Alternative Treatment Trends #3: Physical Therapy as Direct Point of Access

Many states currently restrict the ability of patients to see a physical therapist as their first point of care. What are the risks—and what are the benefits—to PT as direct point of access?

Access is a big issue for savvy consumers selecting a plan in today’s healthcare marketplace. The ability to see specialists and non-physician healthcare professionals without a referral can be the deciding factor when comparing insurers or choosing between an HMO and PPO.

However, in some states, direct access to physical therapy treatment remains a legislative issue.

According to the Health Care Cost Institute, current state laws restricting direct access to physical therapy include:

  • Requiring a physician referral prior to seeing a physical therapist
  • Time limits on how long a patient can be seen by a physical therapist before requiring a physician visit
  • Education and/or credential thresholds for physical therapists to see patients directly

These restrictions have implications for patients, physical therapists nationwide and the healthcare system at large.

Disempowering the Physical Therapist

Those opposing direct access to PT have contended that physical therapists lack the education needed to recognize infections, fractures and other serious medical conditions. They state that because physical therapists do not order diagnostic tests and make medical diagnoses, they require medical oversight.

Physical therapy is a highly regulated profession across all 50 states, requiring both formal education and clinical training to analyze a patient’s condition and assess his or her PT needs. Physical therapists are trained to recognize when it is appropriate to safely and effectively treat a patient – and when signs and symptoms indicate that the patient should be referred to another healthcare professional.

Much like physicians, physical therapists look for warning signs in the physical exam and patient history that would prompt further testing, as outlined in the Guide to Physical Therapist Practice. When there is concern of a serious nature, the problem would be deemed outside the PT’s scope of practice, and a referral to a physician would be in order.

Impacting Utilization Rates

In turning this argument on its head, one may surmise that because physical therapists do not have the same medical privileges as physicians, seeing a PT first may result in lower utilization of unnecessary medical services. And they would be right.

According to a study by Frogner et al that compared patients suffering from low back pain (LBP) who first saw a physical therapist versus another provider, several positive utilization outcomes were associated with seeing a physical therapist first, including:

  • Significantly lower costs across almost all settings (with a few exceptions)
  • Significantly lower probability of having an emergency department (ED) visit
  • Lower imaging rates

Notably, patients with LBP who first saw a physical therapist also had a lower probability of opioid prescription, which is a likely outcome for patients who visit an emergency department with persistent back pain. It should not be surprising that concurrent with an increase in back pain-related opioid prescriptions, EDs have seen an uptick in drug overdoses. Research shows that opioids do not significantly improve health outcomes, but are associated with an increase in mortality risk.

Expanding Access, Addressing Cost

Overutilization of medical services not only has implications at the patient level; it further clogs a strained healthcare system struggling to control costs and improve access to critical medical care.

Healthcare costs related to LBP, for example, continue to outpace non-LBP expenditures, amounting to $90.6 billion in direct costs and $19.8 billion in indirect costs. As we reform our national healthcare system and face a shortage of primary care physicians, states must look for new ways to offer healthcare access to their citizens while controlling cost. One way is to expand access to non-physician healthcare professionals, such as physical therapists.

In the Frogner et al study, it was found that patients who had PT first saw significantly lower care cost totals compared with those who had PT later or no PT (controlling for patient characteristics and distance between patient and provider). Although there was not a significant difference in pharmacy costs, patients who had PT first accrued lower physician and outpatient costs overall. These patients were also less likely to use imaging services, which, when used prematurely, has been found to lead to higher costs without significant health benefits.

Research continues to be done to support the efficacy and benefits of direct PT care. Over recent years, limitations found in state laws have eroded; however, many unnecessary barriers to direct PT care still remain.

By amending outstanding legislative restrictions, we can empower physical therapists to exercise the extent of their training, provide patients with less expensive and more timely care, and offer an additional entry point to an overburdened national healthcare system.


American Physical Therapy Association (APTA) (2016, April 15). Direct Access at the State Level. Retrieved from

Direct Access: Where’s the Risk?

Frogner, B. K., Harwood, K., Pines, J. M., Andrilla, H., & Schwartz, M. (2016). Does Unrestricted Direct Access to Physical Therapy Reduce Utilization and Health Spending?

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