More states continue to expand PT practice acts to allow us to refer for diagnostic imaging. Maryland, Colorado, Utah, Wisconsin, Rhode Island, North Dakota, District of Columbia, New Jersey, West Virginia, and Arizona all belong to the “PTs allowed to order imaging” club. Iowa just became one of its newest members a few months ago. The stipulations of each of these state’s practice acts differ greatly, but they all allow PTs to refer for imaging in some capacity.
Only a small portion (about 20%) of US states currently allow PTs to order imaging even though it makes quite literally PERFECT sense that PTs would have this ability. I mean chiropractors are able to order imaging. I cannot think of another US healthcare provider, with a doctoral degree, that has the need to order imaging but doesn’t have the privilege. Research shows we are MORE than qualified for this. A study by Mabry and colleagues showed PTs are already using the skills needed to appropriately refer for diagnostic imaging.
Research also demonstrates multiple benefits for patients and the healthcare system overall by allowing PTs to order imaging. So add imaging to the long list of ways research supports expansion of PT privileges but our healthcare and government systems don’t.
This week’s blog post will address 3 major topics related to PT and imaging. 1.) Why we should be able to order imaging – with the hopes this info will be shared. 2.) Debunking some of the myths when it comes to overuse and reimbursement of imaging ordered by PTs. Finally, 3.) how we work to get this privilege and own the responsibility that comes with it.
PT and Imaging – It Just Makes Sense
With the expansion of PT direct access, imaging privileges are the next logical next step. The potential of primary care PT to save the healthcare system a shit ton of money was discussed in an earlier post. Adding the ability now for PT’s to order at least x-rays and MRIs would only increase those savings.
If a patient comes to PT via direct access it seems unnecessary to refer to a PCP just to get an order for imaging. Not to mention the time it takes for this to take place. Right now if a patient needs to get into another physician the wait is usually weeks to months just for that appointment. Then add another wait to actually get the imaging! The ability for PTs to order imaging would decrease unnecessary healthcare utilization since another appointment with a separate provider isn’t needed. It expedites care for patients, increasing satisfaction and outcomes.
These benefits have been demonstrated in our own military service where PTs are allowed to order imaging. If the military has been operating this way for years isn’t it a little odd we wouldn’t make it the standard of care? If there was something going extremely wrong with PTs ordering imaging in this setting I doubt they’d let it continue.
Also, raise your hand if you’ve ever spent part of a session educating a patient to untangle false narratives put in their head because of how another physician explained their imaging results? I know my hand is up sky high on that one.
PT’s are perfect healthcare providers to refer patients for imaging due to our unique skill set. I’m guessing I’m not the only PT who takes the philosophy of a patient is not their imaging? Or image results are not always equal with pain level? Because of what we know about pain and safe patient language, PT’s in my opinion are one of the top provider choices for explaining imaging results to a patient.
The list supporting PT imaging referrals is OVERWHELMINGLY long. I swear I could write this entire blog post just on that but I’d just be preaching to the choir. I’d rather give some info to debunk the two major concerns that surround PT referral for imaging.
The Overuse Myth
One of the biggest arguments against PTs when it comes to imaging referral is that we’ll overuse it. In my opinion, this has got to be one of the most ignorant counter arguments against expansion of PT practice out there for two very basic reasons.
The first reason is we are VERY comfortable seeing people who haven’t had imaging, but want it. Everyday we hear a patient say they want their MRI! Honestly, 9/10 times I don’t think they need one or at least I don’t think it’s warranted yet. In fact, I love nothing more than when the patient gets better and I hear them say “Yeah it’s feeling better so I don’t think I need to get that MRI.”
This feeling wouldn’t change for me just because I had the ability to refer for imaging. From other PTs I’ve talked to, many of them share this same sentiment. Anyone else? PT’s are not a profession that will easily get bullied into unnecessarily referring for imaging.
