Recommendation Report
April 19, 1999
Client Name, P.T. (Name) Medical Center (Street Address) Indianapolis, IN Dear (Client name), Enclosed you will find a detailed report
that summarizes my research into the implementation of direct
access to rehabilitation services for (company name). Included
are the methods that I used to explore this topic and the results
of a survey that I conducted in the outpatient clinic at (Company
Name) Center. As a result of my research and the findings of the
survey, I have made some recommendations based upon these
findings. As a part of this report I have attempted
to answer some of the questions you posed to me during our
interview. Although I could not expand too deeply into the
financial scope of direct access, I tried to evaluate if it was a
cost effective means of treatment. I would like to thank you for your
interest and the assistance you provided to me. It has been my
pleasure to collaborate with you on this project, and I hope that
these findings will be of some use to (Company name). Sincerely, (Student Name)
Will Direct Access Work for Clarian Health?
Project Introduction:
The quality of health care in the United States is the greatest in the world. Because of this it is one of the largest portions in anyone’s budget. Insurance companies and patients alike are looking for ways to cut the cost of medical care while still maintaining the highest quality possible. Direct access is one program that cuts costs while maintaining a superior level of care. Direct access allows a patient to see a physical therapist without the referral from a physician. This gives the patient an alternative entry point into the current system of medical practice.
Statement of Need:
Currently there are 46 states that allow for some form of direct access. Because of this, the physical therapy profession has had to become more accountable for their practice. Competition between clinics has increased the level of care and it has also has brought down the prices for treatment. Currently (Company Name) does not use direct access in their outpatient clinics. Identifying direct access as a cost effective means of treatment and exhibiting how to introduce it into the clinic is the aim of this project.
Research Methods:
A vast majority of information came from medical sources. Several scientific journals along with several websites and current newspaper articles were referenced. Journals on the practice of physical therapy, the general practice of medicine and the specialty of orthopedics were utilized for this project. Several of the websites were those of professional organizations who were affected by direct access as well as some clinics across the country. Current newspaper articles discussed the need for direct access, while some criticized it.
Summary of Literature:
While referencing all of the literature, several interesting points surfaced. Because of the rising cost of medical care, there is a vast change in the way and the frequency in which medical services are paid for. Patients and insurance companies are searching for ways to cut costs. In the debate over direct access there are two main questions that are examined. These are whether or not physical therapists are qualified to diagnose and treat patients, and whether or not direct access is truly cost effective.
Are physical therapists qualified to diagnose and treat patients:
Many wonder if physical therapists in Indiana are qualified to practice under the direct access mode. Throughout the United States physical therapists are required to graduate from an accredited university with at least a bachelors degree, then they must pass a state licensure exam in order to practice. According to the American Physical Therapy Association, who is the governing body of the profession, therapists are qualified to treat all kinds of musculo-skeletal conditions as well as all other types of diseases. In addition, due to their extensive education, therapists are qualified to recognize when a problem is beyond their scope of training. The therapist can refer the patient to be evaluated by other professionals before therapy is instituted.
Cost effectiveness:
There are two major studies that have evaluated the cost effectiveness of direct access. The first was done by Mitchell and de Lissovoy in 1997. They studied claims data from Blue Cross-Blue Shield of Maryland. They found that physician referrals compared to direct access were 123% higher. Also, patients who received physician referrals took 65 % longer to receive treatment than patients who were allowed direct access. Finally, physician referrals generated 67% more claims and 60% more office visits.
The second study was done by Glen Robert and Andrew Stevens of the Wessex Institute in England, also in 1997. They researched eight studies that compared two or more models of providing physical therapy services. Their findings indicate that there was a reduction in time lost from work especially when dealing with back and other orthopedic injuries, an increase in convenience and patient satisfaction, and a reduced cost to the patient and insurance company.
Finally, cost effectiveness does not only deal with the cost of treatment. It also includes the cost of insurance premiums for patients, cost of malpractice insurance for therapists, and the cost of malpractice litigation. According to Crout, Tweedie, and Miller, there is no data to support the suggestion that these rates will increase. Even in states that allow direct access for evaluations and treatment, there is no rise in the rates of health or malpractice insurance. In addition, there is no rise in the rate at which therapists are sued for malpractice.
Survey Analysis:
Because direct access is a relatively new topic, there was a concern on the part of the client about whether or not people would accept it. What good would direct access to rehab services be if no one utilized the service? The client wanted to see if there would be a positive response to direct access, what kind of injuries would most likely be seen, and whether or not insurance would pay for such a program. In order to find the answers to these questions, a survey was prepared and handed out to returning patients at (Client Name) who had been to therapy before and knew what to expect (Appendix A). Of the 29 surveys handed out to these returning patients, 25 were returned, giving an 85% return rate. The survey was broken up into four parts- demographics, physical characteristics, times between injury and appointments with physician and therapist, and willingness to utilize direct access.
Demographics:
The age of the respondents was broken down into the following:
<20 0% 21-30 12%
31-40 28% 41-50 28%
51-60 28% 60-70 4%
70+ 0%
The gender of the respondents was as follows:
Male 28% Female 72%
Physical characteristics
Respondents were asked about their level of physical activity. A breakdown revealed that 44 % of the respondents felt that their level of activity was low, 36% of the responses were moderate, and 20% felt they had a high level of activity. These numbers may play a part in the utilization of direct access. Those patients who are inactive may wish to see a therapist earlier because they may not have the experience with an injury like those patients with a high activity level.
