Legislative change to permit direct access to physical therapy services: a study of process and content issues.

The purpose of this study was t o examine process and content issues related to legislative change to permit direct access to physical threapy services. Data sources were survey questionnaires sent to the presidents of the 52 chapters of the Ametican physical threapy Association (APTA), APTA publications, state statutes, and personal contacts. Results were based on the experiences of 35 chapters, 1 7 in direct-access states and -18 in non-direct-access states. the majority of direct-access states obtained their status in a single legislative campaign; the majority of non-direct-access jurisdictions attempting legislative change have been unsuccessfulfor 2 or more years. Over 80% of the chapters reported using legislative lobbyists. Opposing forces varied from state to state and included hospital and medical associations, physicians, chiropractors, and physical therapists thefollowing limitations on practice in a direct-access mode are found in the various practice acts., diagnosis requirements, eventual referral requirements, physical therapist qualifications, patient consent requirements, and practice setting restrictions. [Taylor TK Domboldt E Legislative change to permit direct access to physical threapy services. a study of process and content issues. Phys ther. 1991,- 71382-389.1 Key Words: Health care,. Law and liability, general; Legislation; physical threapy profession; profesional issues.

"Direct access" to physical therapy services refers to evaluation and treatment of patients by physical therapists without referral from a physician or other health care practitioner. As of September 1989, 24 states have permitted direct access to physical therapy services.1

Because the practice of physical therapy is governed by the states, changes in legislation to permit direct access must occur at the state level. Because legislative processes and practice acts governing the practice of physical therapy are unique to each state, laws permitting direct access have taken many forms. Stipulations in many of the practice acts limit the conditions under which physical therapists may practice directly. Anderson expressed concern that few states have "pure" direct access, which he defined as "the ability to treat clients needing physical therapy without forced outside intervention."2 For the purpose of this article, "direct access" will refer to any situation, no matter how limited, in which patients may obtain physical therapy services, including both evaluation and treatment, without referral. Despite the fact that almost half the states have direct access, few studies have documented the impact of, opinions about, or legislative process related to direct access. Four studies have examined various aspects of physical therapy practice in a direct-access mode. james and Stuart,3 in a 1975 US Army study, evaluated the feasibility of using the physical therapist as the initial "screener" for patients with low back pain. Data collected when physical therapists were the initial screeners were compared with baseline data gathered when physicians were the initial contact for the patient. Patient waiting times, treatment times, and total care times were measured. Quality of care with physical therapists as the initial contact was assessed through patient interviews, physician interviews, and record reviews. Results revealed that patients with low back pain received more expeditious treatment with the physical therapist as the initial contact than with the physician as the initial contact. In addition, physical therapists reported increased job satisfaction as initial screeners. The quality of care rendered by the physical therapists was reported to be satisfactory to the patient, the physician, and the physical therapist.3

Overman et al4 studied the outcomes of first-contact physical therapy management of patients with low back pain in a hospital-based ambulatory care physical therapy clinic. They found that physical-therapist-managed patients expressed greater satisfaction than physician-managed patients with several aspects of their care. In addition, functional improvement for highly dysfunctional patients was significantly greater for the physicaltherapist-managed patients than for the physician-managed patients.4

Durchholz and Domholdt surveyed physical therapists in three direct-access states to determine changes in practice after obtaining direct access compared with before obtaining direct access (AG Durchholz, E Domholdt; unpublished research). They reported that 45% of the surveyed therapists had seen patients through direct access and that those therapists saw only 10% of their patients through direct access. Patient populations reported to be seen most frequently through direct access were orthopedic, neurologic, chronic pain, preventive care, and pediatric patients. Dennis5 studied the incidence of direct-access practice among private practitioners in Victoria, Australia. She found that approximately one third of all patients were referred without screening from medical practitioners. The estimated percentage of initialcontact patients for the individual therapists, however, ranged from 0% to 90%.5

