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Direct Access in Ohio

Physical Therapy
What is Direct Access?
• Definition
o The legal right to seek and receive the examination, evaluation,
and intervention of the physical therapist without the requirement
of a physician referral.

• One of the major elements that the APTA is working

towards in the Vision 2020.
o Autonomous Practice
o Direct Access
o Evidence-Based Practice
o Practitioner of Choice
o Professionalism
Types of Direct Access
• Unlimited
• Provisional
• Evaluation Only
• None

• Which one do you think Ohio has at this

General Information About
Direct Access
• 44 States (plus D.C.) have unlimited or
provisional direct access
o 16 States have Unlimited
 Alaska, Arizona, Colorado, Idaho, Iowa, Kentucky, Maryland,
Massachusetts, Montana, Nebraska, Nevada, North Dakota,
South Dakota, Utah, Vermont, and West Virginia

o 4 States have Evaluation Only

 Hawaii, Michigan, Missouri, Oklahoma

o 2 States have No Direct Access

 Alabama, Indiana

o The remaining states are all Provisional Direct

Direct Access Law

• Law went into effect 6/27/2005 in the state

of Ohio

• 4755.481 – Practice without prescription

or referral
Direct Access Law
• The physical therapist shall, upon consent
of the patient, inform the patient’s
physician or other healthcare professional
of the evaluation no later than 5 business
days after the evaluation
o A business day means any calendar day that
is not a Saturday, Sunday, or legal holiday.
Legal Holidays
• New Year’s Day • Independence Day
• Martin Luther King Jr. • Labor Day
Day • Columbus Day
• Inauguration Day • Veterans Day
o Every 4th year • Thanksgiving Day
• President’s Day • Christmas Day
• Emancipation Day
• Memorial Day
What Information Needs to be Given
to the Physician?

• The law only requires notification that the

physical therapy evaluation was

• No specific information or details need to

be stated to the physician
Direct Access Law
• If the physical therapist determines that no substantial
progress has been made with respect to that patient
during the 30 day period immediately following the date
of the patient’s initial visit with the physical therapist, the
physical therapist shall consult with or refer the patient
back to a licensed physician or other healthcare
professional unless one of the following applies:
o The evaluation, treatment, or services are being provided for
fitness, wellness, or prevention purposes.
o The patient previously was diagnosed with chronic,
neuromuscular, or developmental conditions and the evaluation,
treatment, or services are being provided for problems or
symptoms associated with one or more of those previously
diagnosed conditions
Direct Access Law
• If the physical therapist determines that orthotic devices are
necessary to treat the patient, the physical therapist shall be limited
to the application of the following devices:
o Upper extremity adaptive equipment used to facilitate the
activities of daily living
o Finger splints
o Wrist splints
o Prefabricated elastic or fabric abdominal supports that require
minimal fitting
o Non-therapeutic accommodative inlays
o Shoes that are not manufactured or modified for a particular
o Prefabricated foot care products
o Custom foot orthotics
o Durable medical equipment
Direct Access Law
• If the physical therapist has reason to
believe that the patient has symptoms or
conditions that require treatment or
services beyond the scope of practice of a
physical therapist, the physical therapist
shall refer the patient to the proper
licensed healthcare professional
Direct Access Law

• Nothing shall be constructed to require

reimbursement under any health insuring
corporation policy, contract, or agreement,
any sickness and accident insurance
policy, or the medical assistance program,
or the health care partnership program or
qualified health plans.
Direct Access Law
• Only a Physical Therapist may accept a patient
under direct access

• The Physical Therapist then has the authority to

delegate portions of the patient care to Physical
Therapy Assistants, Students, and Athletic
Trainers as long as the physical therapist
supervises that care
o No specific type of supervision was stated by the
Ohio State Board
Opposition to Direct Access
• Two Main Groups
o Physician groups
 argue that Physical Therapists cannot diagnose

o Chiropractic organizations
 direct access puts patients at risk
 PT education is inadequate in relation to diagnosis
and pathology
APTA’s Response to Opposition
• Physical Therapists are adequately trained and
are qualified to recognize when a patient needs
• APTA’s Guide of Professional Conduct
advocates that Physical Therapists should even
assist patients in finding appropriate medical care
• Physical Therapists have a low incidence of
malpractice and complaints filed against them
APTA’s Response to Opposition
• Health Providers Service Organization (HPSO),
the leading liability carrier, does not consider a
PT a higher risk because they practice without
• There has been no increase in claims against
physical therapists in states with direct access
• No states prohibit a physical therapist from
performing a diagnosis
o A PT diagnosis is essential an order to guide the PT
in selecting the appropriate interventions
Pros and Cons to Direct Access
Pros Cons
• Results in timely and more • Increased liability and
effective manner responsibility
• Referrals cause delays in PT • Risk of PTs missing underlying
services which can increase health conditions
cost of healthcare
o Increase cost of healthcare
o Decrease functional outcomes
o Increase patient frustration
• Increased autonomy
• Increased accessibility and
individual choice for patients
Dutch Direct Access Study
• The Netherlands got direct access in 2006

