Direct Access at the State Level

What does direct access mean and why is it needed?

Direct access means the removal of the physician referral mandated by state law to access physical therapists' services for evaluation and treatment. Every state, the District of Columbia, and the US Virgin Islands allow for evaluation and some form of treatment without physician referral. However, many of those states continue to impose arbitrary restrictions on direct access, or only allow for treatment without referral under very limited circumstances. Be sure to check this summary of the various state direct access laws (.pdf).

These restrictions cause delays in the provision of physical therapists' services to individuals who would benefit from treatment by a physical therapist. Delays in care result in higher costs, decreased functional outcomes, and frustration to patients seeking physical therapy treatment. Eliminating arbitrary barriers results in timely, more effective care.

Are physical therapists qualified to deliver services independent of referral?

Absolutely. Physical therapists are educated at the post-baccalaureate level and receive extensive education and clinical training in the examination, evaluation, diagnosis, prognosis, and intervention of patient/clients with functional limitations, impairments and disabilities. All accredited entry-level physical therapist education programs currently culminate in a Doctor of Physical Therapy (DPT) degree. Physical therapists are qualified to recognize when a patient presents with signs and symptoms inconsistent or outside the scope and expertise of the physical therapist and when the patient should be referred to a physician. 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.

Professional liability insurers and the Federation of State Boards of Physical Therapy affirm that direct access does not jeopardize the health, safety, or welfare of the patient/clients. Health Providers Service Organization (HPSO), the leading carrier of professional liability insurance for physical therapists in the US, states, "Direct access is not a risk factor that we specifically screen for in the underwriting of our program nor do we charge a premium differential for physical therapists in direct access states. We currently have no specific underwriting concerns with respect to direct access for physical therapists."

Is there a concern that if a physical therapist initiates treatment without a referral that they will miss a patient's underlying medical conditions?

The risk of any health care provider missing underlying conditions is always present. However, physical therapists have an extremely low rate of malpractice and a low incidence of claims or complaints filed against them. The rate of malpractice insurance has been shown to be no higher in states where physical therapists practice without a referral versus states where physical therapists practice with referral. Physical therapists are educated and trained to recognize signs and symptoms that are inconsistent or outside the scope of physical therapists' practice and are then able to refer patients to other providers who can provide appropriate care for the patient's condition.

There is evidence from the Federation of State Boards of Physical Therapy and a leading liability carrier, the Health Providers Service Organization (HPSO), that there is no increased risk to patients in states that do not mandate referral before the provision of physical therapists' services. HPSO does not rate a physical therapist as a higher risk because they practice without referral. There has been no increase in claims against physical therapists in states without the referral mandate. Most importantly, physical therapists consider their role in protecting the public's health, safety, and welfare as extremely important.

Physician groups argue that physical therapists cannot diagnose. How can you respond to such a charge?

Diagnosis is a fundamental part of physical therapists' practice. Physical therapists practice according to the disablement model. This model of practice is recognized by the World Health Organization, the National Center for Medical Rehabilitation Research, and the Institute of Medicine. Physical therapists diagnose with respect to physical therapist practice as authorized by state law. In diagnosing a patient's condition in accord with such law, physical therapists are not in conflict with the diagnosis provisions of state laws governing the practice of medicine. No states prohibit a physical therapist from performing a diagnosis. Diagnosis by a physical therapist is essential for the physical therapist to be able to provide the proper interventions. Diagnosis is a label for a cluster of signs and symptoms gathered by examination and evaluation that is essential to guide the selection of appropriate interventions in physical therapy practice.

Why should policymakers be concerned with this issue?

Allowing individuals to make decisions regarding their health care is good policy. 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 states that allow treatment without referral has proven that it is safe. Yet consumers in many states continue to face arbitrary barriers to physical therapist services.

Direct access is about individual choice in health care decisions through the elimination of unnecessary and burdensome regulation.