Who would have thought the fight would last this long?
More than six decades after Nebraska became the first state to allow physical therapy without a physician’s referral, physical therapists across the country are still trying to pass laws that give patients direct access to their services. Here’s a closer look at the progress that’s been made on the direct access front over the years, and at some of the reasons the issue remains a priority for many physical therapists and their practices today.
Why Direct Access is Important
According to the American Physical Therapy Association (APTA), all states had at least limited direct access as of early 2021. That on its own is reason for celebration—a clear sign of how far the profession has come since Nebraska gave the go-ahead to its PTs all the way back in 1957. The sticking point, on the other hand, involves that word “limited.” When states or localities impose restrictions on direct access, they’re essentially creating a barrier between patients and what may be their fastest ticket back to health. “Delays in care result in higher costs, decreased functional outcomes, and frustration to patients seeking physical therapy treatment,” the APTA explains. Direct access restrictions also have an impact on the ability of PTs to practice autonomously. To tell a physical therapist with years of experience they can only see a patient or perform a certain intervention if their doctor thinks it’s appropriate? That simply doesn’t sit right with many of those currently in the profession.
Different States, Different Rules
In its evolving record of the levels of physical therapy direct access enjoyed by patients in different jurisdictions, the APTA divides states into three different categories.
Just three states—Alabama, Missouri, and Mississippi—fall under the “limited patient access” category, where direct treatment is permitted only with certain patient populations or only when the patient has a previous medical diagnosis, for example.
Another 27 states, plus Washington, DC, and the U.S. Virgin Islands, are included in the next category, “patient access with provisions.” In Illinois, where direct access has been permitted since 1988, a PT who is providing services without a physician’s referral must (in most cases) tell the patient’s doctor they’re doing so within five days of their first visit, for example.
The last category—“unrestricted patient access”—is the gold standard for what the APTA would like to see in all states. There are 20 states at this level as of now, and all require physical therapists to refer a patient to another qualified provider when their condition is outside their scope of practice.
The Future of Direct Access
Few PTs would argue against measures requiring them to practice in line with their professional training, and JeMe Cioppa-Mosca, PT, MBA, is no exception. As senior vice president of rehabilitation at Hospital for Special Surgery (HSS) in New York City, Cioppa-Mosca is keenly aware how direct access can help patients, but she also knows that not every PT is ready for the responsibilities direct access can require. “If you’ve just graduated from DPT school,” she explains, “you’re not going to have the experience you need in terms of your evaluation and your ability to identify red flags.”
With this in mind, Cioppa-Mosca says, her department at HSS just rolled out a continuing-education program for physical therapists that covers medical screening and differential diagnosis. Direct access, she believes, is incredibly important to physical therapy, and it’s important to value-based care, where providers are rewarded for care quality and for controlling costs. The goal of the program at HSS is to ensure that PTs are prepared for what direct access entails. “It’s about getting the right patient to the right clinician at the right time,” Cioppa-Mosca says. “If you can do that, you’re doing it right.”
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 11th consecutive year), No. 4 in rheumatology by U.S. News & World Report (2020-2021), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2020-2021). HSS is ranked world #1 in orthopedics by Newsweek (2020-2021). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.
Get our emerging trends guide.
Value-based care doesn’t need to be boring. In fact, it’s what should get you most fired up about the future of PT. We interviewed 10+ industry leaders about VBC, contracting with employers and the end of fee-for-service as we know it. Download our emerging trends guide to get the scoop.