A Comparison of Health Care Use for Physician-Referred and Self-Referred Episodes of Outpatient Physical Therapy

Services delivered by physical therapists account for a significant portion of ambulatory care costs in the United States. In 2006, nearly 3.9 million Medicare beneficiaries received physical therapy (PT) services in ambulatory settings, accounting for about $3.1 billion in payments to outpatient and office-based PT practices (Ciolek and Hwang 2008). Individuals not eligible for Medicare, particularly those with musculoskeletal conditions, also account for a significant portion of the ambulatory PT patient population (Freburger, Holmes, and Carey 2003) and ambulatory PT costs (Martin et al. 2008). In 2007, Americans of all ages had over 164 million ambulatory visits for PT (AHRQ 2009b,c). Ambulatory PT services are commonly accessed through a physician referral, but in most U.S. states individuals may also access PT services through self-referral. Currently, PT practice acts in 46 states allow physical therapists to evaluate and treat patients in ambulatory settings without a physician referral (American Physical Therapy Association 2011). Of these, 17 allow unlimited direct access (i.e., evaluation and treatment without physician referral), whereas others impose some restrictions without a physician referral (e.g., limited to certain diagnoses such as the evaluation and treatment for children with developmental delays). Regardless of state practice acts, Medicare and some U.S. private health insurance plans require a physician referral for reimbursement of outpatient PT services. Self-referral, therefore, is primarily dictated by the provisions of patient health insurance coverage and is less likely in insurance plans where the physician serves as a gatekeeper for PT services. Physician gatekeeping is not new; it was debated heavily in the 1980s and 1990s with the proliferation of health maintenance organizations (HMOs), and it is currently being revisited with the concept of the Patient-Centered Medical Home (Mirabito and Berry 2010). The goals of physician gatekeeping are to deliver comprehensive and coordinated care, reduce ineffective and duplicative care, and ultimately, reduce health care costs. Studies of HMO and non-HMO plans generally indicate that quality of care is comparable and health care use is lower in HMO plans, but access to care is poorer and patients are less satisfied with their care (Miller and Luft 2002). Consistent with the concept of physician gatekeeping, opponents of direct access to physical therapists argue that health care costs would increase due to overuse and/or inappropriate use of PT, continuity and coordination of care would suffer due to decreased physician–therapist communication, and serious pathologies would be missed because therapists lack the appropriate diagnostic skills. Opponents also argue that a physician examination is necessary to correctly diagnose and assess a patient's medical condition before initiation of PT, particularly for Medicare beneficiaries or others with comorbidities (Medicare Payment Advisory Commission 2004). Proponents of direct access assert that physical therapists are appropriately educated to diagnose and treat conditions within the scope of PT practice and to screen for other medical conditions requiring a physician's assessment. They contend that direct access can improve the quality of care and clinical outcomes by decreasing patient wait times and health care costs (e.g., by eliminating unnecessary physician visits/tests, initiating treatment early before complications and chronicity begin), as well as ease the workload of overburdened primary care providers, thereby addressing the anticipated physician workforce shortage (APTA 2004). They also argue that the direct access model of care delivery has been successful in the military, where most individuals self-refer to PT for the evaluation and treatment of musculoskeletal conditions (Moore et al. 2005b). While several research studies have explored the issue of direct access by examining the diagnostic skills of therapists relative to physicians (Overman et al. 1988; Springer et al. 2000; Childs et al. 2005; Moore et al. 2005a, b), few have examined issues related to health care use. Mitchell and de Lissovoy (1997) analyzed 4 years of Blue Cross-Blue Shield of Maryland health insurance claims data and found self-referred PT episodes of care were shorter, had fewer services, and were less costly than physician-referred episodes. As they did not control for illness severity, comorbidities, and other causes of persistent health care use, their findings may have been impacted by selection bias (e.g., patients with less severe problems and/or fewer interactions with the health care system may self-refer). Leemrijse, Swinkels, and Veenhof (2008) analyzed electronic health record data and reported fewer treatment sessions for self-referred versus physician-referred episodes of PT, though they also did not control for illness severity. The primary objectives of our study were to compare patient profiles and health care use for physician-referred and self-referred episodes of PT on a large, non-Medicare, population with a common private health care insurance. We extend previous research by using methods to control for comorbidities/persistence of health care use during the previous year, and by examining PT use during the PT episode of care and all related health care use (i.e., related to problem for which PT was received) in three separate time frames: 30 days prior to, during, and 60 days following the PT episode. We examined related health care use to determine whether overall related health care use differs for self-referred versus physician-referred PT episodes.