cost of high-deductible plans.  As you approach the $40 mark on co-pays it becomes less justifiable from strictly a money perspective.  Many clinics will schedule 2-3x/wk, which means $80-120/week and higher considering the co-pay just mentioned.  This is in addition to scheduling 3-4 clients/hour, resulting in your time with the PT only being about 15-20 minutes of your hour-long session.

Time and Money

• Time spent scheduling and then waiting for your doctor appointment, scheduling and then waiting for a specialist appointment, getting an x-ray and/or other imaging and the money not only spent on that, but not earned as you miss work and lose vacation time leads to very high actual cost (dollars paid) and still higher personal cost (dollars, work time, vacation time, family/personal time paid).  Early intervention for injuries leads to better outcomes, less time spent rehabilitating and less money spent on healthcare.  Less time spent on healthcare means more time spent on your schedule. If that means working, then the time you would have spent at an insurance-based clinic is instead spent earning money, which helps cover the cost of the therapy.

  Who is the right candidate for Direct-Access Physical Therapy?  Truly, almost everyone.  If you value you work time, personal time, vacation time and money, then going directly to a Physical Therapist when something is wrong will allow you to save more of all of these things, particularly if you have a high-deductible insurance plan.  Highly motivated people who want to get better, get stronger, and improve their health, function and fitness would likely find themselves more satisfied utilizing Direct Access for Physical Therapy.  The main crowd that will not be able to utilize Direct Access are those who have Medicare.  However, those who have a Medicare Advantage plan are allowed to utilize Direct Access.

Conclusion

  Direct Access is poorly understood and under-utilized tool in the Physical Therapy realm.  Many who need Physical Therapy are not surprised when their doctors recommend it.  They already knew they needed it, they just had to get a prescription from their doctor to do so.  This is no longer the case.  All 50 states and the District of Columbia have some form of Direct Access.  Direct Access is safe for anyone who wishes to go to a Physical Therapist, as PTs are trained to recognize “red flags” and send you to your doctor if they suspect something more serious is involved than Physical Therapy can treat.  Knowing your out-of-pocket cost for Physical Therapy, the time you will spend going to Physical Therapy each week, the time you will spend with your Physical Therapist during a Physical Therapy session and the number of overall Physical Therapy visits will play a role in your decision to choose Direct Access. 

If you are interested in starting a home exercise regimen for improved health, wellness and mobility, or if you have had an injury or illness that has impacted your mobility and need convenient services that will meet you when and where you need them, please consider contacting us and booking a free consultation. It will only take a maximum of 15 minutes and there is no commitment, we just know we can help.