Reports of three studies related to direct-access opinions were presented at the Sixty-Fifth Annual Conference of the American Physical Therapy Association (APTA). Durant et al6 investigated outpatient views on direct access to physical therapy in Indiana and found that 83% of the respondents were in favor of direct access and that 72% would utilize direct access if they were to experience the same symptoms again. Hamouz et a)7 assessed Indiana physical therapists' attitudes toward direct access and found that 67% of the respondents supported direct access to physical therapy services. LeMasters and Domholdt surveyed 200 physical therapy students who were in their last year of study at eight programs located across the United States. They found that 85% of the students believed achieving direct access to be vital to the development of the profession, 20% planned to concentrate their immediate job searches in direct-access states, and 53% included practice in states with direct access in their longterm plans.

Little formal documentation about the process of obtaining direct access and the content of direct-access legislation is available. The APTA Department of Practice has published an informational booklet about direct access. The booklet provides an overview about direct access and related issues, citing a few state chapters' experiences. The APTA Department of Government Affairs has sponsored Direct Access Information Shares at both th 1989 and 1990 Annual Conferences. There has been no systematic attempt however, to document chapters' experiences in seeking direct access. The purpose of this study, therefore, was to examine legislative change to permit direct access to physical therapy services. Consideration was given to both the process of seeking direct access and the content of direct-acces legislation. Method Four sources were used to collect information about the process of legislative change and the content of direct-access legislation: written surveys, publications of the APTA and its chapters, state statutes governing the practice of physical therapy, and personal contacts. A questionnaire and a request for relevant documents were sent to each APTA chapter president (N = 52; 50 states, District of Columbia, and Puerto Rico) on February 14, 1989. A selfaddressed, stamped envelope was included for the return of the questionnaire and requested documents. Each chapter president was instructed to complete the survey or to route the questionnaire and request for information to an appropriate chapter member for completion. Response was requested by March 15, 1989. On March 21, 1989, follow-up letters were sent to the chapter presidents from whom no response was received.

Two separate survey questionnaires were used, one for chapters in nondirect-access jurisdictions (n=28) and one for chapters in states with direct access (n=24). Both questionnaires consisted of predominantly open-ended questions because of the anticipated variability of experiences among the chapters. The questions were generated based on our observation that both the process of legislative change and the content of ultimate direct-access laws had been problematic for the Indiana chapter and for other chapters. Information requested of both non-direct-access and direct-access jurisdictions included evaluation-without-referral status, number of years of legislative efforts for direct access, use and function of lobbyists, sources of opposition to direct access and methods of demonstration of opposition, sources of support for direct access, and methods used to increase awareness of and support for direct access. Questionnaires for chapters in direct-access states also requested information regarding the date direct access became law, significant differences between the originally proposed bill and the bill that passed, and source of and reasons for the differences. Both questionnaires provided space for additional comments. Included with each questionnaire was a request for additional documents pertaining to direct access including physical therapy practice act, legislative documents, promotional materials, minutes of meetings regarding direct access, and any other pertinent documents or information. Additional information was gathered from chapter publications such as newsletters and promotional and informational mailings. State statutes governing the practice of physical therapy were obtained from the respondent or from the local law school library. Personal communications with chapter leaders were not sought systematically but were used, when available, to add depth. Data Reduction and Analysis The first stage of data reduction and analysis involved the categorization of responses to the survey questions and artifact data (chapter publications and state statutes). Categories for coding of relevant data from the questionnaires and artifacts were determined by the primary author (TKT) after review of all available information. When questions arose about category development, these questions were discussed with the secondary author (ED) until consensus was reached. For example, the number of legislative attempts at direct access were initially categorized by years. Based on survey responses, another category, "indirect opportunity," was necessary. Content of statutes governing the practice of physical therapy was categorized and coded by identification of patterns of restrictions on direct-access practice. Results Response Rate

