Physicians Should Diagnose Physical Therapy Need

April 6, 2015


Representative Myra Crownover
Chair, House Committee on Public Health
P.O. Box 2910
Austin, Texas 78768  

Re: HB 1263  

Dear Chairwoman Crownover:  

On behalf of the organizations listed above, we are writing to express our opposition to HB 1263, which would allow physical therapists to initiate services without a medical diagnosis in place for either 45 days or 20 treatment sessions.  We are unable to support any bill that would remove a medical diagnosis from a patient’s care.    

While physical therapists are important members of the health care team, they are neither licensed nor trained to make a medical diagnosis.  A medical diagnosis serves as the foundation for physical therapy services and acts as a filter to ensure that a patient is provided the most efficient and high quality treatment possible.  Correctly diagnosing a musculoskeletal condition involves a number of factors, including the performance of a comprehensive history and physical examination, and when indicated, imaging, laboratory testing, and other diagnostic procedures, none of which physical therapists have the training or capability to provide.  

Direct Access Opens the Door to Inappropriate Care 
Health care policy debates around the nation focus on producing higher quality and more reasonable costs.  Evidence from the largest physical therapy study looking at the quality of physical therapists’ decisions gave 1,000 randomly selected private practice physical therapists a collection of 12 hypothetical patient scenarios and asked them to choose whether they would provide intervention, provide intervention and refer, or refer on to a physician.    

The decisions were based on criteria developed by physical therapists.  Results demonstrated:  

  • Physical therapists made all of the correct decisions 50 percent of the time.
  • Physical therapists were incorrect 13 percent of the time for musculoskeletal conditions. 
  • Physical therapists were incorrect 12 percent of the time for noncritical emergency conditions. 
  • Physical therapists were incorrect 21 percent of the time for critical emergency conditions.   

(Jette DU et al, Physical Therapy 2006; 86(12))  

In June 2014, the U.S. Government Accountability Office (GAO) released a groundbreaking study that found that physical therapy operating outside of an orthopaedist’s office resulted in a much higher use of physical therapy services, which results in higher costs for patients. The report demonstrated that orthopaedists who provide physical therapy services in their offices had much lower overall costs of physical therapy during the period studied than those physicians who referred to physical therapists who were not affiliated with the physician. The total number of self-referred physical therapy services essentially showed no increase from 2004 to 2010 for orthopaedists who self-referred, whereas non-selfreferred services (independent physical therapy) increased by 41 percent. The orthopaedists and physical therapists were working together and ended therapy when it was no longer necessary or the patient could utilize take home exercises.  

The GAO provided an explanation for this strong growth in services associated with physical therapy (PT) that was not coordinated with a physician:   

“One potential reason for this difference is that non-self-referred physical therapy services can be performed by providers (physical therapists) who can directly influence the amount, duration, and frequency of physical therapy services through the written plan of care required by Medicare. In contrast, non-self-referred services we examined for our prior work tend to be performed by providers who have more limited ability to generate additional services or referrals; for example, radiologists generally do not have the discretion to order more imaging services or more intense imaging procedures.”   

Working Together to Enhance Quality and Efficiency
No amount of increased access to our allied health providers will substitute for the value inherent in a well-trained physician free to make choices in a system that incentivizes high-quality, cost-effective care. Direct access to physical therapy will likely result in increased costs to patients without providing any measureable improvement in quality. It is a low-value solution.  

Texas’ current laws already allow direct access to physical therapy in three different scenarios.  It is important to note that a medical diagnosis is central to all of these direct access situations in which there is an injury, condition, or disorder present.  This ensures the best care possible for patients.  

Lawmakers should focus on one crucial set of data for their constituents: Despite over 40 states allowing some form of direct access (Texas also allows direct access in certain scenarios), not one major medical study has demonstrated a decrease in the total health care costs for a population after direct access without a medical diagnosis was instituted in a state.  Until studies show that expanding physical therapy direct access provides higher quality of care at a lower cost, Texas should focus its time and energy on evidencebased strategies for proven care that is cost-effective.   

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