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Direct Access to PT's - What's it like?
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Direct Access to PT's - What's it like? - October 15, 2003 7:40:00 AM
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Scanner
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I was reading in another forum from Drew that since around circa 1985, PT's have had direct access in most states. I was not aware of this and I think, and correct me if I am wrong, in NJ, a prescription is required
(I base this opinion on the fact I once tried to refer with "Eval. and Treat" and they had me fill out a prescription instead exactly outlining the tx. I wanted).
Anyway, would you share exactly how this works. Do patients call up with LBP, whiplash, shoulder injury, etc., schedule an appointment with a PT, get an eval, and a tx. plan executed? Do you do that w/out imaging to discern a calcific from a non-calcific tendonitis, for instance?
The idea seems so foreign to me here in NJ but I confess a lot of ignorance to the "big world" out there sometimes as an isolated, small business owner.
Educate me. Thanks.
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Re: Direct Access to PT's - What's it like? - October 15, 2003 8:14:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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Scanner,
Actually, NJ DOES have direct access, but because it was achieved in that state as recently as March of this year, you won't be seeing many "experienced" therapists taking advantage of their new-found right and responsiblity. Furthermore, as is the case in many states, insurance won't pay on a claim unless there has been some sort of physician review and referal of the patient. The constant exception to this is BCBS, in which case no physician referal is needed for payment.
In short, "As of 2/13/03 consumers in New Jersey have direct access to physical therapist services, unless an automobile accident is involved or a referral is required for 3rd party reimbursement."
In the end, it makes us specialists of a sort that in the sense that with most plans, if the patient bypassed the PCP and went straight to the neurologist, the MD wouldn't be paid either. It's not therapists in NJ can't see patient's without MD referal, it's just that if that was their entire practice, they'd go broke. Seeing some patients this way and others by referal creates political/marketing difficulties that I'll get into in a moment.
Don't take my word for it though --- here's the recently released statement by John Kasprak, Senior Attorney for OSA:
You asked for information on a recently passed New Jersey law giving patients direct access to physical therapists.
SUMMARY
A newly enacted law in New Jersey gives patients direct access to physical therapists. This law, Chapter 18 of the 2003 laws, establishes standard for direct access, conditions for referral to other licensed health care professionals, and new licensure standards for physical therapists and physical therapist assistants.
DIRECT ACCESS STANDARDS AND CONDITIONS
Under Chapter 18 of the 2003 Public Laws of New Jersey (S. 2004, attached), an individual no longer is required to get a referral from a physician prior to seeking the services of a physical therapist, in most circumstances. Within 180 days after enactment (the legislation was signed by Governor McGreevey on February 13, 2003), the New Jersey State Board of Physical Therapy Examiners must adopt standards establishing conditions under which a physical therapist is required to refer a patient to another licensed health care provider. Until that time, a physical therapist (1) must refer the patient if he fails to demonstrate reasonable progress during the first 30 days of treatment, and (2) within 30 days of initial treatment of functional limitation or pain, consult with the individual's licensed health care professional as to the appropriateness of the treatment, or if there is no licensed professional of record, recommend that the patient consult with one (see § 4, p. 2-3 of the attached act).
The new law clarifies that physical therapists and physical therapist assistants are barred from diagnosing disease or practicing medicine, surgery, chiropractic, podiatry, occupational therapy, dentistry, or prosthetics.
Under the legislation, a referral from a licensed physician, dentist, podiatrist, or chiropractor acting within the scope of his practice is still required if the patient seeking physical therapy wants the services to qualify for reimbursement as medical expense benefits under the personal injury protection coverage of an automobile insurance policy (see § 26, p. 8-9).
LICENSING STANDARDS
The legislation imposes new licensing requirements for physical therapists and physical therapist assistants. Physical therapists must (1) have completed a physical therapy program from an accredited college approved by the board; (2) have a master's or doctoral degree from an accredited college; (3) pass a written examination approved by the board; (4) have experience satisfactory to the board; (5) be at least 18 years of age; (6) have good moral character; and (7) meet other requirements the board may establish by regulation. The law waives the master's degree requirement for applicants who earned a bachelor's degree before January 1, 2003. (see § 8, p. 4)
Physical therapist assistant licensing requirements include an associate's degree and completion of a two-year physical therapy assistant program, satisfactory experience, and passage of the written examination (see § 21,p. 7).
