How would HB 367 expand physical therapists’ scope of practice?
HB 367 would allow a physical therapist (PT) to treat patients without a prescription or referral from an approved health care provider.1
- This only applies to a PT with a doctorate of physical therapy or five years of clinical practice.
- Under current law, without a prescription, a PT may provide educational resources and training, develop fitness or wellness programs, provide screenings, and examine and treat a patient for recently diagnosed chronic illness.
- A PT is required to refer to a provider any patient whose condition is beyond the PT’s scope of practice, or who does not improve after 10 visits or 21 business days (whichever is first).
- The PT must also consult with a provider before continuing therapy if after 10 visits or 21 days, the patient improves and the PT thinks that more therapy is necessary. Continued physical therapy must agree with provider’s direction. The PT must notify the provider of continuing physical therapy every 30 days.
What position does the St. Louis Regional Health Commission (RHC) have on HB 367?
The RHC supports HB 367. Allowing for increased direct access to physical therapy can improve access to health care, improve patient outcomes, and reduce overall health care costs.
What organizations support and oppose these bills?
Organizations who support the bill:
- Missouri Physical Therapy Association
- Arnie C. Dienoff (state public advocate)
- Jean C. Knapp (retired PT)
Organizations who oppose the bill:
- Signature Medical Group
- Missouri State Medical Association
- Missouri Association of Osteopathic Physicians and Surgeons (MAOPS)
What evidence and reasoning have organizations offered in support or opposition of the legislation?
Reasons given in support of HB 367:
- An article published in Health Services Research determined that seeing a PT first (before a physician) for lower back pain (LBP) significantly lowered the probability of having an opioid prescription, advanced imaging service, and emergency department (ED) visits compared to patients that did not.
- The same study suggests that seeing a physician before a PT may lead to earlier, potentially unnecessary imaging and greater health care costs without health benefit.
- Patients with LBP experienced less surgery, injections, specialist and ED visits, and lower health care charges if their primary care physician referred the patient to the PT before referring the patient to advanced imaging services.
- Because PTs initiate nonpharmacological services earlier in the LBP episode, it may alleviate symptoms and accelerate recovery without the need for other health care services. In addition, PTs cannot directly prescribe medication and commonly do not directly order advanced imaging studies. 2
- According to an article published by the Journal of Orthopaedic & Sports Physical Therapy, patients who used direct access to physical therapy for back or neck pain, compared to traditional medical referral, incurred $1,543 less in health care expenses in the year following the start of care. 3
- When patients chose to see a PT first, there were no identified incidents of missed diagnosis or delays in care as a result of PT’s clinical decision making. This suggests that PTs utilizing a standardized, evidence-based screening questionnaire can adequately determine appropriateness of physical therapy intervention. 4
- Other arguments made by the Missouri Physical Therapy Association in support of HB 367:
- The need for a physical therapy referral creates an accessibility problem in under-resourced communities. For example, when there are only two primary care providers in a small town, access is limited.
- Covid exacerbates access issues to PT because if the doctor’s office is closed, patients cannot get referrals.
- Direct access to PT does not take the primary care provider out of the patient’s care.
- In other states with direct access, the number of patients who see a PT without a referral from a doctor remains low (approximately 10-12% on average).
- PT is the only physical function profession that requires doctor appointment and referral every year (e.g. patients can see a chiropractor or acupuncturist directly).
Reasons given in opposition to HB 367:
- The Health Services Research article found that the rate of being admitted to a hospital was higher in the PT first group as compared to those with a physician referral.
- The reasons for the higher hospitalization rates warrant further investigation, although results show that there were no significant differences in hospitalization costs for those who saw a PT first, suggesting that seeing a PT first did not necessarily result in additional costly complications. 5
- Patients who saw a PT first experienced lower out-of-pocket, pharmacy, and outpatient costs, but higher provider costs.
- Higher provider costs may be indicative of a higher frequency of visits that are common for physical therapy care. 6
- Since a provider referral is required for MO HealthNet’s coverage of physical therapy, removing the referral requirement could complicate the process securing coverage. 7
- Other arguments made by opposition, including Signature Medical Group, Missouri State Medical Association, and Missouri Association of Osteopathic Physicians and Surgeons:
- Unintended risks could occur, such as medical misdiagnoses.
- A physician should remain the central component for managing patient care. HB 367 leads to an expansion of scope beyond the education and training required for PTs that could put some patients at risk for further injury. 8
- The bill could jeopardize the requirement/process to disclose a financial relationship between the PT and the physician.
- Hospital groups could buy up physical therapy practices and have financial gain in model. (This is an unrelated policy.)
- Further restrictions, such as limiting treatment to 10 visits before referring back to the physician, are necessary. (The bill does implement restrictions in its provisions).
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Citations
- “Approved health care provider” can be a physician, surgeon, chiropractor, dentist, podiatrist, physician assistant, advanced practice registered nurse.
- Frogner, Bianca & Harwood, Kenneth & Andrilla, C. & Schwartz, Malaika & Pines, Jesse. (2018). Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Services Research. 53. 10.1111/1475-6773.12984.
- Denninger, Thomas R, et al. “The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry.” Journal of Orthopaedic & Sports Physical Therapy, vol. 48, no. 2, 7 Feb. 2018, pp. 63–71. JOSPT, Inc, Movement Science Media.
- Denninger, Thomas R, et al. “The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry.” Journal of Orthopaedic & Sports Physical Therapy, vol. 48, no. 2, 7 Feb. 2018, pp. 63–71. JOSPT, Inc, Movement Science Media.
- Frogner, Bianca & Harwood, Kenneth & Andrilla, C. & Schwartz, Malaika & Pines, Jesse. (2018). Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Services Research. 53. 10.1111/1475-6773.12984.
- Frogner, Bianca & Harwood, Kenneth & Andrilla, C. & Schwartz, Malaika & Pines, Jesse. (2018). Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Health Services Research. 53. 10.1111/1475-6773.12984.
- MO HealthNet currently only covers physical therapy services for patients with a qualified chronic pain diagnosis and provider referral https://dss.mo.gov/mhd/providers/pdf/bulletin41-55.pdf
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