"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Sunday, June 2, 2013

Should Physical Therapists Abandon Direct Access? Vote 'No' on #APTArc20

A recent proposed motion in front of the American Physical Therapy Association (APTA) House of Delegates threatens to overturn 40 years of physical therapists' efforts to improve the professional standing of and patients' access to physical therapists.

The motion, RC20-13, moves to strike from the APTA agenda the pursuit of direct access to physical therapists' services.

Is abandoning direct access a bad idea? 

Here are six issues we should consider before we decide against RC20-13. I've referenced my facts so that you can determine for yourself why or why not RC20-13 is a bad idea:
  1. Forty years of physical therapist advocacy for direct access carries a lot of precedence.  Two generations of physical therapists think direct access is a good idea, why change it now?
  2. The biggest problem with RC20-13 (maybe this should go first?) - why does the APTA think direct access to physical therapists is synonymous with physician status under Medicare? You CAN have one without the other. Consider Nurse Practitioners. These professionals have a lot of decision making authority without physician status. In some states, NPs  can set up their own private practice.
  3. In 2005 Medicare issued Publication 100-02 which was a MAJOR improvement in patient access by eliminating the face-to-face physician encounter for Medicare patients prior to physical therapy.  This was accomplished WITHOUT legislation and WITHOUT any change in physical therapist status under the Medicare program.  This policy was enacted during the period from 2001 to 2010 the APTA sought legislative solutions to achieve direct access.
  4. Is physical therapist 'opt out' from Medicare more important than direct access?  Arbitrary Medicare coverage policies impair the concept of autonomous physical therapist practice which implies collaborative decision making between the patient and the physical therapist.

    Fewer than 1% of physicians eligible for Medicare Opt Out have chosen this alternative payment arrangement which results in negligible savings to the Medicare program.  Physical therapists in private practice might chose this arrangement at a higher rate - especially as Medicare reimbursements get squeezed.
  5. The Patient Protection and Affordable Care Act (ObamaCare) coverage mandates kick in in 2014.  This will drive provider-based, innovative solutions due to changing payment incentives such as Medicare ACOs and Value Based Purchasing. 

    But, some changes have already occurred.  Primary care physicians have overtaken specialist physicians, such as neurosurgeons, as the main revenue drivers in some hospitals in 2012.  In a sample of over 100 hospitals, primary care physicians (family practice, general internal medicine and pediatrics) generated an average net revenue of $1,566,165 while specialists, such as neurosurgeons, generated only $1,424,917.
  6. Hospitals and large healthcare organizations seem to be MORE effective at pushing scope of practice boundaries than the state-based professional associations in the state capitols. The professional associations mostly play an expensive, annual game of "Turf War" which is won by the association with the biggest war chest. 

    Large payers are also looking at their data and finding that direct access to physical therapists is good for business.  The Iowa Study of 63,000 employer-based insured people found that "...the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases...".  

    Large organizations, such as hospitals, insurers and employers, seem to be more accountable for the cost of care and seem to accept the value proposition illustrated by the Starbucks/Aetna collaborative.

    The value of non-physician primary care providers is very simple: its the money we make. Here is the median total annual compensation for the following providers in 2011:
Provider TypeMedian Annual Compensation
General Internist$215,689
Family Practitioner$200,114
Nurse Practitioner$93,977
Physician Assistant$92,635
Physical Therapist$81,110

Physical therapists can provide the best value for common, high-volume musculoskeletal conditions that nurses, PAs and physicians are less qualified to see.

If the APTA direct access agenda is predicated on physician status under Medicare then just drop that - don't drop direct access.

It's too soon to change strategy and there is too much at stake.  I urge the APTA House of Delegate to stay the course - continue to support direct access to physical therapists. 

You can join the Twitter conversation using this hashtag #APTARC20.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

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