Direct Access: Insight into Some of the Barriers and Current Initiatives

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Blogger: Katie Baratta

My name is Katie Baratta and I just graduated from the Regis University School of Physical Therapy. I had the opportunity to spend two weeks at the APTA doing a student internship. I was able to talk to many different members of the APTA, attend the Federal Advocacy Forum, and learn more about what the APTA has been doing to move our profession forward. I’ve written a series of essays about my experiences here at the Association.

I met with Wanda Evans PT, MHS, CKTP (Senior Payment Specialist) and Elise Latawiec MPH, PT (Senior Specialist, Practice Management) who provided me with their insider understanding on this topic as well as directed me toward further resources.

Direct access physical therapy care means that a patient does not require a referral from a physician or other provider prior to a PT evaluation and/or treatment. All graduating Physical Therapists are required to have a DPT–a clinical doctorate–and, thus, they receive extensive training in the ability to recognize “red flags” and refer patients to the appropriate provider when it becomes apparent that the patient may be at risk for something more severe than musculoskeletal involvement.  Studies demonstrate that direct access decreases the time following an injury to the start of the patient’s PT care, reduces the number of visits of therapy needed and results in lower overall costs. Thus, PTs are not only appropriate for this role, but they can end up saving time, money, and patient suffering (as well as costs for the healthcare system overall).

Legislation

There are currently various types of direct access in all 50 states. Each state has jurisdiction over its own Practice Act, which is why there is some discrepancy from one state to another (state-by-state comparison). There are 18 states with unrestricted direct access—this includes Colorado! Some states require specific certification for a PT to provide direct access care, and others allow only an initial evaluation plus a set number of follow-up visits before the PT must contact the patient’s primary care provider. States with limitations in their practice act for direct access are fighting every day for legislative changes to eliminate these barriers; the APTA is aware of this and is actively assisting in these state-level legislative efforts.

However, the legal foundation is only the first step to getting patients the direct access care that we know would be beneficial. Common barriers to direct access that PTs reported in an APTA survey last year include reimbursement concerns, limitations in marketing, fear of alienating referral sources, restrictions by the PT’s employer, and lack of knowledge of state direct access laws.

Reimbursement                                      

Historically, third-party payers (ie insurance companies) have required a referral from a physician or other designated professional. Aside from Medicare/Medicaid and other federal programs like the VA or Armed Services (which have their own regulations on Direct Access), insurance policies vary by carrier and on a state-to-state basis. As the state legislation changes, the payers have been slowly adapting, with some payers more progressive than others in regards to reimbursement for direct access services. The APTA has been engaging with payers directly to eliminate the referral requirement at events such as the Insurance Forum, in comment letters, during in-person meetings, and in their day-to-day contacts. The APTA communicates this message to large employers who create their own insurance policies for their employees, as well, and are thus able to help employers set the terms of the insurance contract for their employees independently.

How can individual APTA members get involved on the reimbursement front? Each state chapter has a Reimbursement Chair.  The Chair’s responsibilities include learning as much as possible about trends with different payers in that state (and taking note if a lot of PTs have been reaching out with similar issues or complaints regarding the same payer) and assisting those therapists within their own state. The APTA nationally works in conjunction with the state chapters on payment/insurance issues and helps to connect states together when confronted with similar challenges. Patients and their advocates can also petition their Insurance Commissioner if they are inappropriately denied care or access to medically necessary services. The Insurance Commissioner advocates for consumers; s/he does not represent the insurance carrier.

Fear of alienating referral sources

Wanda and Elise described several studies in which direct access evidenced no negative impact on the physician-patient relationship. In fact, a key component of direct access is the necessity of PTs to refer patients to the appropriate provider when a patient’s symptoms and underlying pathologies are outside of our scope of practice. Given that PTs must make referrals back to other providers, it becomes a mutually beneficial relationship amongst different healthcare practitioners.

