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Why should your physical therapy clinic care about direct access?

Updated: Oct 9, 2018

EuMotus co-founder and Harvard Business School graduate Boris examines direct access physical therapy through a business perspective.

There are two main ways a physical therapy clinic can obtain more patients - direct access, and physician referral.

On the latter, physical therapy clinics are completely dependent on a third party sending patients over. While this can be great for business, especially if attached to a big hospital rehabilitation network. However, there is a risk of relying nearly exclusively on external parties for getting new patients.

Fortunately, the APTA states that some form of the former form of acquiring customers in direct access is allowed in all 50 US states [1].

So who is the physician referred physical therapy patient, and who is the direct access patient? What are their characteristics and conditions and why should the PT clinic owner care? Ojha et. al. review the literature on direct access, and we present a few of the more interested findings relevant to direct access below [2].

79% of direct access patients finished course of care, relative to 60% in physician referred group! [3]. This is a 32% increase in treatment completion, which is great for both health outcomes, and for the business bottom line!

This difference in treatment completion is significant, since an uptick in patient retention would lead to an increase in revenue. A patient visit leads to approximately $100 in revenue booked, while a missed patient visit leads to no revenue booked. Figuring out ways to minimize missed visits is key to keep the physical therapy business financially healthy!

For a largely fixed cost business in physical therapy (a bigger office or more staff is likely not needed for an increase in customers), we would expect this to lead to greater profitability. A 5% increase in revenue, in this case by way of increased patient retention, results in a 25% increase in profitability [6]. Check out our patient retention calculator to dig deeper into the effect of increased patient retention due to incorporation of our motion analysis system.

Self-pay (cash-based physical therapy) patients are reported as the biggest group of direct access customers [1]. This difference could be due to higher rates of word-of-mouth referrals from satisfied patients rather than doctors.

Direct access can lead to better outcomes and happy patients. Direct access patients have better outcomes at discharge vs. physician referred patients [3] [4]. Approximately 9% more direct access patients achieved discharge goals than referred patients. [3][4]. Patients with better outcomes are more likely to refer friends and colleagues. This can help you to grow your business organically with friend-referred patients who already have some level of buy-in.

Who would you choose? Physician referred patients or direct access patients?

Another interesting finding was that there was less reported pain on average for direct patient, vs referred patient upon discharge [3]. Direct access has also been shown to reduce burden on the healthcare system: less costs - less drugs, less imaging, while achieving superior outcomes [2].

Interestingly, Ojha found less visits for direct access customers, than for physician referred customers in two US studies [2], which brings into question direct access patient self-selection. It could be that direct access patients are motivated to get better and stick to their course of treatment. There is also strong evidence to show direct access group patients take less drugs, and required less imaging [2].

So who is the direct access patient? While the studies reviewed above have some biases and limitations, we are starting to generate a picture of how they compare to a physician referred physical therapy patient. We do not necessarily have a full picture of the direct access patient, but we can see that perhaps they are different from the physician referred patient.

Ok, so why should I take action?

Only 1 in 10 patients who could use physical therapy was referred to physical therapy by a physician [5]. Clearly there is opportunity of improvement of positioning physical therapy as the movement and physical health experts in the US. While some improvement of this positioning is dependent on national organizations such as the APTA, we will focus on what PT business owners and PT clinic directors can take to make their business leverage direct access.

Is direct access allowed by regulation in the US?

All 50 states allow at least some form of direct access to physical therapy [1]. Here is an intro to tactical tips approaching regulations and insurance with direct access [7].

Great! What do I do now?

Step 1 to direct access: put a big open for business sign on your clinic [8].

How would you put a big open for direct access sign on your physical therapy business?

Sounds good, but what are the concrete steps owners and directors can take to position their physical therapy businesses as open for direct access patients?

Check back in next week’s blog post on physical therapy clinic marketing for direct access!

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Have questions or tips on direct access to physical therapy? Curious about using motion analysis to generate demand for your clinic? You can reach out at boris/at/eumotus/com.


[1] Direct Access Survey Report. APTA. 2017. Accessed September 2018.

[2] Heidi A. Ojha, Rachel S. Snyder, Todd E. Davenport; Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review, Physical Therapy, Volume 94, Issue 1, 1 January 2014, Pages 14–30

[3] Holdsworth L, Webster V . Direct access to physiotherapy in primary care: Now?—and into the future? Physiotherapy . 2004;90:64–72.

[4] Leemrijse CJ, Swinkels IC, Veenhof C . Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy. Phys Ther . 2008;88:936–946.

[5] APTA. Lower back pain study. 2017. Accessed September 2018.

[6] Reicheld. 2001. Accessed September 2018.

[7] Direct access physical therapy basics. 2017. Accessed September 2018.

[8] EuMotus created graphic, with emojis from Accessed September 2018.

[9] Tumisu via pixabay. Accessed September 2018.