Do State Direct Access Laws to Physical Therapy Influence Healthcare Utilization and Costs Among Medicare Patients With Atraumatic Rotator Cuff Tears? An Instrumental Variable Approach

OBJECTIVES: The American Physical Therapy Association categorizes the extent of direct access in every state to physical therapy (PT) into 3 categories: limited, provisional, and unrestricted. The objective of our study was to assess whether known variations in early use of PT due to differences in PT direct access laws are associated with differences in healthcare spending and utilization.

METHODS: Using Medicare claims data from 2016 to 2018, we identified beneficiaries with a new onset of shoulder pain (index date) in 2017 with a subsequent diagnosis of atraumatic rotator cuff tear. We used PT direct access laws as instruments for whether patients saw a physical therapist within 30 days (early PT) from the index date. We then used two-stage least squares to assess the impact of early PT on total healthcare spending and use in the year following the index date + 30 days.

RESULTS: Of the 66,361 patients included patients 15.1% of the patients used early PT. The first stage regression shows that patients in states with unrestricted or provisional access to PT had higher utilization of early PT. After adjusting for potential confounders, our results show that patients whose early PT use was sensitive to PT direct access laws had lower rates of hospitalization and treatment for atraumatic rotator cuff tear. We found no reductions in total spending, possibly due to a shift from outpatient, inpatient, and home health aide spending to provider fees and prescription drugs.

CONCLUSIONS: We found that among patients whose early PT use was influenced by PT direct access laws, there was a reduction in healthcare utilization for some services. Our results suggest that policymakers in the states that are wishing to increase the use of PT may consider liberalizing their direct access laws. Future studies should assess the impact of these laws on patient health outcomes.