Education

A lot of concern stems from a a lack of education on the part of employers, insurers and potential patients. PTs need to demonstrate their clinical excellence to, essentially, prove that we are worthy of this responsibility, as well as to continue to educate all stakeholders on the importance and benefit of getting PT before medication/surgery. The first step for every PT is to become educated on what your state’s practice act specifically says about direct access and understand any limitations that may be in effect.  Educating patients, employers, and other healthcare practitioners is the next step. The APTA has developed many resources detailing the benefits and safety of direct access available online (more info).

Resistance to Change or Pushing for Progress?

There are some PTs who are more comfortable in the traditional referral arrangement than with unrestricted direct access. They may not want the additional responsibility, or they may simply prefer to do what they have always done.  That is okay!  Nobody is looking to force them to become direct access providers.

However, if you are one of the PTs who cares about the transition toward direct access and autonomy as a practitioner, make sure you’re an active member of the APTA! This is essential to better educate yourself, your patients, and other healthcare providers and to develop a strong voice with your state chapter and insurance agencies.

For more information on the current APTA involvement, as well as additional resources, check out its Direct Access page.

Class of 2017 DPT Student Lindsay Mayors Reflects on Her Clinical Rotation

Name:  Lindsay Mayors

Hometown: Akron, Ohio

Undergrad: University of Dayton

Fun Fact: My first experience skiing was on my third birthday in Keystone, Colorado!

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Today, the Class of 2017 has reached the halfway point of their 8-week second clinical rotation. The past two semesters have been filled with management courses, case studies, exams, practicals, and research. In April, we completed all three management course series; needless to say we were ready to get out into the clinic! Students are working in a variety of settings including acute care hospitals, inpatient neurological rehab, sub-acute rehab, long-term acute care, home health, outpatient orthopedic, outpatient pediatric, and school-based therapy from Virginia all the way to Alaska. We are applying our freshly developed clinical reasoning skills and continuing to learn immensely from our clinical instructors.

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Lindsay and her first year mentor, Vickie

Many of my classmates will tell you that I am one of the “peds people.” I started the program in August 2014 with my mind set on becoming a pediatric physical therapist. I would be nearly skipping in the hallways on the way to pediatric-based labs or lectures. So, when it came time for me to start my second clinical rotation at a skilled nursing sub-acute rehabilitation facility, I did not know what to expect. It seems to be a common theme among students to not prefer to work with the geriatric population. I know that I even had my doubts. Would I know how to relate to the elderly population? Would my 5’2 stature have the body mechanics to help patients transfer in and out of chairs or their hospital beds? Would I get bored doing seemingly the same exercises with patients day after day? Will this type of rotation be helpful for me if it is not the setting in which I ultimately would like to work?

Within just two days of the clinical rotation I had my answers. I am overjoyed when I get to connect with the elderly population. I remembered and have safely applied the transferring tips from a faculty member with my similar stature (Thanks, Christina!). The exercises that I perform with patients are all but monotonous. I have had the opportunity to apply skills from all three of the management course series with patients. Sure, many of the patients have similar physical therapy diagnoses, but beyond the diagnosis each is incredibly unique.

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Liz, Lindsay and Carol at the Class of 2016’s research night in April

Each has their own personal story, their own medical history, their own family dynamic, their own goals, and their own hobbies. Not one personality resembles another. This is what makes this setting so exciting for me. Learning about what has molded a particular patient into the individual that they are now is the highlight of my day. Shaping treatment plans to match a patient’s personal goals and find the highest level of independence for them allows me to use my creativity in a new way with every patient. We walk (a lot), stand on foamy surfaces and toss balloons, and maneuver wheel chairs around obstacle courses. We talk about the joys, challenges, and hilarities of life. I have recognized that the age of a patient–whether 3 or 93 years young–is not a barrier. We are all human. We enjoy being heard, feeling validated, feeling empowered, and having our days be brightened by a smile.

So, I would like to challenge any student who has similar doubts as I did a mere month ago to take a step into the unknown. Unravel your pre-set plans and experience something on the extreme opposite spectrum from the setting in which you think you want to work. Sure–I am still interested in being a pediatric physical therapist, but at the very least, my mind has been opened to new considerations. No matter the population I ultimately end up working with, I now have a broader understanding, appreciation, and passion for the field of physical therapy because of this rotation.

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Lindsay and her classmates are currently all at clinical rotations across the country