Opinion and Health Care Costs and Physical therapy and Health Care & Life Sciences

PEASE: Archaic physical therapy laws drive up health costs

July 20, 2009
As a physical therapist and practice owner, I regularly field questions about musculoskeletal injuries. On any given day at the park or in the coffee shop I am asked, “What can I do for this nagging back pain?” or “How can I best strengthen my shoulder after a tennis injury?”

These inquiries lead to the bittersweet question from the suffering consumer: “Can you help me?” I would like to say simply, “Of course I can help, make an appointment.” But I can’t.

If you want to see a physical therapist in Indiana, you must first see a physician for a consultation and referral. It’s the law.

Indiana is one of only six states where patients are denied direct access to physical therapy treatment, and one of only two states where evaluation without referral is prohibited. The historical reasoning for the referral requirement originated with the technical nature of training for physical therapists up to the 1970s, when care was always provided in connection with a physician’s care.

However, as education of physical therapists has moved to a professional doctoral degree in the past decade, and despite years of attempting to change the practice act through the Legislature, Indiana has failed to recognize the value of physical therapists as first contact for consumers who need musculoskeletal care. In a state that claims to value active lifestyles, fitness, hard work and unrestrained trade, removing the barrier to direct access to physical therapy makes sense.

Let me be clear: Physical therapists value relationships with physicians. Decisions made in the best interest of the patient happen when we work collaboratively. Clearly there are times when the system, as it exists, serves the patient. Examples include cases involving trauma, acute illness, disease or those requiring a surgical consult. That’s when a more extensive work-up by a physician prior to providing physical therapy is critical.

Yet in the majority of other cases, screening and examination by a physical therapist is the most appropriate, timely and cost-effective way to manage patients with uncomplicated musculoskeletal pain.

Significant portions of a physical therapist’s doctoral education focus on interpreting clinical signs and symptoms of pathology. Physical therapists in Indiana, as they are in other states, are well qualified to discriminate between patients with signs and symptoms stemming from true musculoskeletal problems versus those with pain resulting from undiagnosed illness or disease.

Are there potential risks to patients from physical therapists in a direct access environment? Not according to the military, where physical therapists are the professional of choice to screen and provide care for musculoskeletal complaints. And not according to malpractice insurance company rates, which do not differentiate between physical therapists working in states with or without direct access to physical therapy services.

In March, federal legislation was introduced to allow patients with Medicare direct access to physical therapists services. The Medicare Patient Access to Physical Therapists Act is intended to reduce barriers to recovery including the need for a referral to physical therapy in all states with direct access.

Again, because of the restrictions in Indiana’s practice act, Hoosier patients would be excluded from this unrestricted access to physical therapy.

Aside from health benefits, direct access to physical therapy would save money for patients and the economy in general. A study at Virginia Mason Medical Center in Seattle found the cost of care for a patient with low back pain was reduced from an average of $2,290 to $807 by streamlining access to physical therapy and eliminating MRIs for uncomplicated patients.

While we continue to read about the high cost of health care, the reality is everyone will benefit when the cost in health care dollars and time needed to provide high-quality care are minimized. Some injuries may require extensive work-ups by physicians, while others require the peace of mind provided by lab work or imaging prior to beginning rehabilitation.

Removing the time and cost barriers inherent in a referral-only system and allowing patients direct access to physical therapy is one of the many ways Indiana can help Hoosiers lower the cost of their health care and improve their overall well being.•

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Pease is a partner in Body One Physical Therapy and a former educator at the University of Indianapolis and Indiana University. Views expressed here are the writer’s.

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