Is Direct Access the Key to Cutting Health Care Costs?

Executive Summary

Direct access is a program that allows patients to freely see a physical therapist without the referral from a physician. In the past the physician would evaluate the patient and decide if physical therapy was necessary. This worked well if the doctor could see someone in a short period after the onset of the symptoms. However, the increasing number of patients makes it difficult for doctors to see patients as soon as they call for appointments. With direct access, the patient can start down the road to recovery as soon as the problem begins.

There is some cause for concern though. Many wonder if therapists can effectively fill this role. There are questions about the amount of schooling and the level of experience of new graduates. Therapists must complete a rigorous and difficult curriculum to get their degree. However, after they get a degree they must pass a state licensure exam in order to practice. In addition, graduates have more knowledge today than ever before.

Many also wonder if direct access can really save both time and money. Although studies show that treatment times are reduced, the time spent waiting to begin treatment is significantly less, and there is no rise in health insurance premiums or malpractice insurance premiums. It lowers cost by screening the cases and treating those who really do not need a physician by someone who is capable of treating that affliction.

Direct access is not utilized in Indiana. This makes it difficult for health care organizations, both large and small, to effectively treat patients while saving money. At (Client name), a large health care provider in Indianapolis, direct access would allow them to treat many patients in a reasonable amount of time while saving money also.

Direct access has been proven to be successful. It utilizes physical therapists to their fullest potential. Not only will direct access save time and money, it will raise the standard of health care for all.

 

Introduction

Suppose that someone hurts their shoulder on the job. They schedule an appointment with a physician and they have to wait a week to get in. During this time they continue to work and are continuously complaining of pain. During the appointment the physician makes a diagnosis, a sprained shoulder, and sends them to physical therapy for strengthening and to increase the range of motion in which the patient can move the injured shoulder. During therapy, the therapist talks to the patient and discovers that it took a week to see the physician. The therapist makes the comment that had the patient been seen earlier, the time it took to heal the wound have been much shorter than it will currently be. This fictitious scenario could very easily happen. With the increasing number of patients that doctors are seeing, it is more difficult for them to see a patient within a relatively short period of time. Because of this many people want to institute a new approach that will allow patients a new entry point into the medical system. This new approach is direct access. Direct access allows physical therapists, who are educated health care professionals, to save both time and money by treating patients to the fullest extent of their ability. Following is a discussion of the national and local system, the issue of whether physical therapists have enough education to practice in a direct access mode, and the question of whether direct access really saves both time and money.

National Trends of Direct Access

Because of the rising cost of medical care, many companies are looking for ways to cut costs. Unfortunately, because of these cuts it is difficult of get thorough treatment. Because of this, many states allow for direct access of physical therapy services to patients, but what exactly is direct access? According to Mitchell and de Lissovoy (1997), direct access is the ability of a health care consumer to freely visit a physical therapist without first securing a referral from a physician. However the use of direct access is not a nationwide plan of action. Currently there are 27 states that allow for an evaluation and treatment without a referral, 16 states that allow for an evaluation only, and only four that require a physician’s referral for both an evaluation and treatment (Crout, Tweedie, Miller, 1998).

Local Trend of Direct Access

As for Indiana, it is one of the four states in which a physician’s referral is required for the evaluation and treatment of a patient by a physical therapist. However, Indiana’s law is 41 years old and the state’s definition of the practice of physical therapy is 10 years old (American Physical Therapy Association, Indiana chapter, 1998). This law fails to recognize a physical therapist as a highly trained health care professional. Today, therapists are highly qualified individuals with incredible amounts of formal education and clinical training. According to the American Physical Therapy Association, this training allows therapists to evaluate a patient's condition, assess his or her physical therapy needs, and if appropriate, safely and effectively treat the patient.

As a result of the out of date law in Indiana, much time and money is wasted when it comes to treating patients. Yet, as health care professionals, physical therapists want to treat patients to their fullest ability. This is why there is such a push towards direct access. However, although the physical therapy profession is pushing for direct access, it does not want to stretch its power beyond the limits of the profession (American Physical Therapy Association, 1998).

The good news is that in Indianapolis there isa large amount of support for direct access. According to (name of client), a physical therapist who is the outpatient supervisor at the (name of medical center), direct access could change the profession structurally and financially (personal interview, 3 March 1999). (Client name) said that direct access will cause clinics and therapists to do something to make themselves marketable, because they would no longer rely on physician referrals for patients. The competition between clinics will lower prices and increase the quality of care because it makes the therapist more accountable for their actions.

When asked about the level of education needed to practice in the direct access mode, (client name) commented, "Today’s graduates know more coming out of school than we did years ago, but their lack of experience would be a hindrance. I might recommend that a senior therapist be paired with a new graduate to act as a mentor so the new therapist would gain the necessary experience without having to risk putting themselves on the line so early in their career" (personal interview, 3 March, 1999).

If direct access can safely accommodate the patient and allow them to experience healing process without the aid of a physician, then why is it only utilized in 46 states and not all 50? (Client name) holds a bright optimism about direct access to physical therapy services in Indiana. She states, "Only three other states besides us do not institute direct access. It is not a new plan and it has been proven to work. I think direct access will not only benefit our profession, but patients and the practice of medicine as a whole" (personal interview, 3 March, 1999).

Are Physical Therapists Qualified to Diagnose and Treat Patients?

If direct access were to be instituted in Indiana, would physical therapists be qualified to treat patients under the new guidelines? The answer is yes. In order to practice physical therapy in Indiana, as well as any other state in the United States, therapists must graduate from an accredited university with at least a bachelors degree; graduates must pass a state licensure exam in order to practice in that particular state (American Physical Therapy Association, 1998). These requirements must be met whether a state allows for direct access or not.

However, are therapists qualified to diagnose the disease a patient may have? This is the key issue in the debate over direct access. Even though therapists have an extensive background in musculo-skeletal and other physical conditions (Callingwood Physical Therapy Services, 1997), what about cancer and other diseases in which therapists do not have an extensive background (McGinley, 1997)? According to the American Physical Therapy Association (1998) physical therapists are also qualified to recognize when a patient demonstrates conditions, signs and symptoms that need to be evaluated by other health care professionals before therapy is instituted. Therapists are trained to recognize when it is appropriate to refer patients to these other professionals for consultation.

New Graduates: How Will They Perform in Direct Access Modes?

Another question to be addressed is whether new graduates would be able to practice under the direct access mode (Crout, et all, 1998). One study tried to prove that if there were deficiencies in educational curriculum and lack of clinical experience, it would cause the new graduates to be unprepared to practice in the direct access mode. However, the practicing therapists that were surveyed for the study believed that their knowledge as new graduates was lower than that of today’s new graduates (Crout, et all, 1998). However, since the institution of direct access, many university programs have made changes to (paper continued...)

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