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 Type	Median 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.

Is there a physician shortage in America?

Uwe Reinhardt is an economics professor at Princeton and former keynote speaker at the American Physical Therapy Association (APTA) Annual Conference sometime back in the 1990's.

Professor Reinhardt pokes holes in the "doom-and-gloom" scenario of a pending physician shortage in America and I agree.

I wrote about this fallacy on November 28th, 2011 in Can Physical Therapists Replace Physicians as Primary Care Providers in Hospitals?

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I believe economic necessity will intervene as public policymakers and private payers join forces to push physical therapists into direct access roles for musculoskeletal conditions.

The time is right now. According to Professor Reinhardt:

"...the suspected physician shortage now imputed by critics of the Affordable Care Act may actually drive our health system into more efficient medical practice.

Step No. 1 in that direction, of course, would be to lighten the enormous administrative load now heaped by our health insurance system onto physicians devoted to rendering patient care."

Delegating high-volume spinal pain, sports injuries and many chronic pain patients to physical therapists would relieve much of the physician workload and eliminate the physician shortage.

California and Florida Physical Therapy Bills Move Forward

Physical therapists across the United States have gotten off to a fast start in 2012, as evidenced by two bills moving forward in California and in Florida.

California Senate bill SB 924 allows consumers to go directly to a physical therapist for treatment without first going through their doctor.

Senator Curren Price's bill was approved unanimously Monday, January 30th, 2012.

The Senate bill is a compromise bill that requires a therapist to refer a patient to doctors if the therapist learns that the patient needs medical attention.

It also requires the therapist to get a doctor's approval if the therapy goes beyond 12 visits or 30 business days.

Previous versions of the bill were opposed by the politically powerful California Medical Association (CMA). The CMA has not taken a position on the new compromise bill. The bill now goes to the California State Assembly.

Also, congratulations to the Florida Physical Therapy Association (FPTA) which scored an impresive victory Tuesday, January 17, 2012 as HB 799, the physical therapy temporary license bill by Rep. Tom Goodson passed out of its first committee of reference.

HB 799 by Rep. Goodson amends chapter 486, Florida Statutes, to allow Physical Therapy graduates of accredited programs, who are waiting to take the exam after graduation, to work under a temporary license permit.

The graduate would work under the direct supervision of a physical therapist while working (in the same room) and could only function in this temporary capacity until the results of the first exam are known. A licensed physical therapist may only supervise one temporary licensee permit at a time.

If the graduate with a temporary permit passes, they can continue working under the temporary permit until the permanent license is issued. If the graduate fails the exam, the temporary license is revoked and they may not work until passing the exam.

The legislation will also grant a similar license to physical therapist assistant graduates. Again, they would work under the direct supervision of a physical therapist. Similarly, if the exam is passed, they may continue working but cannot continue if the exam is failed.

New Decision Support Tool Prevents Diagnostic Errors

Physical therapists practicing in a direct access setting of performing diagnostic work may find these new tools helpful to maintain a low rate of missed diagnoses.

Isabel Healthcare of Ann Arbor, Michigan and the British Medical Journal (BMJ) of London, England came together to create a new diagnostic decision support tool to help doctors diagnose rare diseases that may be overlooked in the busy clinical environment.

The doctor enters key patient findings into the computer or handheld device and the computer returns a list of potential diagnoses with high-risk "Don't Miss" diagnoses flagged.

A 2009 report titled Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors revealed the top misdiagnoses in medicine. Of 669 cases, the following misdiagnoses were reported:

Disease	Number of cases	Incidence
Pulmonary embolism	26 cases	4.5% of total
Drug reactions or overdose	26 cases	4.5%
Lung cancer	23 cases	3.9%
Colorectal cancer	19 cases	3.3%
Acute coronary syndrome	18 cases	3.1%
Breast cancer	18 cases	3.1%
Stroke	15 cases	2.6%

Isabel is a 10-year old clinical decision support tool that has been validated in the peer reviewed literature and is endorsed by the American Medical Association (AMA). 

BMJ Best Practice is a point-of-care decision support tool that provides the latest evidence-based medical information from the BMJ Evidence Centre.

Prevention of diagnostic errors can lead to improved accuracy and time of diagnosis and better treatments for patients.

Timing of Diagnostic Errors
Testing phase: failure to order, report, and follow-up laboratory results	44%
Clinician assessment errors: failure to consider and overweighing competing diagnosis	32%
History taking	10%
Physical examination	10%
Referral or consultation errors and delays	3%

This new tool may be of interest to physical therapists who practice in a direct access or primary care setting.

Increasingly, physical therapists are being asked to perform diagnostic decision making in direct access or primary care settings.

The use of new tools and new technologies should help physical therapists maintain a low rate of misdiagnoses.

Columbia U, Duke U and Washington U Students Can Make the Physical Therapists' Diagnosis

Direct Access to Physical Therapists has been in effect in the United States since the 1950's and NO state direct access law has EVER been overturned.

Watch the entire video. 13:01min.



Thanks to Ryan J. Grella, PT, DPT, OCS and Adam Geril, DPT at Medical Business Leaders Network

The Florida Physical Therapy Association's 2010 Legislative Advocacy Academy

They say you should never watch sausage or our state's laws being made - you may enjoy the final product but you won't enjoy the legislative process.

This year physical therapists will challenge ourselves to update and modernize the physical therapist practice act (FS. 486).

The 2010 FPTA Advocacy Academy in Tallahassee put the lie to that old chestnut - when you get involved in grassroots advocacy for physical therapy you challenge yourself in a way that is scary and thrilling at the same time - I know because I did it from January 31st-February 1st, 2010.

I sat in a class of about 15 physical therapists and the FPTA Chief Executive Officer, Craig Crosby, while we listened to lobbyists, media consultants, staff lawyers, legislative assistants and other folks familiar with sausage, er... I mean laws, being made.

The agenda was as follows:

• Ken Jacob, physical therapist and the legislative process


• Sheila Nicholson, FPTA president and attorney on grassroots advocacy


• Barry Monroe from the Florida Senate Health Care Staff


• John Van Gieson, media consultant


• Bob Rowe, physical therapist update on manipulation and chiropractic legislative intent.


• Gene Adams and Martha Edenfield, FPTA lobbyists in Tallahassee


• Lisa Weisman, House legislative aide in Tallahassee

The final result is an educated, motivated workforce that will help physical therapists introduce and pass a new practice act that will modernize our profession by, among other means:

1. protecting the designator, DPT, as the Doctor of Physical Therapy.
2. removing only specific designators (eg: practice acts 458, 460, et al) from referring to physical therapy.
   
   Anyone remember the issue with Advanced Registered Nurse Practitioners (ARNP)?
   
   They couldn't refer to PT because they weren't specifically designated. ARNP's receive their license under the nurse practice act (FS. 464) which is not specifically designated as being able to refer to PT. This issue will go away under the new practice act.

Direct Access is improved with this change although, for political reasons, the '21-day rule' will not be changed.

The new legislation can first be introduced on March 2nd, 2010 - the start of the 2010 legislative session in Tallahassee.

Physical therapists can help the process by calling your local, state legislator now, before March 2nd, and recommending support for an upcoming physical therapy bill.

A specific bill number will be available soon and updates are available at the FPTA website.