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7 Direct Access Myths Debunked

Here's the truth about seven of the biggest direct access myths out there.

Brooke Andrus
5 min read
September 27, 2017
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The fight for direct access to physical therapy has been raging for a while—we’re talking several decades—and as with any long-standing controversy, rumors abound. So, in the interest of removing some grist from the gossip mill, let’s tackle a handful of the biggest direct access myths out there:

Myth #1: Direct access only applies to private outpatient physical therapy practices.

Truth: One of the most pervasive myths in the therapy industry is that direct access only benefits providers who practice in private outpatient settings. However, as this APTA article explains, not only are therapists in “major hospital and health systems...successfully treating outpatients without referral,” but they’re also providing therapy services in a direct access capacity “in private-pay home care, in industry, on the sports field and performing arts venues, in school systems and pediatric centers, and through admission orders in ICUs and other in-patient settings.”

In many countries outside of the US, hospital-based direct access to physical therapy is much more commonplace—and thus, much more culturally accepted. For example, as explained here, after a London-based hospital began staffing its walk-in center with both PTs and nurse practitioners, it reported a surge in patient satisfaction, with 90% of patients reporting that they likely would return to the center rather than access care elsewhere. And the trend of hospital-based direct access is starting to gain steam in the US—especially in smaller organizations with limited resources. Frances Mahon Deaconess Hospital—located in the tiny town of Glasgow, Montana—recently announced a new policy allowing patients to “self-refer themselves to physical therapy services, therefore bypassing the need for an extra physician appointment.” According to the hospital’s announcement, the new model is not only “easier for the patient, but research suggests that in appropriate cases, allowing direct access to physical therapy can lower healthcare costs, reduce requirements for diagnostics imaging, and provide more expeditious resolution of the patient’s symptoms.”    

Myth #2: Payers will not reimburse physical therapists for services provided without a physician referral.

Truth: Therapists should never, ever assume that an insurance company requires a physician referral as a condition of coverage for rehab therapy services. Why? Well, in the words of the APTA, “information from both payers and physical therapist providers indicate very positive trends toward reimbursement without referral.” Translation: many insurances will reimburse for rehab therapy services without a physician referral, although some do still require one. But verifying insurance details for any patient is a best practice anyway—and that principle applies whether a patient is self-referred or not. In fact, with the proliferation of high-deductible health plans (HDHPs), patients are paying a greater portion of the cost for all types of care—not just physical therapy. For that reason, it’s important to not only verify each patient’s benefits, but also get an idea of what the patient’s out-of-pocket financial responsibility will be. Then, be sure to communicate that information clearly—and ideally, in a way that emphasizes the value of your services. That way, the patient won’t get hit with any unexpected bills—which could deter them from accessing physical therapy services in the future.

Myth #3: Direct access doesn’t change the market for physical therapy.

Truth: Many direct access skeptics harp on the fact that it’s one thing to have a law on paper, and quite another for that law to effect any real change. While some in the PT industry might question the immediate business benefits of direct access, the truth is that the market for direct access services exists—it’s just that many potential direct access patients have not yet realized that they want or need physical therapy. In fact, as WebPT’s president and co-founder Heidi Jannenga points out in this article, “Of all patients with neuromusculoskeletal issues, only about 8% seek out rehab therapy.” So theoretically, 92% of the patients who could benefit from physical therapy treatment fail to obtain it. Talk about a huge market opportunity!

While it could take some time for industry-wide marketing efforts to gain enough traction to successfully create demand among those consumers, individual practices can still leverage the power of direct access to increase their bottom lines—one patient at a time. Remember, it’s not just about converting prospective patients into actual patients—it’s also about turning those patients into loyal customers who will come to you directly should they experience any future neuromusculoskeletal issues. More than that, it’s about leveraging those patients to generate even more self-referrals. In other words, you've got to boost your practice's "viral coefficient," which, as this resource explains, is "the number of new users an existing user generates. This metric calculates the exponential referral cycle—sometimes called virality—that accelerates company growth."

Additionally, many practices are starting to offer cash-based wellness and fitness services as a way to keep patients coming back on a regular basis after they’ve completed their therapy treatment. That way, you can retain the business of the patients you already have—only in a more customer-based capacity. A few more tips for marketing to your individual network of current and past patients: Advertise your cash-pay service offerings with blurbs in your clinic newsletter, posts on your social media pages, or signs in your office—and make sure people know they can book an appointment with you directly, without a physician referral. (For a comprehensive overview of how to take your practice fully or partially out-of-network in order to capitalize on private-pay, check out this free webinar.)

Myth #4: Direct access patients don’t “buy in” to rehab therapy as much as physician-referred patients do.

