PT Classroom - Direct Access: A Change in Mindset and Practice to Reduce Cost and Improve Care  ׀ by Monique Serpas, PT, DPT


Monique Serpas, PT, DPT is a physical therapist who holds a Doctor of Physical Therapy from Concordia University Wisconsin (2008) and a Bachelor of Science in Kinesiology from Louisiana State University (2004). She practices in an outpatient setting and treats orthopaedic, balance, and vestibular disorders. This past spring, she worked with a multidisciplinary team to develop a falls prevention program. Additionally, she is a Titleist Performance Institute Certified Golf Medical Professional, offering services to help prevent and rehabilitate golf injuries. She is a member of the American Physical Therapy Association (APTA), Wisconsin Physical Therapy Association (WPTA), and the Orthopaedic and Neurology sections of the APTA. She is involved in the PT professional organization, serving on the Southeast District of the WPTA as Academic Liaison Committee Chairperson. In her spare time she is an author of a blog "Geaux to Physical Therapy" which helps educate visitors on physical therapy services and physical therapy.



Direct Access: A Change in Mindset and

Practice to Reduce Cost and Improve Care

On January 6, 2011, Hawaii passed direct access legislation and joined the ranks as the 46th state to allow direct access to physical therapy services without a physician referral. With last year's healthcare reform and the discussions surrounding it, the cost and efficiency of healthcare has been brought to the forefront of every American's mind. Now, more than ever, physical therapists are poised to be the solution to rising healthcare costs related to the treatment of musculoskeletal injuries by way of direct access to physical therapy services.

In corresponding with American Physical Therapy Association (APTA) reimbursement specialists, each insurance provider has different policies in regard to direct access, however, more and more are allowing it due to its cost effectiveness. A study of insurance claims made to Maryland’s Blue Cross Blue Shield from 1989–1993 shows that episodes of physical therapy care for acute musculoskeletal conditions were shorter and more cost-effective ($1,004 vs. $2,236) for direct access PT compared to physician-referred PT. Also, physician-referred clients had 67% more therapy visits and 60% more office visits compared to direct access clients. The researchers show that more medication, injections, and imaging studies were utilized in physician-referred clients, impacting the total of paid claims per episode of care. Claims that utilized direct access were 137% cheaper overall. With direct access, clients can see a physical therapist earlier and hopefully prevent conditions from becoming chronic issues that are less receptive to conservative treatments. Allowing for direct access in our practice will not only decrease the cost of care but also improve patient outcomes.

Due to unrelenting lobbying by the APTA, state-level PT associations, and grassroots efforts by physical therapists, direct access is available in most states with the exception of Michigan, Indiana, Tennessee, and Alabama. So, how has this changed our practice? The Direct Access Utilization Survey conducted by the APTA in February 2010 found 55% of surveyed PTs (in nine polled chapters) are utilizing direct access and educating their clients about it. Over 80% of private practice PTs have utilized direct access compared to just 34.2% of health care system/hospital-based outpatient PTs. Of the practitioners that utilize direct access, 69% reported that direct access clients constituted 10% or less of their client base. 60% of practitioners utilizing direct access market directly to consumers, with the three most effective strategies being building relationships with existing customers, participating in community events, and advertising. 43% of practitioners utilizing direct access reported they market directly to non-physician referral sources including coaches, athletic trainers, personal trainers, and nurse practitioners with face-to-face interactions being most effective.

Many primary care practitioners including physicians, nurse practitioners, and physician assistants are aware of physical therapy services for the treatment of musculoskeletal disorders. I'm happy to see more and more urgent care and emergency room referrals for evaluation and treatment for diagnoses like sciatica, back pain, and ankle sprain. However, where we as physical therapists really need to focus our message and marketing is to the general public. Are physical therapists thought of as the practitioner of choice for musculoskeletal injuries and pain? Does the general public know what physical therapy is and what it can do for them? Do they know that they can go directly to a physical therapist without a physician referral?

Healthcare reform and the victory of gaining direct access in Hawaii provides every physical therapist with an opportunity to have these conversations with each patient. It's as simple as telling them at discharge, "If you have any other musculoskeletal problems in the future, you are not required to see your physician prior to coming, just make an appointment for an evaluation." However, we can do better. Grassroots efforts are needed from every physical therapist establishing PTs as trusted practitioners in the treatment of musculoskeletal disorders. Get into the community more. Do health fairs. Volunteer at endurance athletic events such as 5Ks or century rides. Write an article for a newspaper or magazine. Comment on news articles pertaining to PT. Establish or write for a blog. Discuss specialty practices in PT with each patient. Give community presentations on topics in PT. The benefits to your patients, practice, and profession will be tangible and rewarding.

As you can see, physical therapy has an immense opportunity to be a solution to rising healthcare costs through the use and promotion of direct access. Most insurance companies allow direct access, but as the utilization survey found, not all PTs are utilizing direct access. This is in part due to the general public’s lack of awareness of physical therapy and the benefits of our services. Efforts by the APTA to improve client awareness of physical therapy and direct access can be made more effective by the grassroots efforts of each and every physical therapist. With these changes in mindset and practice, physical therapists can make a measurable impact on the cost and quality of care.

You can find additional resources on direct access at the reference link below including a general overview, rationale, laws by state, and the Mitchell cost effectiveness study at

Last revised: January 11, 2011
by Monique Serpas, PT, DPT


APTA | Direct Access in Practice. (2010). Retrieved December 28, 2011, from

APTA | Direct Access Resources. (2010). Retrieved December 28, 2011, from

Mitchell, J. M., & de Lissovoy, G. (1997). A Comparison of Resource Use and Cost in Direct Access Versus Physician Referral Episodes of Physical Therapy. Physical Therapy, 77(1), 10 -18.

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