A new study suggesting that the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases could have significant implications for the U.S. health care system, according to the American Physical Therapy Association (APTA).
The study reviewed 62,707 episodes of physical therapy using non-Medicare claims data from a Midwest insurer over a 5-year period. Patients who visited a physical therapist directly for outpatient care (27%) had fewer visits and lower overall costs on average than those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.
The study is noteworthy because services delivered by physical therapists account for a significant portion of outpatient care costs in the United States, according to the study, and some health insurance plans require a physician referral for reimbursement of these services. In addition, although 46 states and the District of Columbia now allow some form of direct access to physical therapists, some of them nonetheless impose restrictions if patients have not been referred by a physician.
Physical therapists have long known that direct access to our services is safe and effective, R. Scott Ward, PT, PhD, APTA president stated in a press release. The elimination of referral requirements and other restrictions has been a priority of APTA for decades. This study provides further evidence that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all. We encourage researchers and insurers to continue to further investigate this important issue that could have a profound impact on patient care.
Led by Jane Pendergast, PhD, professor of biostatistics and director of the Center for Public Health Studies at the University of Iowa, the study retrospectively analyzed 5 years (2003-2007) of private health insurance claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and South Dakota. Researchers found that self-referred patients had fewer physical therapy visits (86% of physician-referred) and lower allowable amounts ($0.87 for every $1.00 of physician-referred) during the episode of care, after adjusting for age, gender, diagnosis, illness severity, and calendar year. In addition, overall related health care use or care related to the problem for which physical therapy was received, but not physical therapy treatment was lower in the self-referred group after adjustment. Examples of this type of care might include physician services or diagnostic testing.
According to Rick Gawenda, PT, president of APTAs Section on Health Policy and Administration, the study should cause insurers and policymakers to rethink the physician gatekeeper concept when it comes to physical therapist services.
Evidence shows that, in the case of physical therapy, the physician gatekeeper model is doing exactly the opposite of what it was originally designed to do; it does not reduce ineffective and duplicate care nor reduce health care costs, Gawenda stated in a press release. Its time to end the physician referral requirement in every state, and it's time for all payers to embrace direct access to physical therapists."
In summary, our findings do not support the assertion that self-referral leads to overuse of care or discontinuity in care, based on a very large population of individuals in a common private health insurance plan with no requirement for PT [physical therapy] referral or prohibition on patient self-referral, the authors wrote. We consistently found lower use in the self-referral group, after adjusting for key demographic variables, diagnosis group, and case mix. We also found that individuals in both groups were similarly engaged with the medical care system during their course of care and afterwards.