Twenty-eight chapters 16 in nondirect-access jurisdictions, 12 in direct-access states) returned the survey questionnaires. Twenty of these chapters also supplied various state publications and materials related to direct access. Six of the chapters in direct-access states included their state statutes with the completed questionnaire. The state statutes of the remaining 6 direct-access states were obtained from the local law school library. Personal communication via telephone yielded one response from the legislative committee chairperson of a non-direct-access jurisdiction's chapter that had not returned the survey questionnaire. Personal communications at the APTA-sponsored Direct-access Information Shares yielded information from an additional 6 chapters (1 in a non-direct-access jurisdiction, 5 in direct-access states). Thus, overall, 35 (67%) of the 52 chapters were represented in this study. Of the 24 chapters in direct-access states, 17 (70%) were represented. Of the 28 chapters in non-direct-access jurisdictions, 18 64%) were represented. Because of the varied sources of information, the number of chapters represented in each subsection of the "Results" section also varied; the number of chapters represented is indicated in each subsection. Process

Length of time with direct access n=17). The chronological order in which states obtained direct access and the number of years of direct-access status are presented in Table 1. Seventy-five percent of all the states with direct access have had such status 5 years or less. Table 1. Chronological Order of States Obtaining Direct Access

Year Years

Direct- with

Access Direct - Legislation Access State Enacted Status Nebraska 1957 33 California 1968 22 Maryland 1979 11 Arizona 1983 7 Massachusetts 1984 6 West Virginia 1984 6 Nevada 1985 5 North Carolina 1985 5 Utah 1985 5 Alaska

1986 4 South Dakota 1986 4 Idaho 1987 3 Kentucky 1987 3 Montana 1987

3 Colorado 1988 2 lowa 1988 2 Illinois 1988 2 Minnesota 1988 2 New

Hampshire 1988 2 Vermont 1988 2 Washington 1988 2 New Mexico 1989 1 North Dakota 1989 1 Wisconsin 1989 1 7 5.58 SD 7.32 Range 1-33 Patterns of legislative attempts (n=32). Five of the 18 chapters in non-direct-access jurisdictions (ie, Hawaii, Mississippi, NewJersey, Pennsylvania, and Virginia) have made no outright attempts to obtain direct access. These 5 chapters, however, reported being in various stages of planning for introduction of direct-access legislation. Statutes in Hawaii, Mississippi, New jersey, and Pennsylvania permit physical therapy evaluation, but not treatment, without referral. Three direct-access states obtained direct-access status without overt legislative attempts via indirect opportunities for legislative change to permit direct access. In Nebraska, for example, the original practice act was drafted with no stipulation for referral. "Sunset legislation" review was used in Massachusetts as an opportunity to obtain direct access. Sunset legislation is legislation that includes a date on which the legislation expires. For the legislation to remain in effect, it must be reviewed and the date extended for another period of time.9 During the review of sunset legislation pertaining to the practice of physical therapy in that state, the Massachusetts chapter of the APTA successfully pursued a change that allowed direct access. The Vermont chapter reported that chiropractors proposed legislation to amend the physical therapy practice act to include chiropractors as referring practitioners. The Vermont chapter used this opportunity to compromise with the chiropractors to gain direct access. The revised chiropractor bill was enacted, and Vermont obtained direct access, with little financial burden to the state chapter. The remaining chapters have made formal legislative attempts for changes to permit direct access. Table 2 shows that the majority of chapters in states with direct access obtained this status with a single successful legislative attempt. A majority of chapters in jurisdictions without direct access have made unsuccessful legislative attempts for 2 years or greater. Geographic distribution. The Figure illustrates that there does not appear to be a geographical trend related to the order of obtaining direct access. it should be noted, however, that North Carolina is the only southern state with direct access.

