Texas HB 607 and SB 433 are, simply put, consumer access bills. They don't change the scope of practice of physical therapists (i.e. what they can and cannot do as part of their clinical practice). These bills simply remove the current gatekeeper status of physicians. As it currently stands, physical therapists in the state of Texas are the only health care providers remaining that require a referral from a physician. With this having a direct impact on access to care and cost of care for consumers, it is important for everyone to write to their representatives in the House and Senate to support these bills.  I sent the following letter to all members of the House Public Health Committee and the Senate Health and Human Services Committee this past week.

I am a physical therapist in Texas and am writing to you in support of HB 607/SB 433. This consumer access bill would allow Texans direct access to physical therapy services without a referral by another licensed healthcare provider.

There are three primary reasons to support this bill:

Cost: The current regulatory practice - allowing doctors to be gatekeepers to physical therapy in our State - adds enormous costs and waste to our health care system. The added costs are not just to Texans as individual consumers, but also to the State of Texas in Medicare costs. As but one example, a 1994 study by Mitchell and de Lissovoy noted that the total paid claims for "physician referral episodes of care" averaged $2,236, as compared to $1,004 for "direct access episodes". Data such as this has existed for the past 15 years. As costs have continued to skyrocket since then, there is a need to move forward with a regulatory practice that will provide more cost-effective care to all Texans.

Access: The current regulatory practice creates a barrier to health care for Texans. The reality of clinical practice is that when patients are faced with a choice to either 1) go to a gatekeeper (in order to then be referred to a physical therapist) or 2) simply not go at all, they tend to choose the latter option. This creates chronic situations out of acute ones. An acute problem that can be dealt with in a very short period of time can now become a chronic issue that yields years of health care expense.

Training: Physical therapists are internationally recognized as experts in therapeutic exercise prescription. The educational process is extensive and on-going. Under the current regulatory practice, a patient can be advised on therapeutic exercise prescription by virtually any healthcare provider and even personal trainers (none of which have any formal training in therapeutic exercise) - yet a patient requires a gatekeeper referral to exercise the option to see a physical therapist (a healthcare provider who's primary educational background is in therapeutic exercise prescription).

HB 607/SB 433 does not expand the physical therapy scope of practice, nor does it affect the current statutory duty to refer to a healthcare professional for conditions outside of the scope of practice of a physical therapist. The evidence from states that have updated their physical therapy practice act shows that allowing citizens to access a physical therapist without a referral has not negatively impacted liability claims.

I believe it is time for Texas to make a change that benefits all Texans. I would like to thank you in advance for your support of HB 607/SB 433.

If there is any way that I can be of assistance or provide further information regarding this issue, please contact me at 512-914-0871 (email This e-mail address is being protected from spambots. You need JavaScript enabled to view it ), or the Texas Physical Therapy Association at 512-477-1818 (email This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Sincerely,

Allan Besselink, PT, Dip.MDT

Director, Smart Sport International

As I bring this issue to the attention of the consumer, many are absolutely surprised and dismayed that the current regulations exist. For those who have been to physical therapy in the past, they have experienced delays in their care; for those that haven't, they are upset that they don't have the option to access a physical therapist directly - for both issues of access and cost.

For further information on these bills, please refer to my previous post. If you support these bills, please take action! Legislators need to hear a strong voice from their constituents to overcome the political inertia of medical lobbyists.

In the state of Texas, you can't see a physical therapist for treatment without a referral. It's the law - plain and simple. It doesn't matter what your insurance company says regarding your particular "referral requirements" because that relates specifically to whether or not they will reimburse  for your treatment (or not).

Seeing a physical therapist as a first line of health care and assessment is an accepted standard internationally, in many other U.S. states - and even within our own military. But not in Texas.

So here's the crazy reality of this long-outdated regulatory practice.

Let's say you have back pain … or an ankle sprain … so here are some of your current options:

You can see a massage therapist - who may provide some form of exercise program - though massage therapists have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.

You can see a chiropractor - who may provide some form of exercise program - though chiropractors have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.

You can see a physician - who may provide some form of exercise program - though physicians have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.

You can see an advanced nurse practitioner - who may provide some form of exercise program - though nurse practitioners have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.

You can even see a personal trainer - an unregulated and unlicensed occupation - who may provide some form of exercise program - though personal trainers have, for all intents and purposes, little or no formal training in therapeutic exercise prescription.

Under the current law, you can go to any of these "providers"  - all having little or no formal training in therapeutic exercise prescription.  But if you want to go to a physical therapist - the internationally accepted "experts" in therapeutic exercise prescription - you have to have a "gatekeeper" (the list includes physicians, dentists, chiropractors, podiatrists, physician assistants, and advanced nurse practitioners) approve it first.

This is where Texas House Bill 607 and Texas Senate Bill 433 come into play. Both of these pieces of legislation have been filed to provide direct access to physical therapy in the state of Texas. Both are consumer access bills. Neither change the scope of practice of physical therapists in the state of Texas, but they do eliminate the current "gatekeeper" scenario that limits a patient's access to care.

The available evidence squarely supports direct access for physical therapy. Here are the reasons why:

1. As I mentioned previously, physical therapists are internationally accepted as "exercise experts". Our training is focused on the use of therapeutic exercise in the treatment of disorders of the musculoskeletal and neurological systems. Physical therapists have the formal training and education to make functional and mechanical diagnoses for our patients. This is the reality. It is part of our task as physical therapists - to evaluate, to assess, to establish a plan of care. Physical therapist professional education prepares us for autonomous practice, and it is already a part of our current scope of practice.