• Why is this important for us?

o The majority of Dutch health insurance
companies reimburse physical therapy clinics
in direct access cases
Dutch Direct Access Study
• Purposes of the study:
o What percentage of patients make use of direct
access to physical therapy?
o Has the population of patients seen by physical
therapists changed after introduction of direct
o Are patients who use direct access different from
patients referred by a physician in regard to
demographic characteristics, features of their health
problem, and the duration and effects of their physical
therapy treatment?
Dutch Direct Access Study
• What percentage of patients make use of direct
access to physical therapy?
o 28.4 % of population going to physical therapy in a
private practice setting were direct access patients

• Has the population of patients seen by physical

therapists changed after introduction of direct
o Compared to 2005, there was no increase in the
amount of people that utilized physical therapy
Dutch Direct Access Study
• Are patients who use direct access different from patients referred by
a physician in regard to demographic characteristics, features of their
health problem, and the duration and effects of their physical therapy
o Yes! The most common reasons for a patient to utilize direct access are:
 Non-specific back pain
 Non-specific neck pain
 Patients that are more highly educated
o Other significant reasons for patients to utilize direct access are:
 Acute / Sub-acute pain (Pain lasting for less than 1 month)
 Younger individuals
 Patients with reoccurring complaints
 Patients that have received previous physical therapy

• Patients who receive physical therapy through direct access receive

fewer physical therapy treatments than patients who are referred
Who Pays for Direct Access?
• Some insurance companies will cover direct
access, however, the majority do not cover direct
access at this time in Northeast Ohio
o Before accepting a direct access patient it may be a
good thing to either have your facility check the
insurance or have the patient themselves check with
there insurance company
o If the insurance company does not cover direct
access physical therapy, you as a facility needs to
inform the patient.
o Options to give to the patient:
 Have them sign a form and pay out of pocket
 Have them see their physician to get a referral
 Give them the option to refuse therapy at that time
Who Pays for Direct Access?
• At this time, Medicare and Medicaid do
not cover patients who attend physical
therapy through direct access.
o There is a bill in both the House of
Representatives and Senate in regards to this.
To amend title XVIII of the Social Security Act
to authorize physical therapists to evaluate and
treat Medicare beneficiaries without a
requirement for a physician referral, and for
other purposes.
The Medicare Direct Access Bill:
What Does it Say? What Would it Do?
• Changes the wording in the law to state
what the physician does
o No longer states that the physician must make
a referral
• Includes Occupational Therapists and
Speech Language Pathologists
o Same changes in wording that are seen in
physical therapy section of bill
The Medicare Direct Access Bill:
What Does it Say? What Would it Do?
• Defines what a “Qualified Physical
Therapist” is
o Those graduating on or after January 1, 2005
 Received a Master’s or Doctoral degree by an
accredited PT program
 Has graduated from a PT program outside of the
US that was equivalent to the programs within the
US at that time
o Those graduating before January 1, 2005
 Qualified to render PT services under the
regulations at the time of graduation from a PT
The Medicare Direct Access Bill:
Latest Action
• House of Representatives
o Referred to the Committee on Energy and
Commerce, and also Committee on Ways and Means
on 3/31/09
 Amount of time is determined by the Speaker of the House

• Senate
o Read twice and referred to the Committee on Finance
on 4/30/09
Ohio’s Support for the Bill
• The House of Representatives has 2 co-
sponsors in the state of Ohio
o Congressman Steven LaTourette (OH-14)
 Geauga, Lake, and Ashtabula counties
o Congressman Michael Turner (OH-3)
 Montgomery, Clinton, Highland, and northern Warren

• The Senate has no co-sponsors at this

time in the state of Ohio
How Can We All Get Involved?
• Write, Phone, or Email one of your
o Senator Sherrod Brown
 Term ends 2012
o Senator George Voinovich
 Term ends 2010
o Congressman Dennis Kucinich
 Term ends 2010

• If member of APTA,
Cost-Effectiveness of
Direct Access
• The total paid claims per episode of PT:
o Physician referrals = $2,236 on average
o Direct access = $1,004 on average
 Physician referral episodes were 123% or 2.2
times higher than direct access episodes
• Physician referral episodes were 65%
longer in duration than direct access
Implementation of Direct Access
into Southwest General
and LifeWorks
• The following are the
steps taken by the
University of
Wisconsin Hospital
and Clinics Authority
o Wisconsin is a
provisional direct
access state like Ohio
Implementation of Direct Access
into Southwest General
and LifeWorks
• Initial Step: Staff Consensus
o Does everyone truly want to work with direct access
within the clinic?