Evaluation-without-referral status (n=22). Ten of the 18 non-direct-access jurisdictions represented in this study permit physical therapy evaluation without referral. The average number of years with such status among these states is 5.4 years. Of 12 direct-access states, only 4 permitted evaluation without referral prior to obtaining direct access. The number of years of physical therapy evaluation without referral prior to the passage of direct access ranged from 3 to 17 years, with an average of 10.8 years (Tab. 3). Use of legislative lobbyists n=24). The majority of state chapters represented in this study used legislative lobbyists in their efforts. Ten (83%) of 12 chapters in non-direct-access jurisdictions that have sponsored legislative campaigns for direct access reported using a lobbyist. Wyoming's chapter, which has mounted one unsuccessful direct-access attempt, reported that a lobbyist is not needed because of the chapter's ability to mount mass grass-roots efforts. Ten (83%) of 12 chapters in direct-access states reported using a lobbyist in their efforts. In Nebraska and Vermont, the special circumstances surrounding the acquisition of direct access did not require the services of legislative lobbyists. Six chapters in direct-access states emphasized the important role the legislative lobbyist played in their success. Methods to increase support for direct access n=29). State chapters reported using numerous methods to increase awareness of, and support for, direct access, including letterwriting campaigns, distribution of printed materials and brochures, political campaign donations, one-on-one negotiation with opposing parties, and one-on-one contact of legislators by physical therapists and lobbyists. Legislator contact during physical-therapy-sponsored events has included fitness screenings of state legislators at the state capitol and legislative luncheons. In addition, chapters reported using physical therapist and patient testimonials during legislative hearings. Two chapters communicated the importance of having well-planned and organized testimonials during legislative hearings. Sources of support for direct access n=29). The degree of support for direct access varied from state to state. Individuals in favor of increased autonomy for physical therapy have included physical therapists, dentists, family practitioners, and patients. One state chapter reported the support of state legislators with prior exposure to physical therapy services. Table 3. Evaluation-witboutReferral Status of Non-Direct-Access and Direct-Access Jurisdictions

No. of Years Non-Direct- of Evaluation Access Without Jurisdiction Referral Georgia 7 Hawaii 3 Kansas 7 Louisiana 6 Michigan 2 Mississippi 10 Pennsylvania 14 Tennessee 2 Texas 9 Wyoming 6 District of Columbia 5 5?

6.45 SD 3.61 Range 2-14

No. of Years of

Evaluation Without Direct-Access Referral Prior to State Direct-Access Status Colorado 3 North Dakota 10 South Dakota 17 Vermont 13 k 10.75 SD 5.91 Range 3-17 Five chapters reported that patients openly supported direct access and were willing to make testimonials regarding their positive experiences with physical therapy. Groups and organizations supporting direct access have included state physical therapy associations, home health associations, insurance companies, and extended care facilities. Interestingly, sources of support in some states were sources of opposition in other states. Sources of opposition to direct access n=29). Hospital associations, insurance companies, medical associations, physicians, and chiropractors were identified as sources of opposition to direct access to physical therapy services. Five chapters reported that physical therapists openly voiced opposition to direct access during legislative hearings. As the sources of opposition varied, so did the reasons for opposition. Some physicians and medical associations suggested that the education of physical therapists is not sufficient to permit physical therapists to be the initial contacts for entry into the health care system. In addition, some physicians suggested that, because physical therapists are trained to assess musculoskeletal dysfunction and not to make medical diagnoses, serious medical problems may be missed if physicians are not the initial contact for entry into the health care system. In one state, a physician, who received a degree in physical therapy in the 1950s, testified that physical therapists are not qualified to be first-contact health care providers because of insufficient education. Hospital associations expressed the concern that, with increased autonomy, physical therapists would pursue private practice, resulting in a shortage of physical therapists in hospital departments. Chapters reported that opposition was demonstrated via verbal testimony during legislative hearings, legislative lobbying, and financial donations to key political campaigns. Chapters reported defusing potential opposition through education, negotiation, and compromise. Content

Because the practice of physical therapy is governed at the state level, practice acts are unique to each state. Variations in practice acts exist in both non-direct-access and direct-access jurisdictions. Many of the variations found in direct-access legislation do not permit the practice of physical therapy in a "pure" direct-access mode.2 Chapters reported that, in some instances, such stipulations were the result of compromising with opposing parties. Others indicated that such stipulations were included in an attempt to defuse anticipated opposition. Stipulations found in direct-access legislation can be placed into five general categories: (1) diagnosis, (2) referral requirements and relationships, (3) physical therapist qualifications, (4) patient consent, and (5) type of practice setting and patient population. The first category involves stipulations related to diagnosis. Laws in California, Illinois, and New Mexico require patients seeking physical therapy without a referral to have a current or initial diagnosis.10 In Wisconsin, a written referral is not required when a physical therapist provides services to an individual for a previously diagnosed medical condition. The diagnosing practitioner, however, must be informed that physical therapy services are being initiated.11

