The Donut Hole in Primary Care PT

The occurrence of federal legislation that heavily impacts the practice of Physical Therapy typically comes from changes to the Medicare and Medicaid system. These laws don’t normally change how we practice, but moreso change how we document and bill for things. However, several bills recently introduced to Congress could significantly impact how Physical Therapists provide services.

One of these bills, HR 5365 – Primary Health Services Enhancement Act, has the potential to expand our ability to provide care for patients under Medicare and Medicaid by cementing the Physical Therapist as a primary care provider1. This bill gives Physical Therapists the ability to provide services to Medicare and Medicaid beneficiaries and independently bill for that care in rural health clinics and federally qualified health centers. The bill was introduced to Congress (where it still sits) in September 2021. So, why is this important? I’ll use Texas as an example, but most states have low-access rural areas that will benefit from this.

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The State of Texas has 35 counties that have no primary care physician and ranks 41st in the country for physician-to-population ratio2. If you do the math, that means every available physician (not just primary care) has 1913 patients who require their care. This is a problem that is expected to grow by another 47% by 2032. Unfortunately, only 47% of primary care offices in Texas utilize mid-level providers to expand access and those in single-provider offices, which are more likely to provide care for rural areas, are least likely to utilize mid-level providers3. Many organizations are looking at solutions including increasing physician reimbursement, increasing funding and scholarships for physician education, and medical student debt relief programs, but to no avail4. It’s time we look outside the box by increasing access to other qualified providers to offload the current workforce, which would create overall better working environments for physicians.

“Instead of relying on old models and assumptions of how things have always been done, teams develop new solutions that are matched to the details of the problem.”

Dr. Jason Silvernail, a U.S. Army PT, in reference to how the military solved a physician shortage in the 1960s5

Where do Physical Therapists come in? The utilization data from 2013 shows that almost 105 million of the 1.25 billion physician visits in the United States were for musculoskeletal or soft tissue-related conditions6. According to this data, the most frequently reported musculoskeletal condition was knee pain and the most costly was non-specific low back pain, both conditions that are effectively and efficiently treated by Physical Therapists7. This means that Physical Therapists could offload nearly 10% of visits from primary care providers across the country. But you may be asking, “Is this safe?”

Decades of research answer this question with a resounding, “Yes.” Not only is it safe, but it is also less costly, more time-efficient, and results in better patient outcomes (Frogner, et al., 2018; Fritz, et al., 2012 & 2017; Arnold, et al., 2019; Bornhöft, et al., 2019; Demont, et al., 2020, Garrity, et al., 2020). The military has been practicing in this manner for decades and they have produced a large amount of research to show that Physical Therapists are significantly better diagnosticians of musculoskeletal conditions than primary care physicians and are equally as accurate in diagnosis and referral as orthopedic surgeons (Plack, 2000; Moore, et al., 2005).

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This is all only in reference to musculoskeletal conditions, but the evidence for use of prescribed guided exercise for the treatment of multi-system health conditions such as obesity, diabetes, heart failure, hypertension, chronic obstructive pulmonary disease, depression, cancer, and many others has been well established for decades (ACSM, 2021). Quoting Dr. Silvernail, a PT in the US army, “There may be barriers to translating such a [military] model to civilian care, such as high copays and Medicare not recognizing PTs as primary care practitioners, but such barriers are based on health policy, not on medical necessity or appropriateness5.”

“…barriers are based on health policy, not on medical necessity or appropriateness.”

Dr. Jason Silvernail, PT, US Army

As the law currently stands, veterans, active-duty military and their families, and people with private third-party payers can access a Physical Therapist directly in all states and the Physical Therapist can independently bill for their services. This creates yet another donut around Medicare and Medicaid recipients, as they do not currently have this access. The passage of HR 5365 has the potential to fill this donut hole for this large group of people1. This solves more than one problem, as access to primary musculoskeletal (and hopefully chronic disease) care will increase for a population that utilizes these services at a higher rate than the general population (Liu, et al., 2016; Fritz, et al., 2011), offloading other providers who are already stretched too thin.

Overall, this bill does not change our profession or our services at all, as the military has been utilizing primary care Physical Therapists since the Vietnam War5. In an interview with the American Physical Therapy Association, Dr. SIlvernail stated, “No single provider can do it all—that’s why you need a team. PTs are ready now to take on this team role if we are willing to confront the policy obstacles that stand between Americans and the quality care provided by doctors of physical therapy as part of primary health care teams.” The Primary Health Services Enhancement Act is the policy change Medicare and Medicaid beneficiaries need to increase access to quality care, especially in rural settings.

