What's all the fuss about direct access? (2002 APTA Presidential Address).

As a profession, we've celebrated each state's passage of direct access, and the news of each victory has been celebrated with the same enthusiasm as if it were the first. Today, 35 states have direct access to physical therapist services. Forty-eight states allow physical therapists to conduct an initial examination without a physician's referral.

Until late last year, the quest for direct access has been a state legislation issue. But in November 2001, something extraordinary happened: We took the fight for our patients to the federal level. Because of the high regard and the respect that policy makers have for us as health care professionals, Congress listened--and acted.

In November, the Medicare Patient Access to Physical Therapists Act [HR 3363] was introduced in the US House of Representatives, and, in April 2002, a companion bill [S2386] was introduced in the US Senate.

This legislation is monumental! In fact, I believe it is the most important legislation with which we've been involved during the past 20 years.

The Direct Access bill would allow Medicare payment for the services of physical therapists provided without a physician's referral. It also makes technical corrections that would separate physical therapy and speech-language pathology services once and for all, to avoid situations such as the current shared cap under Medicare.

Our formal position on the direct access bill states: "The physician referral is unnecessary and limits access to timely and medically necessary physical therapist services. Such access for beneficiaries is critical as Congress looks to reform the Medicare program." (1)

Another important benefit of this legislation is its potential for setting a precedent. Medicare is the largest health care insurer in the country. Imagine the possibilities once the Medicare program puts its stamp of approval on direct access to physical therapy! This is exactly the kind of example that private insurers are likely to follow.

As a profession, we've set a clear goal of truly autonomous practice for all physical therapists by the year 2020. In order for that to happen, direct access has to be achieved in 2 ways:

* First, it has to be legal. In other words, it must be recognized within each state practice act.

* Second, direct access to physical therapy has to be recognized by third-party payers. Although it is legal in 35 states, most insurers still require a physician's referral in order to provide reimbursement for physical therapy services. In many cases, this can render direct access meaningless to patients in settings that are dependent on third-party reimbursement.

We all know that the burden of referral weighs heaviest on those who are economically disadvantaged. They may not have the transportation to get to the physician for the referral. They may not be able to afford time away from work for the physician visit and then for the appointment with the physical therapist. They may, in fact, be intimidated by the idea of having to visit the physician to ask for a referral to the physical therapist.

Direct access is truly about access to needed health care for all citizens. And this is why the Medicare Patient Access to Physical Therapists Act is so, so important.

The push for direct access under Medicare and the fight for the legality of direct access in every state are much more than just legislative issues or just practice issues. These efforts have everything to do with realizing our dreams for our patients and for ourselves as a profession, and they cut across the 3 prongs of physical therapy--practice, research, and education.

Unified as a profession, we have embraced a common vision for our future. We know where we are going, and we know how to get there. In fact, we are well on our way. We have a Vision. We have a landmark description of physical therapy in the Guide to Physical Therapist Practice. (2,3) We have a Clinical Research Agenda. And we have a commitment to the clinical doctorate as the preferred professional degree.

We are ready. The time has come for full and complete autonomy!

The quest for autonomy did not start with direct-access legislation. Generations of physical therapists before laid the bricks in what is now this strong foundation on which we stand poised to realize full professional autonomy.

Recently, I read a draft copy of a PT Magazine article in which one of our distinguished Catherine Worthingham Fellows, Sam Feitelberg, PT, MA, was quoted on the topic of autonomy. He said, "I remember my first job as a physical therapist in September of 1953. I sat at the end of a long table and waited for a nurse to come into the room and give me the prescription from the physician for the patient that I was about to see. I was not allowed to talk with the patient about the evaluation, the diagnosis, or prognosis. I was simply to follow the order for treatment. And the only time I might have the opportunity to speak with the doctor would be if HE had a problem with ME."

Sam went on to say that he knew early on that he would not be content to practice this way.

Sam, and hundreds like him, worked diligently throughout the years to change things.

One of our most beloved and esteemed colleagues, Florence Kendall, along with her husband, Henry O Kendall, played a major role in drafting the original state practice act in Maryland in 1947. She has called it "a labor of love, with the only compensation being the satisfaction of helping attain standards for the quality of physical therapy in the health field."

Throughout our history, we have been on a quest for independence. And what has always set us apart on this journey, I believe, is our spirit of cooperation--our desire to work within, not apart from, the larger medical community.

Almost 50 years ago, another of our revered Catherine Worthingham Fellows, Helen Hislop, PT, PhD, addressed this desire in a Physical Therapy editorial, stating, "We seek stronger, not weaker, ties with medicine. We seek cooperation, coordination, and communication with all branches of medicine. (But) we still affirm the basic right to govern our own affairs." (4)

Throughout our history, we can be grateful that our predecessors had the foresight to fight for that basic right.