The second category of stipulations relates to referral requirements and relationships. Laws in Minnesota and New Hampshire l2 stipulate that, when treating a patient without a referral for a period greater than 30 days, a consultation with, or referral to, a physician is required. Vermont law requires that physical therapy patienttreatment plans be developed in consultation with, and periodically reviewed by, a physician.13

In New Hampshire 12 Colorado,14 and North Dakota,15 the law stipulates that failure to refer a patient to another health care practitioner when a patient's problem is outside the scope of physical therapy is grounds for the suspension of a license to practice physical therapy. Maryland law stipulates that, when patients are seen based on referral, practice must be consistent with the referral made.16 The third general category of stipulations placed on the practice of physical therapy in a direct-access mode involves physical therapist qualifications. In Minnesota, state law requires physical therapists to have worked as licensed physical therapists for 1 year to be permitted to practice physical therapy in a direct-access mode.10 In New Hampshire, to be eligible to practice physical therapy in a direct-access mode, a therapist must have 2 years of experience as a licensed physical therapist, be engaged in continuing education as set by the licensing board, submit references from two physicians with whom the therapist has a working relationship, and interview with the physical therapy advisory committee. if the requirements are met, the physical therapist is designated as a "physical therapist 11" and is permitted to practice physical therapy in a direct-access mode. A physical therapist 11 is distinguished from a "physical therapist l," who is permitted to practice physical therapy only under the referral of a person licensed to practice medicine, dentistry, podiatry, or chiropractic.12 As of February 1, 1991, 52 therapists (out o a total of 648 therapists) in New Hampshire have obtained licensure as physical therapist IIs Jean Bond, New Hampshire State Licensing Board; personal communication).

The fourth general category of stipulations relates to patient consent. Direct-access legislation that was enacted by the legislature in Rhode island, but vetoed by the governor, included the stipulation that the physical therapist explain the scope and limitations of the practice of physical therapy to a patient seeking physical therapy without a referral. The patient then must sign a consent form prior to evaluation and treatment by the physical therapist." The final category of stipulations placed on physical therapy practice in a direct-access mode relates to type of practice setting and patient population. Wisconsin's direct-access law stipulates that

referral is not required when a physical

therapist provides services: in

schools to children with exceptional

educational needs ... ; as pan of a

home health agency; to a patient in a

nursing home pursuant to the patient's

plan of care; related to athletic activities,

conditioning or injury prevention;

to an individual for a previously diag - nosed medical condition after informing

the diagnosing practitioner. (pi) Discussion and Conclusions Because the qualitative nature of our research does not lend itself to concise conclusions, our discussion and conclusions will be interwoven. First, the limitations of the research will be addressed; second, suggestions for further research will be given; and third, three major conclusions will be made. Limitations

There were two major limitations to this study. First, not all chapters provided information for this study. Non-random factors may have influenced which chapters responded to the request for information. For example, a majority of the chapters in states with direct access represented in this study obtained direct access during the first attempt at legislative change. Perhaps the chapters that did not respond to the request for information had longer, more complicated experiences that would have been more difficult to describe. The second limitation was the potential for bias in the analysis of data. This is an inherent concern in any qualitative study. The information given generally represented one person's view of direct access in his or her state; the interpretation of that information represented the two investigators' interpretations of the data. We believe that bias was adequately controlled through the use of several sources of information to corroborate one another and through the use of two investigators who challenged each other's conclusions until consensus was reached. Further Research

Direct-access research could proceed in many different directions. The legislative process could be researched further through an in-depth study of opposition to direct access. The process could be viewed from the framework of medical dominance of health care or marketplace influences. The impact of direct-access legislation could be studied from the perspect of patient outcomes with direct-access practice, physical therapist willinged to use the direct-access mode for patient treatment, or physician-therapy interaction in direct-access practice. Major Conclusions

Because the practice acts and political environments are unique to each state, it is not realistic to recommend a plan of action for all chapters seeing direct access. Chapters pursuing legislative change to permit direct access, however, may wish to consider the following points, based o the results of this study:

7. The majority of the chapters in study that obtained direct access so either during the first year of attempting change or via an indirect opportunity for change.

