Direct Access in Physical Therapy

–Returning for the second time as our guest blogger is TJ Janicky; a marathoner, triathlete, constant learner, and 2015 #DPTstudent at Rutgers. You can catch up with him here or @TJ_Janicky on Twitter. Thanks for this post, TJ!–

If you are a physical therapist or student of physical therapy, you most likely hear the term “direct access” used on a daily basis.

Direct access is the term denoting the ability of a patient to seek treatment from a physical therapist without a prescription or referral. Direct access allows physical therapists to practice as the primary entry- point into the health care system for individuals with musculoskeletal impairments.

What continues to surprise me is how little our patients (our best advocates) know and understand this term. I speculate a number of reasons including lack of provider education to our patient/clients, decreased motivation for providers to educate patient/clients secondary to reimbursement restrictions set by third party payers. Lack of provider understanding of direct access, lack of legislative education and advocacy, fear of physical therapy autonomy by other healthcare professions and even physical therapists. The list goes on. The fact of the matter is direct access has many significant health and economic benefits that can be addressed when patients entry point to the healthcare system begins with the physical therapist.

Currently, billions of dollars are wasted on unnecessary medical costs (imaging, expensive lab tests etc.), which could be avoided with conservative treatment. Early access to physical therapy shows greater quicker improvements in functional outcomes, decreased progression of chronicity and decreased subjective pain scores. Direct access in its truest form is important not only to save healthcare dollars, but to give patients the right to choose and to be the leaders on their path to optimal health.

Mitchell et. al. compared direct access utilization in the state of Maryland to traditional physician referral methods. Direct access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classed as physician referral. Total paid claims averaged $2,236 for physician referral episodes and $1,004 for direct access episodes; this $1,232 difference signifies that the cost to Blue Cross-Blue Shield for physician referral episodes exceeded the cost for direct access episodes by about 123%.¹

Stated very well by Ojha et. al. in the Journal of the American Physical Therapy Association, results of the recent literature on the subject directly support current health care reform efforts in which legislators and health care providers have sought to provide efficient care through cost reduction and optimizing patient outcomes.¹ To date, all 50 states have the ability to utilize direct access, however restrictions set by third party payers and regulations set by individual states often hinder the process to utilize direct access to its fullest extent. Finally, there is a lack of public awareness and autonomous health-seeking behavior among consumers. Consequently, even though most physical therapists have direct access privileges through their state practice acts, the large majority of patients are still managed through episodes of care that are initiated by physician referral.²

The Direct Access Equation:

direct access jpeg

As a naïve physical therapy student, direct access comes across as very simple. Entry-level physical therapy education equips us with the skills to examine and identify medical red flags outside of physical therapy scope of practice, requiring a referral out to the appropriate provider. We are competent to be the access point to health care for a wide variety of patient populations. Direct access is documented extensively in the literature as being responsible for saving thousands of healthcare dollars per episode of care when utilized prior to often-unnecessary medical interventions. There are many who are proponents of direct access. There are also many of those who oppose the autonomy that direct access provides. The most outspoken of opponents include the AMA, The American Academy of Orthopedic Surgery, state medical societies and chiropractic groups. The AMA continues to believe that “although allied health care professionals are useful as physician extenders, they would not serve the public well in an autonomous role.”³ I DON’T KNOW ABOUT YOU, BUT THIS STATEMENT RAISED MY BLOOD PRESSURE A FEW POINTS.

One such documented concern carried by physicians is our ability to detect spinal metastases. As a third year DPT student, I can confidently say screening for signs and symptoms that would raise concern about cancer are covered extensively in entry level education. According to an article by Deyle, the incidence of tumors in general musculoskeletal practice has been determined to be 0.12% or approximately 1/1000 patients with back pain Age greater than 50, a history of cancer, pain that has no relieving factors, night pain and sudden significant weight changes are signs that warrant referral to a physician.4 If a patient is not over 50, does not have a history of cancer, does not have sudden health changes such as unexplained weight loss and is responding. to conservative treatment, research states spinal tumors can be ruled out with 100% sensitivity.4

I believe a large portion of this ignorance on the physicians end comes from a general lack of understanding of physical therapy and physical therapy education. They are most likely (and when I say most likely, I mean they are) unaware of the extensive training we have to examine, diagnose and treat musculoskeletal and neuromuscular conditions. They are unaware of the extensive training we receive in school about recognizing common medical pathologies and recognizing signs and symptoms warranting a referral out. Two questions that come to mind are: 1. Do they care? 2. If no, how do we make them care?

I believe the solution to those answers lie in the hands of the very people we see day in and day out. THE PATIENT. If physicians do not want to listen to us, then maybe they will listen to their patients. We should be educating the public about who we are and what we do regularly; patient/clients are a no-brainer in that we already have scheduled time to talk. The education does not end there, so how can we continuously integrate the importance of direct access and physical therapy into the daily routine of our patients?

A simple way is to set up and automate the sending of educational information, relevant content, and information about your clinic to your current patients and surrounding community. With a patient relationship management strategy, not only can you make sure that all of your patients are educated on the benefits on direct access… you can also pinpoint your most engaged and satisfied customers (your customer evangelists). Then, you can strategically customize messages to your customer evangelists to increase community awareness, drive patient-generated referrals, and systematically turn your patients into lifelong customers. Because as well all know, customer evangelists are our most valuable marketing asset. They are your volunteer sales force; the key to turning patient-generated (direct access) referrals into your most valuable referral source!

If you want to learn more about how StriveHub Reach can help with your patient relationship management strategy, click below.

Check Out StriveHub Reach

Results of a recent “Direct Access Survey” I conducted were quite interesting. The survey was posted via Twitter.com and I received a total of 17 responses to the six-question survey.

  1. Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10-18. http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/MitchellStudyonDirectAccess.pdf.

  2. Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30. doi: 10.2522/ptj.20130096.

  3. Snow BL, Shamus E, Hill, C. Physical therapy as primary health care: public perceptions. Journal of Allied Health. 2001:30(1):11-19.

  4. Deyle GD. Direct access physical therapy and diagnostic responsibility: the risk-to-benefit ratio. J Ortho Sports Phys Ther. 2006;36(9):632-634. doi:10.2519/jospt.2006.0110.

TJ Janicky



There is no certainty. There is only adventure. Marathoner - Constant Learner - Rutgers Doctor of Physical Therapy 2015