All of the respondents had some sort of orthopedic injury. A breakdown revealed that 52% had an injury to their back, 32% had a knee injury, 8% had a neck problem, and 8% had trouble with their shoulder. This shows that the clinic at I.U. deals with a large orthopedic population. According to research, orthopedic injuries are those in which direct access is most beneficial. Since a large majority of the patients are orthopedic related, it make sense to accommodate them.
Times between injury and appointments with physician and therapist:
Physician appointments
The respondents gave this breakdown when they were asked how long it took them to see a physician after their injury (see figure 1):
0-3 days 24% 4 days-1 week 36%
1-2 weeks 20% >2 weeks 20%
Fig. 1
These results indicate that there is a lapse in time between the date of injury and the initial visit with the physician. Although a majority wait for only four days to one week, this is still a significant amount of time between the date of injury and the date in which one seeks treatment. Whereas with direct access the treatment begins as soon as the therapist is seen, and the patient does not have to wait to see the physician.
Physical therapy appointments
The respondents gave this breakdown when they were asked how long it took them to see a physical therapist after their injury (see figure 2)
<1 week 0% 1-1.5 weeks 16%
1.5-2 weeks 4% >2 weeks 80%
Fig. 2
This shows that there is a sizeable period of time between the date of the injury and when a patient sees a therapist. This is crucial because with most orthopedic injuries, like the ones seen in the clinic, the therapist is the one who actually treats the symptoms of the condition, not the physician.
Willingness to utilize direct access:
When asked if they would be comfortable in seeing a therapist before a physician, an overwhelming majority of the respondents said they would consider visiting a therapist before seeing a physician. The percentages were (see figure 3):
No 20% Yes 80%
Fig. 3
(Company Name's) biggest concern was whether or not patients would utilize direct access if it were available. Because of the overwhelming number of patients that would utilize direct access, it would prove beneficial to both the client and it’s patients to institute some form or direct access into (Company Name) rehabilitation department.
Conclusions:
Research shows that there is an interest in direct access by (Company Name) patients. In order for (Company Name) to continue the highest quality of care available, it is important that direct access is implemented into its rehabilitation services department. Because of this the following recommendations are made.
Finding #1: People, especially those with orthopedic injuries, would be interested in utilizing direct access if they knew it were available.
Recommendation #1: Set up a committee with orthopedic doctors and physical therapists, who writes certain protocols for specific diagnoses. Also, this committee can establish the policies and procedures that the clinic would use in the new direct access program.
Recommendation #2: Establish a program that educates the public and makes them aware of direct access and its positive effects. This can range from flyers in the doctors office, to air time at a local television station. This would promote direct access and interest the public.
Finding #2: There is a concern by some that physical therapists are not qualified to practice under the direct access mode of care.
Recommendation #1: Form a committee that evaluates the proficiency of treatment. This panel would include doctors, therapists, and other related professions.
Recommendation #2: (Company Name) could institute a program that would require therapists to attend continuing education courses. This would allow therapists the ability to stay knowledgeable in the constantly changing world of medical technology.
Finding #3: Direct access is cost effective and promotes timely treatment.
Recommendation #1: Form a committee that would evaluate the claims data for each year of the programs existence. This committee would catch any inefficiency or costly procedures, while still maintaining the quality at the highest level.
Recommendation #2: (Company Name) could hire some consultants from other successful clinics across the country to establish the new program at their facilities.
Appendix A
Direct Access Survey
I am a college student who is researching the benefit of direct access to physical therapy and other medical services. The answers that you give here are strictly confidential and the results of this survey will be presented to (Company Name). Please take some time to complete the survey, and return it to the clerical staff at the registration desk. Thank you for your time and consideration.
Note: Direct access is the ability of a health care consumer to freely visit a physical therapist without first securing a referral from a physician. (Mitchell, de Lissovoy, 1997)
1. What is your age?
A. 20 or younger (0) B. 21-30 (3) C. 31-40 (7) D. 41-50 (7)
E. 51-60 (7) F. 60-70 (1) G. 70+ (0)
2. What is your gender?
Male (7) Female (18)
3. How would you describe your level of physical activity? (times per week)
A. Very low (0-1) (2) B. Low (2-3) (9)
C. Moderate (4-5) (9) D. High (6-7) (5)
E. Very high (7+) (0)
4. How many times have you seen a physical therapist?
A. 1-3 times (4) B. 3-5 times (9)
C. 5-7 times (9) D. 8-10 times (2)
E. 10+ times (1)
5. What type of injury do you have? (Why are you here?)
Back (13) Neck (2)
Knee (8) Shoulder (2)
6. How long did it take for you to see your doctor after your injury?
A. 0-3 days (6) B. 4 days-1 week (9)
C. 1-2 weeks (5) D. greater than 2 weeks (5)
7. How long has it been between the date of injury and the first appointment with the therapist?
A. less than 1 week (0) B. 1-1.5 weeks (4)
C. 1.5-2 weeks (1) D. greater than 2 weeks (20)
8. If direct access were permitted in Indiana, in some cases, would you be comfortable in seeing a therapist before you went to a physician? Ex. sore back, sprained ankle, sore shoulder, etc.
Yes (20) No (5)
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