Several chapters in this study found themselves making repeated, unsuccessful attempts at obtaining direct access. Those who have done so might consider deferring their effort for legislative change to pursue 1 or more years of in-depth planning an research. During this hiatus, emphasise could be placed on educating the public, the opposing groups and organizations, and the legislators, who ultimately determine the outcome o the legislation. In addition, chapters might be alert to other possibilities and opportunities for pursuing legislative change such as sunset legislation review or other amendments t the practice act.

2. The majority of states with direct access did not have physical threapy evaluation without referral prior to obtaining direct access. Those states that did bad the evaluation-witbout-referral status for a relatively long time prior to obtaining direct access. We believe that some chapters have perhaps pursued direct access too soon after obtaining evaluation without referral. Eight of the 12 states listed under "unsuccessful attempts" in Table 2 already had evaluation without referral at the time of the survey. The remaining states, with neither evaluation nor treatment without referral, need to consider whether achieving evaluation without referral only will jeopardize future attempts to achieve direct access.

3. Stipulations placed on direct access limit the professional autonomy that physical therapists hope to achieve through direct access These stipulations that limit direct access are often the result of compromise to gain passage of any type of direct-access legislation. The main categories of stipulations were prior diagnosis requirements, eventual physician referral requirements, physical therapist qualifications, patient consent requirements, and practice setting restrictions on direct-access practice. In our view, chapters considering compromises to their direct-access legislation need to consider whether the original goal of the legislation can still be met with the proposed stipulations. Even with the most stringent stipulations, direct access does offer the consumer an alternate entry point into the health care delivery system. References

1 Pickard NW. New Mexico, North Dakota approve direct access to physical therapy. Progress Report of the American physical threapy Association. 1989;18(6):10.

2 Anderson L. 1989 American Physical Therapy Association Board of Directors and Officers elections. Progress Report of the American physical threapy Association. 1989; 18(3):19.

3 James JJ, Stuart RB. Expanded role for the physical therapist: screening musculoskeletal disorders. Phys ther. 1975;55:121-131.

4 Overman SS, Larson JW, Dickstein DA, et al, Physical therapy care for low back pain: monitored program of first-contact nonphysician care. Phys Ther. 1988;68:199-207.

5 Dennis JK. Decisions made by physiotherapists: a study of private practitioners in Victoria. Australian Journal of physiothreapy. 1987;30:181-191.

6 Durant TL, Lord LJ, Domholdt E. Outpatient views on direct access to physical therapy in Indiana. Phys ther. 1989;69:850-857.

7 Hamouz L, Barron A, Porter RE. Indiana physical therapists' attitudes toward direct access legislation. Phys ther. 1989;69:393. Abstract.

8 LeMasters A, Domholdt E. Direct access opinions of physical therapy students. Phys ther. 1989;69:392. Abstract.

9 Safire WL. Safire's Political Dictionary. Ne York, NY: Random House Inc; 1978:705-706.

10 Direct-Access Information Share. Sixty-Fifth Annual Conference of the American Physical Therapy Association; june 11-15, 1989; Nashville, Tenn.

11 Pickard NW. PT direct access for Wisconsin is law; Rhode Islanders must wait 'til next yea Progress Report of the American physical Therapy Association. 1989; 18(8):1-2.

12 NH Rev Stat Ann ch 328-A (1989).

13 Vt Stat ch 38.

14 Colo Rev Stat ch 12, article 41 (1989).

15 ND Cert Code ch 43-26 (1989).

16 Md Health Occ Code Ann title 13 1989).