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March 6, 2017 Senator Van Taylor P.O. Box 12068 Capitol Station Austin, TX 78711 Representative Stephanie Klick P.O. Box 2910 Austin, TX 78768 Re: HB 2118 and SB 728 Dear Senator Taylor and Representative Klick: On behalf of the organizations listed above, we are writing to express our opposition to SB 728 and HB 2118, which would allow physical therapists to initiate services without a medical diagnosis in place for 30 days. While physical therapists are important members of the health care team, they are neither licensed nor trained to make a medical diagnosis. A medical diagnosis serves as the foundation for physical therapy services and acts as a filter to ensure that a patient is provided the most efficient and high quality treatment possible. Correctly diagnosing a musculoskeletal condition involves a number of factors, including the performance of a comprehensive history and physical examination, and, when indicated, imaging, laboratory testing, and other diagnostic procedures. Physical therapists are not able to provide these services.

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A Better Solution for Patients: One Evaluation and Treatment We firmly believe that the best course for an individual who is suffering from discomfort is to first see a physician in order to obtain a medical diagnosis before embarking on any treatment regimen. But, we recognize that many lay people try an exercise program on their own to alleviate painful conditions of the spine or limb by asking friends for advice, or searching for online advice. Rather than base a “therapeutic” exercise program on the advice of other lay persons or from surfing the internet, it would be reasonable for people over five years old to get a one-time instruction from a licensed and regulated professional, such as a physical therapist, on what exercises they should and should not do and the proper technique for performing them. If the discomfort does not respond to such a program, that is a sign that further workup is required in order to establish a medical diagnosis upon which further treatment can be based. The most important point to keep in mind about physical therapy is that it is fundamentally comprised of exercises to improve joint flexibility, as well as the strength, stamina, and coordination of specific muscle groups. Doing so can give relief of discomfort from a number of common musculoskeletal conditions. It is important to note that once these exercises are learned, many can be self-performed at home or at a gym. Physical modalities (ultrasound, stimulation, heat, cold, whirlpool, massage, etc.) only provide temporary relief of discomfort; they do not provide long-term benefit. Although such modalities often come to mind when lay people think about physical therapy, they are not necessarily the most important aspects of physical therapy treatment. Physical therapists are trained to instruct people on therapeutic exercises. Under current Texas law, physical therapists may evaluate a person without a prescription for a specific injury or condition, but they may not provide treatment without a proper medical screening first being established. For a person over five years old with a specific injury or condition to see a physical therapist for a one-time instruction of a home exercise program without first obtaining a medical diagnosis and a proper screening would be reasonable. Any treatment beyond that, however, should be guided by a medical diagnosis from a physician. Adding the ability of physical therapists to have one evaluation and treatment for patients five years and older without an appropriate referral would add to the three existing scenarios in Texas law that allow for direct access to physical therapy. Asymptomatic individuals may visit a physical therapist without a referral for physical assessments or instructions. A patient may return to a physical therapist for a previous injury or condition that was the subject of a referral within the past year. Patients may visit a physical therapist first for an evaluation. The physical therapist may then sign off for further treatment with an appropriate provider. Direct Access Opens the Door to Inappropriate Care Health care policy debates around the nation focus on producing higher quality and more reasonable costs. Evidence from one of the largest studies looking at the quality of physical therapists’ decisions gave 1,000 randomly selected private practice physical therapists a collection of 12 hypothetical patient scenarios. The physical therapists were asked to choose whether they would provide intervention, provide intervention and refer, or refer on to a physician. The decisions were based on criteria developed by physical therapists. Results demonstrated: • Physical therapists made all of the correct decisions 50 percent of the time. • Physical therapists were correct 56.1 percent of the time for 100 percent of non-critical cases.

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• Physical therapists were correct 49.6 percent of the time for 100 percent of critical medical cases. (Jette DU et al, Physical Therapy 2006; 86(12)) We believe that these results demonstrate that physical therapists are not the proper health care provider to serve as the first point of contact for a patient. In June 2014, the U.S. Government Accountability Office (GAO) released a groundbreaking study of physical therapy services provided to Medicare patients. The report demonstrated that orthopaedists who provide physical therapy services in their offices had much lower overall costs of physical therapy during the period studied than those physical therapy services that were referred to physical therapists who were not affiliated with an orthopaedist. The total number of self-referred physical therapy services essentially showed no increase from 2004 to 2010 for orthopaedists who self-referred, whereas non-self-referred services (independent physical therapy) increased by 41 percent. The GAO provided an explanation for this strong growth in services associated with physical therapy (PT) that was not coordinated with a physician:

“One potential reason for this difference is that non-self-referred physical therapy services can be performed by providers (physical therapists) who can directly influence the amount, duration, and frequency of physical therapy services through the written plan of care required by Medicare. In contrast, non-self-referred services we examined for our prior work tend to be performed by providers who have more limited ability to generate additional services or referrals; for example, radiologists generally do not have the discretion to order more imaging services or more intense imaging procedures.”

Health care is entering an era in which all types of providers – including therapists and physicians – are working together in a team care approach that focuses on every aspect of a patient’s episode of care, and this GAO study is one of the strongest examples of the value of coordinated care. The study demonstrated that when a patient’s physical therapy is coordinated, the physician and physical therapist can work together to end the physical therapy when it is appropriate to do so. Physical therapy direct access focuses on a fragmented health care delivery model. Working Together to Enhance Quality and Efficiency No amount of increased access to our allied health providers will substitute for the value inherent in a well-trained physician. Direct access to physical therapy will likely result in increased costs to patients without providing any measureable improvement in quality. It is a low-value solution. It is important to focus on one crucial set of data for Texas patients: Not one major medical study has demonstrated a decrease in the total health care costs for a population after direct access without a medical diagnosis was instituted by a state legislature. Until medical studies show that expanding physical therapy direct access without a medical diagnosis provides higher quality of care at a lower cost, Texas should focus its time and energy on evidence-based strategies for proven care that is cost effective.

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Sincerely,

Don R. Read, MD

Texas Medical Association

Kyle F. Dickson, MD Texas Orthopaedic Association

Joyce E. Mauk, MD

Texas Pediatric Society

Tricia C. Elliott, MD

Texas Academy of Family Physicians

Deborah L. Plagenhoef, MD

Texas Society of Anesthesiologists

Victor H. Gonzalez, MD

Texas Ophthalmological Association

Steven Hays, MD

Texas Chapter – American College of Physicians

Kimberly Carter, MD

Texas Assn of Obstetricians and Gynecologists

David E. Garza, DO

Texas Osteopathic Medical Association

Timothy C. Allen, MD, JD Texas Society of Pathologists

Richard K. Hurley, MD

Texas Pain Society

Jay N. Yepuri, MD Texas Society of Gastroenterology & Endoscopy