According to the American Physical Therapy Association (APTA), 46 states currently have what they call “some form of direct access”. I am not sure what, exactly, “some form” means. If you look at the states that have “unfettered direct access” – which is also a misnomer unto itself – you are looking at about 16 at last count.
Texas is considered a “direct access” state. I can tell you right now – it simply is not, in any way, shape, or form. But the APTA continues to put Texas (and many other states) in this nebulous category of “some form of direct access”. Sure, you can do an evaluation of a patient without a referral – but what good is that if you can’t then treat the patient without someone else’s consent or approval?
Telling the media, legislators, lobbyists, and worst of all, patients – that patients have “direct access” to physical therapy – is simply not telling the truth. When we go back to legislators and tell them we only have “some form of direct access, but we need to expand it”, should we really expect them to do so? “Well, you already have it according to your own professional association”, I can hear them saying. One would have to wonder if this in fact impairs our position in the health care world instead of enhancing it.
You either have direct access to a physical therapist – or you don’t. There’s no in-between. You can either access a physical therapist, by patient choice, without limitations and referral requirements and other silliness – or you can’t. You can either make full use of their skills and training within their scope of practice – or you can’t.
It’s that simple.
This would require a patient having access to health care first and foremost, something that in the state of Texas is a significant problem. Texas ranks dead last in access to health care. The primary care physician supply ratio ranks 47th in the nation.
Two groups of practitioners – physical therapists and advanced practice nurse practitioners – have proposed valid solutions to this growing dilemma. If a patient has direct access to appropriate care within these providers’ current scope of practice and education, more patients will have access to necessary care and patients will have choices regarding their care.
In Texas, the 82nd Legislative session is upon us. Health care will almost certainly be an important issue. Once again, direct access to physical therapy will be a topic of discussion amongst legislators. But there is another debate being waged on similar battle grounds - with a common foe.
Sadly, this is no longer the case.
In the current insurance-based payment model, your insurance company will "approve" payment for a certain number of physical therapy visits for your current episode of care (and oftentimes over a calendar year). This is typically anywhere from 8 to 12 physical therapy visits. This is what CAN be utilized, not what MUST be utilized.
Physical therapists that are part of these insurance networks are usually reimbursed at a very low rate per patient or per treatment activity. In order to compensate for this, it is then in the best financial interest of the physical therapist to either a) utilize ALL available treatments that have been approved by the insurance company, or b) increase the overall cost to the insurance company in the hope of attaining a greater income based on the percentage paid by the insurance company. The average cost per visit billed by a physical therapist, based on a number of references, is in the range of $100 to $200 per visit.
The patient is typically billed a copay, and many insurance companies are also implementing a specific deductible for physical therapy or allied health services, or a percentage of the bill to be paid by the patient. Patients are now typically faced with $40 copays and up to 20% of the cost of care along with their copay. That can bring the total to well over $60 per patient visit.
More treatment visits do not mean greater improvements in function. Though the national average for back pain is along the lines of 12 visits per episode of care, most practitioners are utilizing non-evidence-based assessment and treatment strategies, and are not focusing on elements of competent self care in conjunction with clinical care provided in order to optimize the patient outcome.
Fortunately, there are some new approaches that return to a focus on quality and value in health care.
Taking another step forward on this line of thought - in order to solve the problem, you need to be able to think, to reason, to “connect the dots” of your thinking, and to do so logically and based on good, sound data. I don’t think that’s much of a quantum leap in thinking either.
Sadly, this is not the clinical reality that patients experience – with physicians, with chiropractors, with massage therapists, with physical therapists, or with countless other clinicians.
That’s a strong statement that may require some explanation.
A typical episode of care, in the current paradigm of what is “acceptable care” (note how I did not say “evidence-based care”) is 8 to 10 visits. As I mentioned earlier, this is considered by many to be “great care” and is even advertised as such. These same 8 to 10 visits are costing the patient, on average, anywhere from $64 to $80 per visit, with a total of $512 to $800 out-of-pocket for any given episode of care. This investment may not provide much value-added benefit nor quality, especially if evidence- and science-based strategies have not been implemented in competent self care strategies. Sadly, the disconnect between quality and value has become the accepted standard amongst clinicians and patients – for all the reasons that I outlined in Part I.
Add to this the fact that for every $10 spent on health care, $9 are spent on overhead. Yes, just $1 is spent on actual care, and even that is being lost in the quality/value debacle. But we also know that for every year of education, health care costs drop. So having people better educated in the process of their care makes good sense economically and culturally.
Seven years ago, my clinical practice moved from an insurance-based model to an out-of-network fee for service model. But what I have found over the years is that patients are so driven by “what their insurance covers or pays for” or “who is in or out of network”, that they fail to fully comprehend and consider the issues of quality and value.
A fee for service model can provide an out-of-pocket cost saving, though conflicting value systems remain. Innovation can provide quality, outcome, value, and cost-efficiency, but something radically different will be required to transform our current models. Let’s examine how a fee for mentorship model provides a value proposition that is revolutionary in how we view health care, physical therapy, and health in general.
Health care is in dire need of transformation. The system as we know it has been built on a foundation of principles that have conflicting values. Whether it’s the reimbursement models or the practice patterns, or both, the concepts of “quality” and “value” have been lost in the mix. What has become the accepted standard of care and delivery has become outdated, and in the midst of it, the patient – the driver of all of this – has been forgotten.
In any other realm, we look to quality and value as two key elements of an exceptional customer experience. A free and open marketplace fosters this. Consumers critically examine cost, quality of service, and results in their decision-making process for just about everything – cars, homes, education, you name it. Except health care.
Patients have learned to accept the gross failures and inadequacies of the health care system. Are patients satisfied with their care? Sure. But are their expectations of this “accepted standard” really at a high enough level? Or are they satisfied with something less simply because they have been told that that is the accepted standard?
This becomes all the more apparent in the world of physical therapy. When there are clinicians proclaiming that “first class service and results” create “the top physical therapy clinic for patient satisfaction” – and then stating that the “average length of stay is 10 visits – guaranteed” – I shake my head in disbelief. When 10 visits per course of care is considered “great care”, I have to wonder about what has become the accepted standard these days.
And there is plenty of finger-pointing by the clinicians at the insurance companies. It’s their fault for such low reimbursement rates, right? On the surface, there are many instances in which the finger-pointing may be well-deserved. But when you point a finger, as they say, four point back at you. The clinicians are as much to blame as anyone, and much of that has to do with a simple lack of innovation at a far deeper, systemic level. It starts with the clinician, their product, and their means of delivery.
Transformation requires a deeper level of understanding of the systemic problems, so let’s start there first.
As a physical therapist in Texas, I have watched the continued struggle with direct access to Physical Therapy. Texans can see a Physical Therapist for an initial evaluation, but cannot subsequently receive treatment without a physician referral. As a McKenzie practitioner, not having direct access is an enormous barrier to caring for our patients. With an assessment process that naturally shifts to treatment, we are faced with a dilemma. If the assessment reveals a directional preference, then instead of simply taking the next step and educating the patient regarding the importance of this, we must then interject "you need to see a physician for a referral."
In an era of “evidence”, there is plenty to indicate that direct access to Physical Therapy would increase a patient’s access to appropriate and necessary health care, decrease their cost of care and restore the patient’s right to choose.
In order for our health care system to move forward, it is time for all of us to put our best foot forward and foster a medical system that is truly patient-centered.
Allan Besselink, PT, DPT, Ph.D., Dip.MDT has a unique voice in the world of sports, education, and health care. Read more about Allan here.