The new law also directs the licensing board to establish continuing education requirements for physical therapists and physical therapist assistants (§ 25, p. 8).
Back to my diutribe . . .
Here in NC, at my clinic, I see most patients after being cleared by the primary care physician, but I do see a few patients with BCBS or self-pay without physician referal (and the evaluation takes a bit longer to do as an obvious result). If a radiograph is indicated, if medication seems indicated, or if I've the slightest doubt of what I'm dealing with - - - I'm on the phone with the PCP, all of whom appreciate the initial medical screen, subjective history, and NMS objective findings as it saves them time. Am I responsible if I miss something in the medical screen? YES and for reasons that Dr. Wagner will, I'm sure raise, that's a little scary --- but all I have to do is distinguish normal from abnormal and get in contact with an MD if the case indicates it. The MD's I work with are FAR more confident that I'll call them for medical referal than they are of the local "all things to all people" chiropractors.
In any event, patients by referal/patients off the street . . . it's not an easy balance to strike, I don't want to irritate any referal source by doing too much portal-of-entry care, but most of these patients come to me after a failed trial of chiropractic for a previous injury anyhow --- so the medical physicians generally don't feel threatened by my seeing their patients this way, because in general, the patient wouldn't have ended up in their MD office anyhow.
The chiropractors in the area --- well that's another story!
Hope that helps.
Drew
[This message has been edited by Andrew M. Ball PT PhD (edited October 15, 2003).]
[This message has been edited by Andrew M. Ball PT PhD (edited October 15, 2003).]
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Re: Direct Access to PT's - What's it like? - October 15, 2003 10:10:00 AM
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Scanner
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No, I wasn't aware of that law change (last to know). I'll take your word for it.
So, you give an example of someone failing under chiropractic care calls up your clinic and you evaluate and treat. How did they arrive at the decision to call you? Newspaper ad? Public speaking? Public service announcement from the APTA? Referral from family member who you are currently seeing? Honestly, I don't think anyone of my patients here in NJ would think of it, even if they had BCBS, although they certainly should and I don't see the choice as a bad thing.
How many portal of entries/month do you get in terms of %age vs. referrals/prescriptions?
I guess I could just write "eval. and treat" now since the law has changed, which makes my job easier.
Anyway, I had a new patient (an RN) present yesterday with acute LBP and history of thyroid cancer. Remarkably fit - lotsa hiking, eats well, normal weight, no smoking. I almost didn't get an x-ray on her as she was 54 and so healthy other than the previous history (they instruct us 50 is the cutoff age for radiographing) and all examination and other history signs pointed to mechanical LBP/strain/sprain. But then halfway through the exam, she admits that "well, there has been some burning for over 6 weeks."
So, I think, "Okay, it's chronic - better get an x-ray." (not even really considering the 50 cut off age)
You can see where this is going - a suspicious lesion of blastic mets is present at L2 pars.
This one was about 1 foot off my bow. I admit to getting lax and almost missing this.
I am now ordering a bone scan and a CT scan after I got on the phone with the family doc, who absolutely deserved a phone call.
We pleasantly talked and he admited that the communication between our professions is lax both ways because I complained no one ever gives me bone density results (gee, do ya think that is important to a DC?)
He, BTW, didn't want to see her unless the tests confirm positive although I would have been happy to refer her (and will, if it is positive - the radiologist said it could be a giant osteophyte).
Anyway, besides answering my questions above, it begs the question - without diagnostic prescriptive powers, how do you catch cases like these, not that I have had many? Would you refuse to see anyone over 50 and in pain who hasn't been cleared by the family MD?
Or do you just accept that you will miss a certain number of these type of cases and hopefully won't be sued because of good PR (PT's have great relationships with their patients, I'll admit)?
Thanks.
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Re: Direct Access to PT's - What's it like? - October 15, 2003 5:55:00 PM
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Bournephysio
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"Do patients call up with LBP, whiplash, shoulder injury, etc., schedule an appointment with a PT, get an eval, and a tx. plan executed?"
Yes, thats exactly how it works.
