Direct Access and the McKenzie Practitioner

Direct access for physical therapy services has been an important part of the Vision Statement of the American Physical Therapy Association (APTA). It has been a battle fought and won on the state level resulting in 38 states with some form of direct access. Direct access is not a new topic for our profession. The APTA has been fighting for the rights of patients to see physical therapists without having to obtain a physician's referral for over 20 years. The battle continues at the state level but has now gone to the federal level, direct access under Medicare. This is a very important goal for our profession and a big step in lowering the barriers for patients to receive our care. This direct access bill would allow Medicare payment for the services physical therapists provide without a physician's referral.

I'd like to ask you two questions:

1. Why is this important to us as McKenzie practitioners?

2. Why should you be part of the APTA and part of this direct access fight?

I hope to answer these questions and at the end of this article sign you up as a member of The McKenzie Institute®, the APTA and a believer in the need and right to direct access for our patients.

I have been practicing direct access in my state for years but very few insurance companies will pay for direct access. Although the law permits me to see my patients without a referral from a physician, the insurance world is still requesting a script or referral from a doctor. This has infuriated me many times because these patients recognize me as the professional of musculoskeletal injuries and seek my help, but have to jump through insurance hoops to get my services reimbursed.

We all have seen the scripts and referrals they receive from their physicians that are no help at all to us; s/p MVA, back pain, lumbago, sciatica or slipped disc. That visit with the physician which took on average seven minutes and normally happens with the patient fully dressed, without movement assessment and palpation, and is of no help to us at all.

Another problem is that patients normally have to wait to get an appointment to get the referral to go to physical therapy leading to an unnecessary delay in care. A study by Dr. Jean Mitchell and Dr. Greg deLissovoy of Georgetown University and Johns Hopkins University found that reimbursement under direct access will realize cost savings of approximately $1,200 per patient episode of care. So not only does it provide quicker entrance to our services, it also saves money.

Physical therapists in the armed forces have been practicing direct access for years without any problems. But is it safe? The answer is yes. We have a long history of direct access, now in 38 states, and the evidence from the federation of State Boards of Physical Therapy and HPSO, a leading liability carrier, shows no increased risk to patients in states who have direct access. HPSO does not rate a physical therapist as a higher risk because they practice without a referral. If it wasn't safe do you think the armed forces would allow direct access?

The fear from physicians who say we are not educated to be the entry point of musculoskeletal care and will overlook major pathology is unfounded. Think about this, when would things be missed; in the seven-minute fully dressed assessment by the physician or the physical therapist who has close interaction with these patients for at least a half hour 2-3 times a week. I am only talking about musculoskeletal pathologies, and of course we should contact the physician immediately if we suspect pathology that is nonmusculoskeletal in nature, pathology that is not appropriate for physical therapy or pathology that does not improve within a reasonable amount of time. But that is what we already do with a referral. A study published in April 2002 in the Journal of Bone and Joint Surgery (JBJS) by Kevin Freedman, MD, MSCE and Joseph Bernstein, MD, MS showed clearly that there is inadequate musculoskeletal training in medical schools.

Our profession is ready for direct access. Maybe not all physical therapists are but they can choose to remain practicing the way they have been for years with the referral from a physician. Remember, direct access is not a must! But it should be an option.

Still I can hear you thinking: What has that got to do with me, the McKenzie practitioner?

I can not think of a better trained practitioner to be that entry point for musculoskeletal injuries. Certified McKenzie practitioners-that is, credentialed and diplomats-have received, on top of their regular physical therapy education, unique advanced assessment and treatment skills.

The McKenzie Method® has provided us with a structured, evidence-based, logical and safe method to assess patients with musculoskeletal injuries. I think we are very well trained to look for the pathology and the red and yellow flags. We know when the assessment doesn't make sense and the red flags come up and when we need to refer a patient to their physician for additional medical care or diagnostic testing. How many times do you still look at the referral when a patient comes in? Or do you grab your McKenzie assessment form and start from scratch and at the end come to a conclusion and treatment plan?

We have been assessing patients without the help of physicians because their little note stating "back pain, please ultrasound, hot pack, massage" hasn't helped us in the last decade! The McKenzie Method is proven to be a safe and valid, well-researched method of assessing and treating patients. We have passed the test as credentialed practitioners or even more extensive and grueling training in the McKenzie Method for the diploma holders. I think we are the physical therapists who should feel most comfortable with direct access because of our advanced training and skills. We should be leading this battle for direct access.

Unfortunately many McKenzie practitioners are not members of the APTA. If we consider ourselves professional, we should at least be a member of our professional organization. I would challenge everybody to become a member of The McKenzie Institute® because they give us the education, the method, and the ongoing support to provide the best care for our patients and to become a member of the APTA to make sure our patients can come to us without unnecessary hurdles. I think we owe such a modest investment to our patients.

References
1. Mitchell JM, de Lissovoy G. A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10-18.

2. Health Providers Service Organization, in a March 22, 2001, letter to the American Physical Therapy Association, on file at APTA.

3. Massey, BF Jr. 2002 Presidential Address: What's all the fuss about direct access? Phys Ther. 2002;82:1120-1123.

4. Freedman, KB, Bernstein, J. Educational deficiencies in Musculoskeletal Medicine. JBJS (American) 2002;84: 604-608.

Reprinted with permission from The McKenzie Institute® USA
Spineline, 2003, Vol. 7, No. 4
Direct Access and the McKenzie practitioner.pdf
http://www.mckenziemdt.org/spineline.cfm