Truth: The logic behind arguments against direct access for physical therapy is that because patients completely trust their physicians’ expertise, they’re more likely to stick with a program suggested by a physician than one they sought on their own. But that sentiment doesn’t really fall in line with the data. In fact, this study, published in Physical Therapy (PTJ), showed that:

  • “patients reported a higher level of satisfaction when they received physical therapy through direct access versus physician referral,” and
  • “patients receiving physical therapy through direct access versus referral had better outcomes at discharge.”

The above-cited study also highlighted a “decreased cost in the direct access group...likely due to decreased imaging, number of physical therapy visits, and medications prescribed.” And this APTQI research report determined that total spending for Medicare patients with low back pain who access physical therapy first was 75% lower compared to patients who underwent surgery first and 19% lower compared to patients who received injections first. For patients with high out-of-pocket costs—like those with the previously mentioned HDHPs—that could equate to a hefty chunk of savings. And if that’s not enough to drive buy in—pun intended—then I don’t know what is.


Myth #5: Direct access doesn’t exist in every state.

Truth: While it’s true that total, unrestricted direct access to physical therapy isn’t available in every state, what many people don’t realize is that there are different levels of direct access. As this PT in Motion article explains, “The term can describe degrees of access, from unrestricted patient access to all the services a PT has to offer, to patients' ability to receive an evaluation from a PT (who must then refer the patient back to a physician before commencing treatment), to requirements that patients obtain physician referrals only for certain interventions specified in the practice act.” And, as of 2014, some form of direct access is available in all 50 states and the District of Columbia. What does that mean for PTs? Well, as Jannenga explains in this Evidence in Motion blog post, “ every single state, we now have the ability to at the very least perform an initial evaluation for anyone who walks into our clinics.”

Yes, some states still restrict the type and quantity of services physical therapists can provide on a direct access basis, and yes, the PT industry still has a lot of ground to cover in the push for unlimited patient access to physical therapy across the board. But the important thing is that the groundwork is there, and the momentum shows no signs of slowing. As Jannenga writes, “Direct access to therapy has shifted from being the exception to being the rule.”

Myth #6: Direct access will give physical therapists a huge increase in patient volume.

Truth: While pro-direct access legislation certainly lays the foundation for increased consumer demand for physical therapy services, it doesn’t directly translate into more patients. For PTs to convert this newfound business opportunity into actual business, they’ve got to flex their marketing muscle. As physical therapist Bill Whiteford says in this PT in Motion article, “Getting word to the public about our services has been a challenge in this profession...In wellness and fitness, people could see anyone and everyone, as long as it wasn't a PT. Now that that's changed, we really have to become the profession of choice.” That means becoming more visible in the places potential patients go to find healthcare providers—namely, the Internet. So, for starters, take a good, hard look at your online marketing efforts—especially when it comes to online reviews. After all, as WebPT CEO Nancy Ham explained in this webinar on the state of the rehab therapy industry, half of Millennials and Gen-Xers—and even 40% of Baby Boomers—use online reviews to select their providers. That means therapists need to not only keep a pulse on patient satisfaction, but also leverage the social-proof power of their happiest customers (i.e., ask for reviews). The best way to do that? Automate the entire process using a PRM software like WebPT Reach, which leverages NPS tracking to help practices identify their most pleased patients—and then automatically emails those patients to request online reviews.

Myth #7: Allowing patients to bypass their primary care physicians puts their health at risk.

Truth: Ah, the liability argument—a concern as old as the direct access movement itself. The problem with this long-held contention among direct access foes is that it’s rooted in pure misconception. Today’s PTs are doctorate-level medical professionals whose training and education make them more than qualified to not only conduct initial evaluations, but also to recognize when a patient’s medical needs fall outside of their practice scope. In fact, as stated in this article, the APTA’s Guide of Professional Conduct “advocates that physical therapists should assist patients in receiving appropriate medical care when the physical therapist’s examination and evaluation reveals signs and symptoms inconsistent with a condition that can be appropriately treated with physical therapy or needs a physician's care and expertise.”

Even liability insurers agree that direct access does not correlate to increased liability risk. According to this APTA resource, Health Providers Service Organization (HPSO)—the leading carrier of professional liability insurance for physical therapists in the US—does not consider direct access availability to be an additional risk factor and thus, does not charge a premium differential for physical therapists in direct access states. Furthermore, “physical therapists have an extremely low rate of malpractice and a low incidence of claims or complaints filed against them.” As for historical trends, per analysis provided by HPSO and the Federation of State Boards of Physical Therapy, the data shows that “there has been no increase in claims against physical therapists in states without the referral mandate.”

History has taught us that any challenge to the status quo is bound to breed concern—and that creates an environment ripe for myth-making. What direct access rumors have you heard? Share ’em in the comment section below, and we’ll do our best to debunk ’em.

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