• If yes, write a proposal to:

o Chair of the Department of Orthopedics and
o Hospital’s fiscal, legal, and risk management
o Hospital’s Medical Board
o Hospital Authority Board
o Some Physicians within the Hospital for backing
What Should be Included
in the Proposal?
• An overview of the Ohio Direct Access Law
o Include extra steps that maybe required for it to work
in a Hospital-Based System
• Name of other institutions that have implemented
• Examples how it would coincide with Southwest
General’s business plan
• Evidence of direct accesses cost effectiveness
• Proposed outcome measures for program
What Else May Be Required?
• Creation of an Oversight Committee
o Made up of department administrators,
physical therapists, and physicians
o Why?
 Ensure board representation of primary
stakeholders for program development
 Ensure ongoing program assessment and quick
resolution of problems if they arise
What Else May Be Required?
• An addition to the policies and procedures
to ensure physical therapists are
functioning within the scope of practice
• A physician on site (initially) to be
available for consultation and/or periodic
chart audits
• Further physical therapist qualifications
and application process
Therapist Qualifications
• APTA American Board of Physical Therapy Specialties
current certification in a relevant practice area
• Completion of APTA credentialed residency or
fellowship program in a relevant practice area
• An advanced academic degree with a clinical emphasis
o Does not include DPT
• Advanced clinical practice training
o Based on quality, emphasis, and extent of practice experience or
a certain number of CEUs
• Advanced or Expert Clinical Practice Level within the
Therapists Wanting to Practice with
Direct Access
• Must meet 1 of the 5 qualifications
previously stated
• Apply to Oversight Committee
o Cover letter
o Description of qualifications
o Resume
• Completion of Training Program
Direct Access Training Program
• Developed by:
o Physicians
o Physical Therapist

• Program Emphasis:
o Clinical “Red Flag” Recognition
o Plain Film Indication Guidelines
Direct Access Training Program
• Required Readings, Lectures, and
Discussion Sessions
• Patient Case Series Take-Home
o Discussed cases with physician
o Questions for take-home assignment on next
Take-Home Assignment Questions
When Training Program
Completed …
Passed Failed
• Able to practice • Not able to practice
through direct access through direct access
• Assigned a provider • Able to take the
number by the House training program again
and Medical Staff
Affairs Office so that
therapists could
directly refer patient to
Pilot Program: How Did it Start?
• Direct Access patient care slots placed in
therapists’ schedules
o If not filled within 24-48 hours, other patients were
• Education and Marketing
o Presentations were made to individuals who were
fielding patient calls
 Receptionists
 Nurses / Nurse Practitioners
 Physician Assistants
o Placing flyers in physician offices and public locations
within the area of service
Evaluation of Pilot Program

• Reviewing physicians also determined that physical

therapists made appropriate decisions of referring or
initiating treatments 100% of the time
o Determined by chart reviews
Problems That Could Arise
• Some therapists are not able to practice
through direct access due to the inability
to meet any of the requirements

Which Raises the Question …

Should recent graduates be able to treat
patients through direct access?
Any Questions?
• American Physical Therapy Association: Vision 2020. (2010). Retrieved from
85&ContentID=32061 on February 4, 2010.
• American Physical Therapy Association: Current Issues. (2010). Retrieved from
8&ContentID=36014 on February 4, 2010.
• American Physical Therapy Association: Medicare Direct Access. (2010). Retrieved
from website:
• Leemrijse, C., Swinkels, I. Veenhof, C. (2008). Direct access of physical therapy in
the Netherlands: Results from the first year in community-based physical therapy.
Physical Therapy. 88(8), 936-946.
• Mitchell, J. (1994). Cost-effectiveness of direct access to physical therapy. Physical
Therapy. 77(1), 10-18.
• Ohio Occupational Therapy, Physical Therapy, and Athletic Training Board: Laws
and Rules Regulating the Practice of Physical Therapy. (2009). Retrieved from
%3d&tabid=75.128th General Assembly of the State of Ohio: The Legislative
Process. (2010). Retrieved from website: on February 4, 2010.