Two years ago, physical therapist Chris Cooper treated a somewhat unusual patient. The 51-year-old man had been playing basketball and turned his ankle. Cooper had certainly seen sprained ankles before. But what made this case unique was that the patient had not been referred by a doctor. He made the appointment for physical therapy on his own.
Facing a high deductible, the patient wanted to avoid the cost of a physician visit, knowing full well the doctor would simply send him for physical therapy just like the last time he incurred a similar injury.
At the initial visit with Therapeutic Associates in Bend, Cooper ruled out more serious problems such as a broken ankle that would have required X-rays and a physician's care.
“We got him in and out, four visits and he was back to playing basketball,” Cooper said.
Few patients know that 46 states, including Oregon, allow for such direct access to physical therapists, without a physician referral. But physician groups and insurance plans have been lukewarm on the idea, arguing that therapists aren't qualified to fully evaluate and diagnose a patient.
Therapy groups are now trying to make the case that they too should be considered a primary access point for health care and direct access could help to lower health care costs.
As part of that effort, the American Physical Therapy Association is touting a new study published in the journal Health Services Research that quantified the cost savings when patients self-refer. Partially funded by the therapy group, the study looked at five years of insurance company data and found that self-referred patients had 14 percent fewer therapy visits and accounted for 13 percent less in health care costs than those referred by a physician. The savings were calculated without including the costs of the physician appointment for those patients who did get a referral.
Janet Freburger, a physical therapist at the University of North Carolina, Chapel Hill, and a co-author of the study, said the researchers could not say why self-referred patients had fewer visits and lower costs after factoring in differences in ages and severity of illness.
“That's the million-dollar question,” she said. “One reason could be that there were differences in severity that were uncontrolled for, so perhaps the people who choose to self-refer to physical therapy are a little bit healthier. Or it could be that the patients who are self-referred are treated differently.”
Allison Suran, a physical therapist who owns Healing Bridge Physical Therapy in Bend, said the difference may be due to patient motivation.
“Maybe these are people who are already more self-motivated, so they're the type of people who also own their physical therapy and are better at following through,” she said. “We rely heavily on what we teach patients and empower them to know what they need to do in terms of exercising, stretching and posture or movement patterns so that they don't need us any longer.”
Therapists say direct access can also get patients into therapy faster, improving the prognosis for their recovery. Suran said that delaying treatment can often turn an acute injury into a chronic pain issue. The longer a musculoskeletal problem is left to fester, the more sensitized the nerves become to pain, until even the slightest awkward motion can trigger a recurrence.
“The Catch-22 is that a certain percentage of people will get better within four to six weeks no matter what. I think that people are often waiting because they don't want to go through the expense,” Suran said. “The sooner we see them, the more likely it is to be more of a mechanical joint or muscle injury and less likely it is to involve the much more complicated aspect of the nervous system.”
While the patients in the study all had insurance, many self-referred patients pay cash. And Cooper said the therapists may approach those cases somewhat differently.
“There seems to be a higher level of accountability to make the value of their dollar higher and to be mindful of the expense of their care when it's not a third-party payer,” Cooper said. Many therapists offer cash patients a discount on rates as well.
Still, therapists have had trouble getting patients to realize they don't necessarily need to go to a doctor first, and even more trouble getting insurance companies to pay for the visits. Only a fraction of health plans allow for direct access even when state laws permit it, and some plans still require the patient to get prior authorization before starting therapy.
In 2005, Congress reviewed whether Medicare should change its requirement that physicians order and oversee physical therapy. But lawmakers opted against any change after an advisory committee recommended against the move, concluding it would raise costs and jeopardize patient care.
Skipping a vital step?
Physician groups have argued against direct access — even with public advertising campaigns — suggesting that therapists aren't qualified to evaluate patients for medical problems and that many conditions can be misinterpreted as musculoskeletal injuries.
Therapists counter that they often have better understanding of musculoskeletal problems than primary care physicians. A 2005 study tested therapists' knowledge of musculoskeletal issues, finding it ranked higher than that of medical school students, physician interns, residents and most specialists other than orthopedists.
“That's our bread and butter, so that's where we've gained skill,” Cooper said. “I'm going to be the first one to refer them on if they're not appropriate to be standing in my office.”
Dr. Cara Walther, an orthopedic surgeon with Desert Orthopedics, said she doesn't see any issue with direct access for things like knee or shoulder injuries.
“Especially for sports medicine overuse injuries, I typically send patients to PT first prior to considering surgery anyway,” she said. “And I find most PTs in Bend are well educated and will refer a patient to me when they recognize a patient needs surgery.”
But she cautioned that spine issues might fall into a different class, and that if patients don't improve with physical therapy, they should be referred to an orthopedist.
Health plans, meanwhile, must balance the cost savings physical therapy can offer over surgical procedures, while trying to keep therapy use under control.
“It has shown to provide positive results for patient health and often can serve as a viable alternative to far more costly surgical procedures,” said Scott Burton, a spokesperson for Regence Blue Cross/Blue Shield. “We do require physical therapy to be prescribed by an eligible provider and rendered by an eligible provider to ensure the treatment is medically necessary, well coordinated with existing care, and in the best interest of our members' health.”
Freburger said their study suggested the risk of overlooked medical conditions when patients self-refer might be overstated.
“There didn't seem to be any discontinuity in care,” she said. “Patients were still very engaged in the health care system, receiving care from physicians and using health care a lot.”
With the increased focus on controlling health care costs at all levels, therapists are trying to position themselves as more of a solution than an added expense. If patients can manage chronic back pain with physical therapy rather than getting MRIs that lead to back surgery, therapists could make an even stronger case for direct access.
“Some of the models that have been discussed include ways of keeping (patients) away from specialists, orthopedists and neurologists, and trying to set them up with primary care teams that would include a physical therapist,” Freburger said. “I think insurance companies potentially could be moving toward that model.”