2. Do physical therapists have the training and education to establish "red flags" in the patient's history, assessment, or treatment that would indicate that physical therapy is not appropriate? This is also an absolute YES. Once again, this is part of our current day-to-day patient care responsibilities. We must be able to decide when it is safe for a patient to participate in physical therapy, and when they must be referred elsewhere.  The difficult cases, the ones that need further diagnostic work-up, are typically NOT the ones that are going to see a physical therapist first - it's those that have conditions like neck and back pain and sprained ankles, issues that - in the literature - respond readily to self care strategies and therapeutic exercise prescription from a qualified practitioner. Studies have shown that there is no increase in the incidence of any medical problems in direct access states. Again, physical therapist professional education prepares us for autonomous practice, and it is already a part of our current scope of practice.

3. Access to health care is an important issue in our health care system. You currently have to go to a gatekeeper for a referral to physical therapy. This currently adds at least one extra step in the process of a patient receiving timely  and effective care that is appropriate to their condition. When given the option to go to a physician first, then to a physical therapist - or simply not bother "jumping through the hoops" (both in cost and in cumulative time), they will oftentimes resort to the latter option, and not get any care at all. This is a barrier to care, making an acute issue a chronic one.

4. Last but certainly not least, there is the cost of care within the current regulatory practices. By adding more steps to get to the appropriate provider, we are creating more barriers to care for the average health care consumer. This "referral" process creates greater costs for the patient and/or insurance carrier.  First you pay your "referring provider" (i.e. physician) for him/her to then send you to a physical therapist, who you will then pay to provide therapeutic solutions to your problem. Why have this extra cost involved?  Studies have shown that there is a direct cost benefit to the consumer by seeing a physical therapist as the first line of assessment. This cost extends not only to the individual but to the state's Medicare system. It has been estimated that there would be a savings of $1200 per patient episode of care - or 55% of the total cost.

So if all the evidence leads us down this path, why is this not the accepted standard of care for all Texans?

This is where we must simply face the harsh reality of our current regulations. There is no evidence that in countries (or states) that have direct access, the cost of care has shown a dramatic increase or a higher incidence of medical problems requiring further medical intervention. As a matter of fact, it's the opposite.  Opponents of more effective legislation are not necessarily driven by patient safety, nor access to care, nor cost of care. So what drives this resistance?

It's not about the patient - and we need to simply stop letting this fallacy be proposed to the public, the legislature, and the media. The primary parties lobbying against this type of legislation are typically physicians and chiropractors, and it is, in all reality, driven by two things: dollars and cents - and power.

Why do these "powers that be" not want physical therapists to have direct access when all of the data supports it being beneficial for the patient and for access to cost-effective health care? Referring sources such as physicians and chiropractors feel that it is not in their best interests financially to have this take place. "It will drop my bottom line" … "It reduces my power as a gatekeeper" … etc.

But as health care dollars grow scarce, and the demand for evidence-based medicine expands, the days of money and power are gone. The gravy train has left the station. The current medical climate forces everyone to be "on their game", to be a provider that a patient would want to utilize to help solve their problem in a cost-effective and timely manner.  In order for our health care system to move forward, it is time for all of us to put our best foot forward and foster a medical system that is truly patient-centered.

Let us not forget, it IS about the patient. It IS about your consumer access to health care. And it IS about the cost of your health care.

What can be done? Speak to your state representative and your senator - they work for you - not the lobbyists. Write letters. Do the reading and understand the issues. And support House Bill 607 (Farabee) and Senate Bill 433 (Carona).

For some supplemental reading, refer to the following:

http://murphy.house.gov/News/DocumentSingle.aspx?DocumentID=61988

http://murphy.house.gov/UploadedFiles/HealthCareFYI?53.pdf

http://www.house.state.tx.us/members/dist69/farabee.php

http://www.senate.state.tx.us/75r/senate/members/dist16/dist16.htm

And while we're at it, how about a few videos to help ilustrate the point - one serious, and one slightly more tongue-in-cheek:

http://www.youtube.com/watch?v=CH4ywhBbp5Q

http://www.youtube.com/watch?v=-Rqa?KU6I2U

I grew up a mile away from the United States. If you turned on the television, you found the obligatory Canadian TV stations. You also found the inundation of U.S. television stations - ABC, NBC, and CBS - from locales in New York or Michigan.

Every four years, we bear witness to the Summer Olympics. And every four years, we're subjected to what seems like an exceedingly nationalistic and biased view of the Olympics. Of late, it's been NBC's perogative to show us any sports in which the U.S. might be dominant.

Every four years, as a born-and-raised Canuck, I have an ongoing debate about the seeming lack of medals attained by my homeland - as compared to the treasure trove of medals attained by the Unites States.

So before we go any further, let's put the raw data out there:

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That's the question I am asking myself since Sen. McCain selected Governor Sarah Palin as his vice presidential running mate.

Forget about the fact that it took the Republican party 24 years after Democrat Geraldine Ferraro - just a few extra years of learning curve in there to acknowledge the potential of gender in the election mix.

So is McCain's choice intriguing? Or disturbing?

First, the former. It may have been a stroke of political genius to select a woman. There are a lot of Hillary supporters just waiting to jump ship on the Democrats and vote for any ticket that has a woman that will symbolically break the glass ceiling. She's young and tenacious. She's a former Miss Alaska runner-up. She's a fresh voice in Washington. Those are all positive elements. She has some understanding of oil and natural resources from her time as Governor of Alaska. She's married to a steelworker and commercial fisherman - so it would certainly sound like she just might be in touch with the heartland of America.  

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