Waiting for all 50 states to have total, unrestricted direct access to physical therapy services reminds me of the one and only time I cooked a Thanksgiving turkey: it was a massive bird, and I was a novice enough chef to not realize how long it would need to bake. And because I’m impatient, I’d take a peek in the oven every 15 minutes or so to see how it was progressing. Slowly but surely, the fine fowl cooked into a beautiful golden brown, and I pulled it out of the oven—just in time for the dessert course.

From where I’m sitting, it seems like PTs have had a similar experience when it comes to standardizing direct access laws across the US. Of course, it’s taken years for things to get to where they are now, which is significantly longer than my paltry poultry parable. (Try saying that five times fast.) But direct access standardization—that is, unrestricted patient access to physical therapy as a first-line treatment option so every patient can truly get PT first—is a critical must-do for the healthcare community. Here’s why:

1. It’s better for patients.

Physical therapists have the proper training to treat direct access patients—and to refer patients to other providers when necessary.

One of the main beefs surgeons and physicians have with patients skipping a doctor’s referral and heading straight to a physical therapist is the risk of injury or an overlooked diagnosis. However, physical therapists are trained to diagnose injuries and diseases related to the musculoskeletal system. As mentioned in this APTA resource, an article published in JOSPT (Moore et al, October, 2005, pages 674-78) described “over 50,000 patients seen by PTs via direct access, and not one incidence was reported of patient injury or adverse event, or of a PT having their license revoked or suspended.”

Furthermore, physical therapists know when a diagnosis is beyond their scope of practice, and they have the proper judgement to refer patients to a physician whenever necessary. The same resource cited above also referenced “30 published patient case reports where individuals came to physical therapy with a variety of musculoskeletal complaints. According to the reports, “the PTs examined the patient, recognized unusual examination findings and referred the patient. This patient referral to a physician led to a more timely diagnosis of a multitude of conditions.”

PT is safer than physician-prescribed medications.

Physical therapy is also a much safer alternative to many of the meds doctors prescribe to mask pain. According to a survey from the American Pain Society, “Chronic pain is highly prevalent in the United States, affecting nearly one-third of the American population.” As a result of the chronic pain epidemic, pharmacological interventions—specifically, opioid prescriptions—have increased exponentially. In fact, as WebPT Co-Founder and Chief Clinical Officer Heidi Jannenga explains in this Evidence in Motion article, “low back pain patients who accessed conservative therapies first were ‘75% to 90% less likely to have short or long-term exposure to opioids.’” 

On the flipside—and coming as a shock to no PT whatsoever—patients who opt for meds or surgery over movement therapy are vulnerable to a barrage of risks, including addiction or death. For that reason, the CDC recommends that patients seek non-pharmacological treatments for chronic pain. And as musculoskeletal experts, physical therapists are perfectly suited to provide such treatment. However, patients may be less willing to jump through hoops to access a PT in states with provisional direct access.

Patients achieve the same (or better) outcomes with physical therapy.

Doomy and gloomy health risks aside, prescription meds should never be the first choice for treating pain, as they don’t actually treat the source—merely the symptom. According to this resource from the CDC, physical therapy and exercise therapy are far more effective at treating and reversing the cause of many types of chronic pain—from osteoarthritis to fibromyalgia. In some cases, PT modalities reduce pain and improve function “immediately after treatment” and “improvements are sustained for at least 2–6 months.”

2. It’s better for healthcare spending.

Referral requirements create an additional financial burden for patients—and a barrier to care. 

So, with all of these health benefits, it makes sense that patients and payers alike would want physical therapy to be more readily available. Unfortunately, the cost of PT care—due in large part to lack of insurance coverage—has put a massive barrier between PTs and their potential patients. And one way we can start alleviating some of that financial burden is to remove the unnecessary visit to a physician’s office. In fact, according to this APTA-backed study, “Individuals who saw a physical therapist first in states with provisional access had significantly higher measures of health care utilization within 30 days, including plain imaging and frequency of physician visits, than individuals who saw a physical therapist first in states with unrestricted access.” Conversely, “those who saw a physical therapist first in provisional-access states had 25% higher relative costs at 30 days and 32% higher relative costs at 90 days, whereas those who saw a physical therapist first in unrestricted-access states had 13% lower costs at 30 days and 32% lower costs at 90 days.”

PTs are experts: they know when a patient is a good candidate for physical therapy—and when he or she is not—which means a trip to the doctor’s office to obtain a referral for PT is completely unnecessary and a total waste of time and money. Cutting out that step lowers the barrier (if only a little) between physical therapy patients and their providers of choice.

Physical therapy is more cost-effective for payers.

But patients aren’t the only ones who benefit financially from increased accessibility to PT services. In the aforementioned article, Jannenga also cites data saying that “claims for musculoskeletal episodes accounted for more than 16% of total spending—a percentage greater than that associated with any other condition. Furthermore, 75% of that spending went toward prescription medications.” (For context, more than 11% of UHC’s total spend was associated with claims for cancer treatment.) In other words, directing musculoskeletal patients toward physical therapy could end up saving the healthcare system a whole lot of dough. And lifting restrictions on direct access encourages patients to seek conservative care paths that result in fewer dollars spent.

3. It’s better for the physical therapy profession.

Direct access helps establish PTs as first-line providers.

Okay, we know physical therapists have the education and clinical decision-making ability to oversee patient care from start to finish. However, because they rely so heavily on physician referrals, PTs have struggled to position themselves as the first-line providers we know they are. Lifting restrictions on access to care could actually help shift this perception.

Furthermore, when PTs have the opportunity to treat patients one-on-one throughout the entire episode of care, they are able to collect more holistic and meaningful outcomes data, because they’re running the care plan from beginning to end. And they can leverage that data to effect positive change—from negotiating for better third-party reimbursement rates to advocating for themselves (and their patients) by proving the efficacy of physical therapy to the government powers that be.

It’s a step toward industry standardization.

Standardization is a big ol’ problem in the PT profession, and that’s especially true with respect to current direct access law. While it’s true that every single state (plus Washington, DC and the Virgin Islands) is a direct access state, as of 2019, only 20 states allow total, unrestricted access to physical therapy services. (Although that’s up by two since last year!) That lack of standardization creates confusion for not only providers, but also patients.

Here’s the thing: PTs receive—more or less—the same education in every state. Each state requires the same degree level and skills in order for an individual to become a licensed physical therapist. So, considering the fact that PTs across the country are held to the same baseline educational standards, it doesn’t make a whole lot of sense for states to not hold them to the same practice standards, too. And once that’s standardized, it could make it easier for lawmakers and insurance payers to create pathways for things like telehealth services—thus, bringing the profession into the 21st century. 


So, there you have it: the top reasons for giving patients unrestricted direct access to care. Did this article whet your appetite for more direct access info? Click here to check out our guide to direct access by state. And, as always, feel free to drop your questions in the comment section below!