Direct Access To Physical Therapy: Lessons From The Global Village

The United States is currently faced with an antiquated, gatekeeper-driven approach to health care that best exemplifies defensive behaviors, territorial debates and turf battles more so than “patient-centered care”. While lobbyists throw millions of dollars at legislators in order to protect the sacred turf of gatekeepers, the patient suffers.

There are many lessons in patient-centered health that can be learned from the global village. The rest of the world has quietly moved forward and embraced direct access to physical therapy as an effective means of enhancing patient-centered care and in increasing access to appropriate care. They have done so with great success. You don’t have to go any further than our neighbor to the north to find one of the world leaders in direct access to physical therapy.

Let’s examine what the international perspectives on direct access to physical therapy, what can be learned from these cumulative international experiences, and what the limiters are in this country.

In 1995, the World Confederation for Physical Therapy produced a declaration of principles of autonomy for the profession. In it, they noted that

“The World Confederation for Physical Therapy (WCPT) believes it is fundamental to professional autonomy that individual physical therapists should have the freedom to exercise their professional judgement, whether they are working in heath promotion, prevention or in the management, treatment/intervention and rehabilitation of patients/clients – as long as it is within the physical therapist's knowledge and competence.

The actions of individual physical therapists are their own responsibility. So it follows that their professional decisions cannot be controlled or compromised by employers, persons from other professions or others.

Patients/clients should have direct access to physical therapist services.”

Autonomy and patient direct access have been an integral part of the profession for decades - in other countries. In the United States, the APTA speaks of “degrees of direct access”, but in my eyes, as a patient you either have access or you don’t. And in the United States, 16 states have what is truly considered “direct access” internationally. Though the APTA is a member of the WCPT, only 32% of states are consistent with the declaration of these principles.

In 2009, an International Policy Summit on Direct Access noted the following that

“Leaders from 18 countries attending the International Policy Summit on Direct Access and Advanced Scope of Practice in Physical Therapy endorsed the results of research that clearly demonstrate that patient self-referral to physiotherapy is best for all health systems, whether public or private. Direct access and self-referral allows patients to access physiotherapy as their first choice for rehabilitation. A physician referral is not required.”

Experiences from other countries (and presentations of such) can be found here.

The evidence has been building for years. A sample list of references can be found below. Fewer treatment sessions. Decreased cost. And, in a study from the UK, released in 2008, even the physicians supported direct access to physical therapy! For example -

‘They [physiotherapists] are more skilled than us in certain musculoskeletal areas and I value their diagnostic skills as well as management of the actual physiotherapy session’

‘It has been very successful, has saved GPs considerable time and saved patients unnecessary trips to the surgery.’

‘It gives more autonomy to the patient to have their own part in helping themselves get well. It reduces the paperwork for doctors.’

‘I feel they have more time to assess patients with musculoskeletal problems and better experience.’

‘The patients refer themselves. If the physiotherapist is uncomfortable they send them back with a clear, concise finding – most helpful’

In the span of just two countries – Canada and the United States – we can traverse the full continuum in perception of direct access to physical therapy.

The progressive viewpoint: The Physiotherapy Act in Ontario, Canada implemented direct access 20 years ago. Physical therapists are viewed by patients as an obvious first line of care for many physical conditions, and are viewed by physicians as equals in the health care system. Physical therapists have been asked to take an even greater role in the health care spectrum because, imagine this, direct access works for the patient.

And on the other end of the spectrum? In the United States, gate keepers such as physicians (and now chiropractors) continue to make unsubstantiated claims against direct access or, worse yet, claims that have already been refuted in the scientific literature.

Internationally, patients have been seeing physical therapists as a first line of care for years and guess what? Patients aren’t dying, aren’t suffering from missed diagnoses, aren’t paying more for care, and, imagine this, they are happy with the results. So if the evidence firmly supports this shifting paradigm in patient-centered care worldwide, then what limits its full implementation in the United States?

Power. And money.

An upcoming article will dive headlong into the turf warriors and money involved that prevents patients from truly being at the center of the health care discussion, that prevents patients from accessing the provider of the their choice, and costs the patient more time and money.

Evidence for the effectiveness of direct access:

http://www.wcpt.org/node/34062#Evidence

http://ptjournal.apta.org/content/77/1/10.full.pdf

http://www.wcpt.org/sites/wcpt.org/files/files/Practice_Direct_Access_refs.pdf

http://ptjournal.apta.org/content/88/8/936.full.pdf+html

Photo credits: cbmd