Imaging is not needed in the vast majority of cases. In my experience it is often used as a crutch in place of a proper clinical assessment. How does knowing a tendonopathy is calcific vs. non-calcific change your treatment? It really shouldn't.
In the case you brought up with the possible met the history was a big flag that you had to be careful. There could quite possible be other signs as well.
There is not much of a difference between patients referred by doctors and those not. Most who see the doctor are not properly medically screened and very few have had imaging. I've been told that gps here can't order mris. Somehow I doubt that but I've never seen an mri from a gp.
Basically, anything I miss would have likely been missed by the gp as well. In those cases that require more caution I need to rely on the gp for further testing which kind of sucks but is rarely a problem.
Doug
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Re: Direct Access to PT's - What's it like? - October 15, 2003 6:20:00 PM
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OAK
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Scanner wrote:
"Anyway, besides answering my questions above, it begs the question - without diagnostic prescriptive powers, how do you catch cases like these, not that I have had many? Would you refuse to see anyone over 50 and in pain who hasn't been cleared by the family MD?
Or do you just accept that you will miss a certain number of these type of cases and hopefully won't be sued because of good PR (PT's have great relationships with their patients, I'll admit)?"
If I was worried about getting sued I would be in a much better postion if I sent my patient to a radiologist, who has much more training than any Chiro in reading x-rays and a severe problem was missed, than if I were I Chiro reading an x-ray and missed a severe problem myself.
My specialty is assessing and treating the musculoskeletal system, not in reading x-rays.
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Re: Direct Access to PT's - What's it like? - October 16, 2003 8:02:00 AM
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mcap56
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The argument that radiographic priveleges make one qualified to see spinal patients directly is thin, very thin.
First, PTs in the military have this privelege.
Second, the job of the primary care medical professional in cases of spinal pathology is very clear. You are too rule out red flags and examine for neurological deficit. This is done quite easily - the guidelines are very clear. If there is any suspicion at all, they the patient should be referred on. I suspect that a competant PT in Scanner's vignette would have referred out. Furthermore, the case is being presented to us in such a way that some signs may have been downplayed to make a point. An elightened clinician would also screen for yellow flags.....but I don't think most people (DC or PT or MD) bother.
Third, X-rays, particularly to the L-spine is a very large dose of radiation.
Fourth, there is evidence that patients given X-rays and a specific diagnosis do worse in the long run. In one study, patients who were given a specific dx were 4.9 times more likely to develop disability. Peforming X-rays on patients and telling them the results without adequate explanation of false positives and other related complications can be devastating. Waddell contends that this is the biggest source of disability in LBP. (Admittedly, MDs may be more culpable in this area).
Fourth, all of the expert reviews and task force guidelines recommend that LB be managed in primary care settings and that X-Rays are uncessary in the vast majority of cases. Only when there are red flags are they necessary. Any patient who hasn't made significant progress during the first few weeks should be referred on anyway.
It is possible to miss certain cases. It is always a risk when working with back or neck pain. But the ability to X-ray adds very little. I have a friend who is a DC and can see up to 70 patients a day. Give me a good 45 minute to an hour evaluation with 1/2 hour follow-ups to reduce the risk of missing sinister pathology any day of the week.
mcap
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Re: Direct Access to PT's - What's it like? - October 16, 2003 8:26:00 AM
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OAK
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BackTalk wrote:
"As far as liability goes, you will be in just as much trouble as the radiologist if they missed something. In today's litigious society you will be sued for sending your patient or patients films, to an incompetent radiologist. "
I totally disagree with this statement. Not having the right to directly order diagnostic tests decreases my liability.
If I refered a patient to their MD and they missed a serious pathology what am I liable for?
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Re: Direct Access to PT's - What's it like? - October 16, 2003 10:17:00 AM
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Scanner
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[QUOTE]I suspect that a competant PT in Scanner's vignette would have referred out. [/QUOTE]
No, a competent PT wouldn't have. A competent PT could have easily missed this.
Fellow/gals, usually you answer my questions here to my satisfication but not this time. In fact, Mcap is somehow implying that he could have caught this with some kick-ass history gathering. Not so.
Because actually, this was an incidental finding on the x-ray. She actually has two problems - possible mets and confirmed mechancial LBP.