The 2nd and obvious reason overuse is a MORONIC myth is everyone’s favorite thing . . . INSURANCE! So with the way things currently work, insurance often doesn’t approve MRIs and other more expensive imaging until the patient tries other treatments first. News flash to those that are trying to use this argument – that isn’t going to change just because PTs can order the imaging!
Example A – a patient participates in PT for 4-6 weeks without improvement. They go back to the referring physician who orders an MRI, which insurance approves. Patient gets an MRI.
Example B – a patient participates in PT for 4-6 weeks without improvement. PT orders MRI, which insurance approves. Patient then gets an MRI.
Both of these situations result in the use of only one MRI. But only ONE results in decreased utilization of the healthcare system. Just going to leave that one there . . .
The Reimbursement Myth
All this talk about insurance brings us to the second myth which is that insurance is not/will not reimburse for imaging ordered by PTs. However, this fear has actually been disproven. A small study by Keil and colleagues tracked orders of diagnostic imaging from PTs over 5 years and found no issues with reimbursement.
Dr. Lance Mabry, has been a big champion of PT ability to refer for imaging. He’s very knowledgeable on this topic and has even done his own research on it, which I mentioned earlier. I highly recommend listening to this podcast with him from the Integrative Pain Science Institute. I found it so educational and informative regarding the misconceptions about PTs and imaging.
On this podcast he speaks directly about this myth of reimbursement denial. What he actually notes is research shows the reimbursement rate to be very high for PT-referred imaging. What’s more interesting is he mentions research shows that the fear of denials decreases the usage of ordering imaging more than anything. So I guess we can add that to our list of times we’ve become our own worst enemy.
Advocacy
I believe imaging privileges is the next step for us as a profession. How do the rest of us get into the “states allowed to order imaging” club? It will come down to the efforts of each individual state. There isn’t going to be some big national ruling on this. Honestly, I think a lot of what we want to accomplish as a profession has to happen at a state level.
I know everyone has conflicting feelings toward APTA, but it is going to take support of state APTA chapters to achieve our goals when it comes to imaging.
If you want to get involved your state chapter may already have efforts in place, but I’d venture to guess they could use all the support they can get. If they don’t, you may be the person for the job! APTA even provides some info about how to start an imaging advocacy effort in this resource.
Strategically, I would say APTA chapters pursuing expansion of practice acts into diagnostic imaging should reach out to those who’ve been successful. Chapters fighting their battle now could have a lot to learn from those who did it previously. What worked for them? What didn’t? What arguments did the opposing side present? What other barriers were there?
That kind of information can make the advocacy efforts of the next chapter much more successful. Anyone been involved or currently involved in their state chapter advocacy for imaging? What’s your experience been so far? Please share in the comments so we can all learn from each other’s experiences!
With Great Power . . .
It’s basically age old wisdom at this point and very applicable in this case . . . with great power comes great responsibility. With the power to order imaging, comes the responsibility to continue to educate ourselves on current diagnostic imaging best practices.
For some of us it may mean reminding ourselves of tools like the Ottawa knee and ankle rules. It may mean introducing ourselves to new ones like the Appropriateness Criteria of Radiology. There’s also new continuing education courses emerging.
Lance Mabry who I mentioned earlier offers a course through Redefine Health Education. Medbridge, which some of you may already have a subscription to has some courses as well. One of my favorite CEU providers, Evidence in Motion, also offers a Musculoskeletal Imaging Course.
If you’re not ready to commit to a course you may have a perfectly good resource likely sitting in the back of a closet somewhere. Anyone else keep that MASSIVE Dutton’s Orthopedic textbook? I have the 4th edition and there is a whole chapter in there on imaging! It goes over different types of imaging, different views, and indications. Granted, some info may not be the most current, but the basics are there and it is a great starting point!
We are more than ready as a profession to take on the responsibility of referral for imaging. Hopefully, more states will be joining the club soon. What makes you most excited about the prospect of being able to refer for imaging? For me it would be telling my patients they don’t have to set up another appointment with someone else to get the referral. What about you? Share in the comments below!
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