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Don’t just take my word for it. Former APTA President Sharon Dunn had this to say “Community health centers provide health care services to over 29 million people in over 12,000 rural and urban communities. Increased access to physical therapist services in these communities is essential for those recovering from Long COVID, and provides a non-pharmacological treatment option for those with chronic pain… this important legislation … will expand patient access to essential physical therapy services, and provide flexibility to community health centers in how they deliver care.”

So, what’s the ask? A Call to Action. Contact your Representatives and Congresspeople and tell them HR 5365 – Primary Health Services Enhancement Act needs their vote. When you do, let me know by commenting below!

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Read more here!

Pressure… Pushing Down On Me…

Breathing. I can’t stress it enough. If you’re not breathing, you’re dead… or in a lot of pain… either way, it’s not good. So breathe! In my practice, I work with a lot of different types of patients with a wide variety of conditions and comorbidities, but they all have one thing in common: they…


WHILE WE WAIT FOR THE NECT CHAPTER OF DIABETES MANAGEMENT, LET’S KEEP TALKING ABOUT INCONTINENCE Chronic management of urinary incontinence can lead to many issues like infection and hospitalization if it doesn’t account for fluid balance! Let’s talk I’s and O’s! #physicaltherapy #incontinence #chronicdisease


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  1. Primary Health Services Enhancement Act, H.R. 5365, 117th Cong. (2021).
  2. Cross, R. (2021). Access to care: Addressing Texas’ physician-to-population ratio. Texas Hospitals Association.
  3. Center for Disease Control and Prevention (CDC). (2014). State variability in supply of office-based primary care providers: United States. National Center for Health Statistics.
  4. Graham Center. (n.d.) Texas: Projecting primary care physician workforce.
  5. Silvernail, J. (2018). Primary care and the Physical Therapist: Lessons from the military.
  6. American Academy of Orthopaedic Surgeons (AAOS): Department of Research & Scientific Affairs. (2013) Physician Visits for Musculoskeletal Symptoms and Complaints. 
  7. Arnold, E., La Barrie, J., DaSilva, L., Patti, M., Goode, A., & Clewley, D. (2019). The effect of timing of physical therapy for acute low back pain on health services utilization: A systematic review.  Archives of Physical Medicine and Rehabilitation, 100(7), 1324–1338.
  8. Frogner, B.K., Harwood, K., Andrilla, C.H.A., Schwartz, M. and Pines, J.M. (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 Serv Res, 53: 4629-4646.
  9. Fritz, J., Childs, J., Wainner, R., Flynn, T. (2012) Primary care referral of patients with low back pain to physical therapy. Spine, 37(25), 2114-2121 doi: 10.1097/BRS.0b013e31825d32f5
  10. Fritz, J. M., Kim, M., Magel, J. S., & Asche, C. V. (2017). Cost-effectiveness of Primary Care management with or without early physical therapy for acute low back pain: Economic evaluation of a randomized clinical trial. Spine (03622436), 42(5), 285–290.
  11. Bornhöft, L., Thorn, J., Svensson, M., Nordeman, L., Eggertsen, R., Larsson, M. (2019). More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment. BMC Musculoskeletal Disorder. 20(1). doi: 10.1186/s12891-019-2553-9.
  12. Demont, A., Quentin, J., Bourmaud, A. (2020). Impact of care models integrating direct access to physiotherapy in a primary or emergency care context for patients with musculoskeletal disease: a review of the literature. Journal of Epidemiology and Public Health [French]. 68(5), 306-313.
  13. Garrity, B. M., McDonough, C. M., Ameli, O., Rothendler, J. A., Carey, K. M., Cabral, H. J., Stein, M. D., Saper, R. B., & Kazis, L. E. (2020). Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain. Physical Therapy, 100(1), 107–115.
  14. Plack, M. (2000). The Evolution of the Doctorate of Physical Therapy: Moving beyond the controversy. Journal of Physical Therapy Education.
  15. Moore, J. H., Goss, D. L., Baxter, R. E., DeBerardino, T. M., Mansfield, L. T., Fellows, D. W., Taylor, D. C. (2005). Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopedic surgeons, and non-orthopedic providers. Journal of Orthopedic & Sports Physical Therapy. 35(2), 67-71.
  16. American College of Sports Medicine, Riebe, D., Ehrman, J. K., Liguori, G., & Magal, M. (2018).  ACSM’s guidelines for exercise testing and prescription (Tenth edition.). Philadelphia: Wolters Kluwer.
  17. Liu, X., Hanney, W., Masaracchio, M., Kolber, M. (2016). Utilization and payments of office-based physical rehabilitation services among individuals with commercial insurance in New York state. Physical Therapy, 96(2):202–211,
  18. Fritz, J., Hunter, S., Tracy, D., Brennan, G. (2011). Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. Physical Therapy, 91,(3):330–345,

Follow @DoctorBthePT on Twitter for regular updates!

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Follow @DoctorBthePT on Twitter for regular updates!

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