If anything, your kickass exam would have led you off track (it did me) because everything suggests (other than the previous hx. of cancer) she had musculoskeletal pain.
In fact, your overconfidence worries me a bit as I have admitted on constrast, this could have easily sailed past me.
Unless PT's had a specific policy of a history of cancer being first radiographically screened, you would have missed this, plain and simple, because it was an incidental finding(not that cancer is ever incidental).
Listen, this may be so rare that it is not worth mentioning in the grand scheme of things for PT's.
The chance of catching a random pathology on x-ray (such as a silent mets or aaa) is approximately 1/2500, not huge, but over a career, it does mean something. It is also an inexpensive test. And with films being so sensitive nowadays, the rad. dosage is less than a couple of plane trips from San Francisco to NY. I barely register radiation dosage into the equation unless the patient is possibly pregnant.
Anyway, I am going off on a tangent. I understand it is hard to answer my questions as they are purely hypothetical.
I will just assume that your profession would accept these cases as "losses" and move on, since they are rare.
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Re: Direct Access to PT's - What's it like? - October 16, 2003 11:27:00 AM
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mcap56
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Scanner:
You present us with a patient who is 54, with a history of cancer and then says there has been some buring over the last six weeks. You are not telling us the full story. We weren't there. WE didn't do teh examination. Is it really that difficult to conceive of referring out with that history and description?. Furthermore, you have not indicated whether it was indeed an osteophyte or mets. (hopefully it was the former). Sure it is possible that we could miss this one. But there are things that would lead some of us to refer on.
The guidelines for ruling out red flags are very clear. PTs, in general, tend to be very, very conservative. There has been no increase in malpractice when PTs have direct access.
Average dose of a lumbar X-ray (3 views) is 3 mSv. A couple of trips on an airplane isn't even close. The debate on X-rays radiation is far from settled. I have read opinions from some medical physicist/radiologists who claim X-rays are the primary cause of cancer in this century. I have read opinions of others who feel that radiation in those doses is actually beneficial. We don't know. There are almost no longitudinal studies. Only high dose to low dose extrapolation from people who have received really high doses. The estimated relationship (linear, quadratic), is just that. Estimated.
Yes....you are correct, since we don't x-ray, we would miss the odd incidental finding. However, most of our patients see MDs. After a month, according to the NY law being debated, they would still have to see their MD. I would content that, in general, patients in P.T., direct access or not, probably have a better chance of having sinister pathology detected.
I think the larger issue here is that many DCs oppose direct access for PT.
mcap
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Re: Direct Access to PT's - What's it like? - October 16, 2003 11:32:00 AM
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Bournephysio
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"Unless PT's had a specific policy of a history of cancer being first radiographically screened"
Yes they would have to be medically screened.
If they did not have a cancer history and there was nothing else in the exam to suggest a problem then it would be missed at first. Once it was evident that treatment wasn't working and the person was referred to their md then it would be caught. If they saw the md first it would have gone from the md to me then back to the md then caught or worse: md then wait a few weeks then to me then back to the md.
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Re: Direct Access to PT's - What's it like? - October 16, 2003 11:35:00 AM
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OAK
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Dear BackTalk:
I realize I can be sued, people have the right to sue anybody! I'm sure they could sue my receptionist for giving them the phone number of this "incompetant" MD.
My point is that since it is not within my "scope of practice" to order and read diagnostic imagry it is not my job to dianose malagnancies or other serious pathologies. Therefore I am LESS liable than a Chiropractor in this instance.
If I had to present a case to a judge my defense would be that I refered my client to a qualifed MD who made a mistake. What would the Chiropractor use as his defense, I read the x-ray and messed up?
To claim that PTs should not be granted direct access because of increased lilablility concerns is ridiculous!
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Re: Direct Access to PT's - What's it like? - October 16, 2003 12:54:00 PM
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mcap56
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I would have to agree that the attorney would sue anyone involved with the case, including your receptionist if possible [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] I worked for a med mal law firm for a while. There were a few rehab cases where the physician was getting sued. The PT wound up in the suit also even though they were not directly involved.
If you rehab someone who then has surgery that goes bad.....you will be sued also. They basically bring in everyone they can. That doesn't mean they end up with liability. Many things can happen along the way.
