Direct Talk - About Direct Access

Surprise ... it's quiz time ...

Consider this scenario: you've been running for a few weeks now, and you've noted a little discomfort in your thigh whenever you run. It's starting to limit your running, and you really don't want to stop training if at all possible. Off the top of your head, who's the first healthcare provider you'd go to see (if insurance and other issues weren't limiters) to resolve this problem?

Wait ... don't tell me the answer just yet. This will all make more sense in a moment. Read on, please. The 80th session of the Texas legislature is now over. Of importance to physical therapists (and patients) statewide is the death of House Bill 1040 (Democrat sponsor) and Senate Bill 1321 (Republican sponsor). Why are these important? They would have given patients direct access to physical therapy. Texas is one of only 8 states remaining in the US that don't have direct access to physical therapy (PT).

At first glance, imagine this - two separate bills in both the House and Senate ... with bipartisan support ... and neither even got to a committee hearing, let alone a vote. Incredible, isn't it?

In other (obviously more important) legislation, they did approve a $5 "sin tax" to attend a strip club in Texas.

Fact.

Am I understanding this correctly? Our tax dollars are hard at work - again. I'm more than happy to know that my elected officials have my best interests covered (no pun intended, of course).

But seriously folks, let's make sure we all understand the issue at hand first (and no, I wasn't kidding about the sin tax - it's for real).

What is "direct access"? As a patient, you can't simply go to a PT like you would any other provider. In Texas, a physical therapist can perform an evaluation ... but in order to provide treatment, he/she is required to have a referral - from, for example, a physician or chiropractor. To many patients, this seems like an "extra hurdle" in the system, and most won't bother with it - they will access other more direct means of care, regardless of the level of appropriateness to their presenting problem. Frankly, I don't blame them - I hate jumping hurdles myself!

So what does the American Physical Therapy Association have to say about all of this?

"Allowing individuals to make decisions regarding their health care is good policy. Individuals in eight states are prohibited by state law from seeking physical therapists' services unless they are referred by another health care provider. Eliminating the referral requirement is one step to making health care more accessible to more people.

"Physical therapist education supports practice without referral. Physical therapist practice in the 42 states that allow treatment without referral has proven that it is safe. Yet consumers in eight states do not have access to these services unless another health care provider refers them to a physical therapist.

"Patient access without the current professional practice restrictions regarding referral is about individual choice in health care decisions. Elimination of the referral mandate does away with an unnecessary and burdensome regulation." (www.apta.org/AM/Template.cfm)

As it stands right now, you can go to just about anyone to get some guidance regarding an exercise program for your problem. Advice is plentiful, be it good, bad or indifferent. I know plenty of massage therapists, personal trainers, and yoga instructors - as but three examples only - who generally have little to no formal training in exercise as it relates to injury (as part of their licensure) - that will gladly give you exercises to solve your problem.

But a licensed professional who's background rests firmly in exercise physiology and the application of exercise to disease and injury? Nope - need a referral for that. Forget about the fact that PTs are trained in exercise-based interventions. Forget about how PTs are ultimately responsible for their clinical decision-making and patient safety - referral or no referral - as they are licensed health care providers in the first place.

Our legislators (state and federal) profess that health care (and the cost of care) is a vital political element for their constituents - but an aspect that would directly impact this (direct access) doesn't seem to be a very high priority. Direct access shortens the process of providing care for those who need it. Simple. It's better for the system - and it's better for the patient. It's become a standard of care in the medical model internationally. It would seem that if it's an acceptable standard of care for 85% of the states of the union ... it would be good enough for Texans.

Perhaps the average person simply isn't aware that this is an issue. Most have no idea that they have to even think about who they go to see for their care - and most simply don't understand how a PT wouldn't be a "first line" provider. The grass roots level is simply under-educated in how it affects their care. On top of that, the taxpayers would probably be a little concerned that their legislators are more concerned about things like a "sin tax" than an issue related to health care quality and accessibility. Many people want to solve their problems by going directly to a source that can guide and educate them, not to jump through hoops to simply appease the system - financially, politically, medicolegally, and otherwise. They want to do it cost-effectively, and they want to have control over who they see and how they see them. When given the options, most people WON'T jump those hoops - they will simply go without, making a simple situation a potentially chronic one, thereby costing "the system" more money over the long term. It's time and money spent without an answer or any more guidance than "if it hurts, just stop doing it".

So why doesn't direct access exist in Texas? This is where we have to accept some harsh realities. Here are a few potential culprits for the stalemate -

1. The legislators: These are the direct representatives of the grass roots population, the constituents that are paying for health care. Don't get me wrong - I applaud them in that we now have bipartisan support in Texas. But somehow, they couldn't seem to get either bill out of committee - though were, as previously noted, far more concerned making sure that we charge a $5 sin tax for entry into a strip club. I guess this is somehow "for the common good". I feel much safer knowing this item has been passed into law, don't you?

2. The lobbyists: What is the old phrase? "Whoever has the money, makes the rules"? How dare I say that? If you don't believe it, you've not spent much time on this part of the planet. A harsh reality - lobbyists control a lot of things that we probably don't want to believe they control. They are territorial for their lobbying group - and, again, this has nothing to do with the patient and what is best for them.

And last, but certainly not least -

3. Our own profession: I've been a physical therapist for 19 years. Our profession seems to be more concerned about transitional doctorate degrees, worried about the Medicare cap, worried about this and that - but for some reason, we're not collectively concerned about our identity, our self-image as a profession. In other countries, being a PT is on par (with respect to public perception and professional reputation) with being a physician. In this country there is a generalized self-image problem within the profession - and for that, WE are responsible.

This isn't an issue of blame ... far from it. That would simply downgrade our responsibility in the situation. If we look at culprits #1 and #2, let's add in another old phrase - "The squeaky wheel gets the grease". If we spoke louder, we might be heard. Though there are always dollars and cents at play, we have to step it up and speak out - and apparently, if we can't get bipartisan support to work for us, and we can't even get a bill into committee, then how loud are we speaking??

Physical therapists are a long way from being in a truly free enterprise marketplace. As a profession, physical therapists have the skills and training as diagnosticians that are generally accepted and highly respected worldwide. They are trained in exercise-based interventions. The law as it stands right now effectively prevents the patient from having choices in their care, and effectively places physical therapists in a role that not even massage therapists, personal trainers, or yoga instructors face. In preventing access to care, we are not only limiting those that would benefit from the care - the payors and the patients - but we also effective limit the ability of the clinician to practice and work. Is that right to work not an important consideration anymore?

If I did the math correctly, it's only another 700 or so days (2009) until the next Legislative session - to try this all over again. But as Stephen Covey notes, "If you do what you done, you get what you got". Forty-two states now have direct access to PT. The military has direct access to PT. This speaks to the accepted standard of care nationwide. But, alas, we wait again - until 2009.

And as for the quiz I started with ... there wasn't a correct answer ... but at least you had the opportunity to choose whatever you felt was appropriate for your health care. Perhaps that's the biggest answer of all.

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