I have talked about our future in the framework of our Vision. And I've talked about our past, as the generations before us fought so valiantly on the early road to autonomy. What about the present?

When I see what today's physical therapists are accomplishing, I couldn't be more proud or excited. We have achieved an advanced level of education, scholarship, and clinical skill that is clearly synonymous with autonomous practice. And this has been achieved by all of us--including those who continue to fight for direct access in their states.

We have defined our scope of practice, and our ability to evaluate, diagnose, and treat is without question. In private practices, in hospitals, in rehabilitation facilities, in skilled nursing facilities, and in patients' homes, we have the unmatched ability to return our patients to meaningful function. For one patient, that may mean returning at 100% performance to the professional playing field; for another, it may mean returning to the backyard garden.

I believe this may be the most promising time ever for physical therapy.

In addition to our continued dedication to the more traditional rehabilitation settings, we are moving into more and more new markets, including prevention and wellness, exercise and fitness, balance and falls prevention, women's health, and ergonomics. Direct access makes it possible for so many to avail themselves of these kinds of programs--and, in effect, prevent future injury, disease, and disability.

We have the potential to dramatically enhance the quality of life for countless Americans, with just as dramatic an effect on health care cost containment. We have already begun to do this. Direct access makes it that much easier.

In addition to our achievements in the clinical arena, I also see physical therapists with a sophisticated political understanding. Back in the 1960s, it was just a handful of physical therapists who worked day and night for months to ensure the specific inclusion of physical therapist services into the original Medicare legislation.

Today, we have hundreds (thousands?) of you and your patients working to secure sponsorship of our Medicare direct access bill. You understand the importance of your political activism. And this activism has paid off. We now have 34 sponsors of HR 3363, as we move toward our goal of 50 to 100 sponsors by the end of this year!

Recently, APTA put out a call to many of our members asking for patients' stories to aid in this lobbying effort. It probably won't surprise any of you when I tell you that the stories are there, and they began coming in immediately. Consider this one, typical of so many:

   As a senior and World War II veteran, I had a bout with shingles last
   autumn. After several doctors' visits and repeated MRIs [magnetic resonance
   imaging scans] and diagnoses, I finally received treatment from a physical
   therapist for my frozen shoulder due to shingles. In between, I had
   doctors' appointments weeks apart before I finally had some help. All that
   time I was in severe pain and required pain-killing drugs to tolerate it.
   The delay in seeing a physical therapist not only prolonged my condition
   but entailed many extra visits, and I believe added costs to an already
   overburdened health care system. I believe I could have been helped
   earlier, less expensively, and more efficiently, and [could have] had
   significant improvement without delay, if I had been allowed prompt access
   to a physical therapist.

If this story sounds familiar to you, I'm sure you and your patients have countless more to add to this cause. We need to hear from every one of you!

To ensure passage of the Medicare Patient Access to Physical Therapists Act, every voice in this profession must be heard!

We need you to urge your Members of Congress to become co-sponsors. If they already are, send them a letter of thanks.

Educate your patients about the importance of this bill. Ask them to write in support of its passage--and thank them when they do.

Become involved in APTA's Federal Government Affairs Liaison Program.

Get all of your colleagues involved!

Before you leave the conference this week, please stop by our Government Affairs tables in the registration area and the Exhibit Hall to see just how easy it can be to get involved.

In closing--

We are so close to seeing our dreams for this profession become a reality. Each of you here today--and the thousands more back in your clinics, and classrooms, and offices, and labs--must believe in our ability to make a difference.

Our practice options are nearly limitless. And our potential to improve the health, fitness, and function of all Americans can be beyond our dreams ... if YOU get involved NOW!

References

(1) APTA Position on the Medicare Patient Access to Physical Therapists Act (HR 3363/S. 2386). Available at: http://www.apta.org/Govt_Affairs/Medicare_DirectAccess/ APTAPosition_MedicareDA. Accessed: July 17, 2002.

(2) Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

(3) Interactive Guide to Physical Therapist Practice With Catalog of Tests and Measures, Version 1.0. Alexandria, Va: American Physical Therapy Association; April 2002.

(4) Hislop HJ. Editorial: ... And yet another. Phys Ther. 1965;45:1030.

BF Massey Jr, PT, is Executive Director, North Carolina Board of Physical Therapy Examiners, 18 West Colony Place, Ste 140, Durham, NC 27705-5582 ([e-mail]).

Mr Massev's Presidential Address was presented at the Opening Plenary of PT 2002: The Annual Conference and Exposition of the American Physical Therapy Association; June 5, 2002; Cincinnati, Ohio.