There already is direct access in so many states and there is no jump in malpractice premiums. However, as we go to meaningful direct access (meaning reimbursement), perhaps they will rise a bit. I know Pts that don't want direct access. But...over the long haul...I don't think our profession has a choice really. Just my opinion.
One thing that works for us is time and relationships. Patients are far more likely to sue if they have been treated poorly and they feel like they have been rushed. This usually doesn't happen in PT.
mcap
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Re: Direct Access to PT's - What's it like? - October 16, 2003 1:16:00 PM
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OAK
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Dear mcap56:
I was just curious about some of those cases you have seen. When the PT was sued what was the outcome? Were they determined to be liable or was the case thrown out?
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Re: Direct Access to PT's - What's it like? - October 16, 2003 7:52:00 PM
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coloradojulie
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I have to say that the very conservative nature of physical therapists makes them ideal candidates for direct access. It is my experience that chiropractors have a degree of percieved medical competence that is equivalent or in some cases superior to acutal medical doctors. I find this attitude absurd, and so do many others in the health care field.
PTs who might miss a cancerous lesion would have the insight that symptoms were not responding to treatment and or that the symptoms were not consistent with musculoskeletal pathology. Then the PT would realize their is some underlying structural pathology beyond the scope of their practice and refer to someone with expertise in this field for further testing. Rather than order redundant, expensive investigative tests. Scanner, honestly, how many of your tests come back normal or absent of pathology?? I worked in a chiro office and was privvy to the radiologists reports and most of these were negative. Maybe one in 10 showed any pathology and generally it was minimal to moderate DJD. He never found cancer or anything spectacular.
In my practice if I think a patient should have an xray or mri, I send them back to the doctor. I have no problem admitting if what I have to offer isn't what the patient needs. I have found several non-musculoskeletal complaints missed by GPs and orthos, such as a rare form of skin cancer on a patients shoulder I was rehabbing (which was surgically removed) and a psoas abscess which was referred as low back pain. In this case, the patient had a history of chrons disease, and his symptoms were inconsistent with low back pain. I referred him back to his physician after our second visit and contacted the doctor. He was admitted that day and the abscess drained.
So it is possible for PTs to realize that the pain from cancer or other pathology is not musculoskeletal in nature. The difference here is that I realize my limitations and am not ego bound enough to believe that I could out do a competent MD. In rehab, yes, in global medical diagnosis absolutely not.
Scanner, on the other hand your attitude is very superior and I find that dangerous.
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Re: Direct Access to PT's - What's it like? - October 17, 2003 6:51:00 AM
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Scanner
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Colorado,
We must not be communicating well because it is your collective attitude I find superior.
I have admitted, that if it weren't for an x-ray, I could have very easily missed this. In this case, the exam confirmed musculoskeletal pathology. If it weren't for me just saying to myself, "Oh well, there is some chronic pain there - better look out for degenerative conditions" I would have missed it.
A PT may have thought (and I can picture this in your outcome based ways):
"Well, even if there is mild DJD there, it isn't going change how I am going to intervene. The x-ray isn't going to change the outcome. So why x-ray?"
In fact, mcap is making a case that x-rays aren't very useful, except in screening for fracture. (Would you refer all whiplash to the MD first too to screen for avulsion fracture?)
I think you are reading too much into my post and getting defensive. I am not saying the lack of diagnostic prescriptive powers (in the states that don't have them) makes direct access for PT's invalid - I was just wondering what would happen in cases like these.
They would be missed. That's all.
Eventually some other provider would catch it.
Let me answer your questions and comments:
[QUOTE]I have to say that the very conservative nature of physical therapists makes them ideal candidates for direct access. It is my experience that chiropractors have a degree of percieved medical competence that is equivalent or in some cases superior to acutal medical doctors. I find this attitude absurd, and so do many others in the health care field. [/QUOTE]
I really don't know any DC's who profess a superiority to MD's. Yes, many try to profess an equivalence in that they want to be recognized as doctors but I really think most want an equivalence to dentists or optometrists, not MD's or DO's.
A valid place in health care, that's all.
