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BY LESLIE CHAMPLIN
Direct access to physical therapy is seeping across the nation. This year, it dribbled into Wyoming. It trickled into Oklahoma and made its way to Louisiana. It welled up in Michigan and flowed through New York.
Like a persistent stream of water, momentum for direct access has swelled to a rising tide, timed to match a surge of support in the U.S. Congress for the Medicare Patient Access to Physical Therapists Act of 2003. Physical therapists' success on the state level augments the impact of the federal Medicare legislation because it would allow PTs to bill their services independently in states with direct access laws.
The likely result: a sea change in the way patients receive physical therapy treatment and in the way that treatment is reimbursed.
Ohio experience
Generally, direct access laws expand physical therapists' scope of practice by enabling them to evaluate and treat patients without a physician's diagnosis or referral. Most states fall short of unlimited direct access. Some state laws require referral to a physician if patients show no progress within a specified period. Other laws require notification of the patient's physician within a certain time after starting therapy. However, a few laws simply remove language that requires physician involvement.
Among this year's crop of bills: Ohio's S.B. 35, which would allow patients direct access to master's-prepared physical therapists without first receiving a physician's diagnosis or referral. The bill marks the fifth attempt to expand Ohio PTs' scope of practice.
FP testimony
This time, family physicians Brian Bachelder, M.D., of Mount Gilead and Steven Brezny, M.D., of Powell joined the fray. In mid-August, Bachelder, Ohio AFP president, and Brezny testified to legislators that the bill could impinge on patient safety by enabling physical therapists to treat patients for whom no diagnosis has been made.
Pointing to his hospital's current therapy referral form, Bachelder acknowledged that physicians often write "evaluate and treat" when prescribing physical therapy.
"But on the second line of the form, it also contains a space for 'Diagnosis -- Condition,'" Bachelder told legislators. "It is this diagnostic information that allows PTs to treat patients, knowing that more serious causes of a patient's symptoms have been screened out."
Brezny agreed. "Of great concern to physicians is the delivery of treatment without a diagnosis," he said in written testimony. "A diagnosis must be made before treatment may begin. If this bill passes in its current form, we are reversing the process and treating patients with a self-diagnosis or no diagnosis at all."
Passed by a 30-2 vote in the Ohio Senate last spring, S.B. 35 has gone to the House, where legislators are "a lot more receptive to our concerns," said Ann Spicer, Ohio AFP executive vice president. "I think the physical therapists realize they're going to have problems in the House. They've asked for some kind of compromise."
Action on the bill is expected when the House reconvenes this fall.
It's about the patient, not the payment
The medical community's opposition to unlimited direct access does not stem from a "turf battle between physicians and physical therapists," wrote Brezny, but focuses on patient safety and expansion in the scope of practice. Physicians have long appreciated the value that physical therapists bring to treatment, he noted. But high-quality patient care depends on accurate differential diagnoses -- something physical therapists cannot bring to their evaluations.
In legislative updates, policy statements and testimony before legislators, AAFP constituent chapters have emphasized the importance of accurate diagnosis in ensuring patient safety during treatment.
"Physical therapists are very good at what they do, developing and implementing treatments to help patients recover after severe injuries and ailments," said the Michigan AFP in a legislative alert. "Where their education is lacking is in recognizing whether the patient is suffering from a condition that is outside their scope of practice. Physical therapists are trained in therapy, not diagnosis."
Physicians don't begrudge physical therapists the right to evaluate and treat a patient "as long as it's done in concert within an appropriate professional relationship with a physician," said Vito Grasso, executive director of the New York AFP, in a recent interview. "Physical therapists are pushing for independent practice so they can have independent reimbursement. But our concern is: Who is going to coordinate care and who wants responsibility for patient outcomes?"
The American Physical Therapy Association has set its sights on independent private-sector reimbursement. Already rallying membership around the Medicare Patient Direct Access Act, the association is developing strategies to garner direct reimbursement from private insurers.
In March, the APTA Board of Directors called for a plan regarding private insurance reimbursement for services delivered without a physician referral.
"With the possibility of Medicare direct access and the increased number of state laws that allow for direct access, we should dedicate additional resources to our efforts," the board said.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
FP Report is published by the
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Copyright © 2003 by
American Academy of Family Physicians.