[QUOTE]
PTs who might miss a cancerous lesion would have the insight that symptoms were not responding to treatment and or that the symptoms were not consistent with musculoskeletal pathology. Then the PT would realize their is some underlying structural pathology beyond the scope of their practice and refer to someone with expertise in this field for further testing. Rather than order redundant, expensive investigative tests. [/QUOTE]
No, Coloradojulie, What would have happened in this case is that you would have successfully treated the overlapping LBP and discharged her on her merry way. That's what I almost did.
The blastic mets is silent and is not contributing to her symptomatology.
[QUOTE]Scanner, honestly, how many of your tests come back normal or absent of pathology?? [/QUOTE]
Mmmm. Probably a higher %age than my colleagues because I don't x-ray everyone but yes, in the spirit of your question, most of my pathology falls in the arthritide category. Some of the pathologies in my six years:
osteoporotic comp. fx.'s
bilat. senile ankylosis of the SI joints (radiologist missed that one)
Scheurmann's disease
Slipped femoral epiphysis
[QUOTE]He never found cancer or anything spectacular. [/QUOTE]
I was taught at my school that if I was a decent diagnostician, I should be catching one metastatic dx./year. I have been in practice 6 years and only found one.
I am curious, since we see the same patients pretty much, do they teach that at PT school?
So, I am either really lucky or not a great diagnostician, probably the latter. Or the MD's in my community are really good and covering my ass (probably this too).
(see my humility?)
[QUOTE]
In my practice if I think a patient should have an xray or mri, I send them back to the doctor. I have no problem admitting if what I have to offer isn't what the patient needs. I have found several non-musculoskeletal complaints missed by GPs and orthos, such as a rare form of skin cancer on a patients shoulder I was rehabbing (which was surgically removed) and a psoas abscess which was referred as low back pain. In this case, the patient had a history of chrons disease, and his symptoms were inconsistent with low back pain. I referred him back to his physician after our second visit and contacted the doctor. He was admitted that day and the abscess drained. [/QUOTE]
Good catch. I may have missed that.
[QUOTE]
So it is possible for PTs to realize that the pain from cancer or other pathology is not musculoskeletal in nature. The difference here is that I realize my limitations and am not ego bound enough to believe that I could out do a competent MD. In rehab, yes, in global medical diagnosis absolutely not. [/QUOTE]
You're missing the point. I didn't outdo anyone. I am not in competition with the family doc here (maybe you are).
Anyway, I'll draw this discussion to a close. I was just more curious how direct access patients arrived at your offices, not debating on the evils of over x-raying, or some notion you got that DC's feel superior and/or whether PT's will miss more pathology.
[QUOTE]
Scanner, on the other hand your attitude is very superior and I find that dangerous. [/QUOTE]
See above.
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Re: Direct Access to PT's - What's it like? - October 17, 2003 7:02:00 AM
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Scanner
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One more thing - the poster who said your malpractice rates will go up is right.
This is what will happen:
You will see a case like the above. The patient will get better for awhile until finally the bone cancer goes symptomatic. She'll then meander into a DC's office, who will x-ray, and then he'll say in a surprised voice, shaking his head back and forth:
"Gee, didn't the PT even order an x-ray?"
(I wouldn't do this - I would try to cover your ass because I would want mine covered but many DC's would)
Now, mind you, there was mechanical back pain there too before, and that what was causing the symptoms but all the patient will think is that you missed something and by golly, I should have been going to a doctor, not a therapist, yadda, yadda. You get the idea.
How do I know?
Because it happens all the time with DC's and orthopods. The patient comes in, the DC suspects a HNP, he fails to get imaging because what the hell, it is probably a bulge, tries to educate the patient, performs an adjustment/rehab, the patient gets worse, goes to an orthopod, and he says, "See there. The DC herniated your disc."
HNP's in this fashion are the 2nd most common contributor to lawsuits for DC's.
The same scenario could happen to PT's, probably more often than cancer.
Your "conservative nature" won't help you here. Welcome to ligitious America.
[This message has been edited by Scanner (edited October 17, 2003).]
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Re: Direct Access to PT's - What's it like? - October 17, 2003 7:55:00 AM
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steve
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So if a missed disk is #2 reason for malpractice, what is the number one reason DC's are sued?
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