Alabama Senate committee approves compromise bill on physical therapy access

The Alabama Senate Healthcare Committee Wednesday approved a bill that would reduce the number of  physician referrals a patient needs for physical therapy.

HB 232, sponsored by Rep. Leigh Hulsey, R-Helena, would allow physical therapists to conduct initial screenings of patients for nonwork related injuries or conditions.

“This bill is a provisional direct access for physical therapy. It essentially takes our current limited [access] and adds a little bit of opportunity for access to go in under certain circumstances,” Hulsey said in her introduction.

The legislation passed the committee on a 12-0 vote. 

A law passed in 2012 requires most patients to get a referral from a physician for each visit. The law provides exceptions for children with a diagnosed developmental disability and nursing home patients.

According to the American Physical Therapy Association, Alabama is the only state in the U.S. with “limited direct access” after Mississippi approved a law this year remove the restrictions. This means that access to physical therapy care is only available under certain criteria. 22 states have what is considered unrestricted direct access, while 27 states have direct access with some provisions/restrictions.

A 2018 review of nearly 1,600 studies suggests that access to physical therapy without referral resulted in fewer treatments, visits to physicians, imaging tests, non-steroidal anti-inflammatory drugs and less need for secondary care. Patients also reported higher satisfaction with the service compared to physician-referred treatments. Direct access was associated with lower costs per patient.

But patients accessing physical therapy without a referral had a higher education level and were younger in age. They also tended to have less severe conditions and were mostly experiencing issues related to the spine.

The bill would require that only a physical therapist meeting specific education requirements may treat patients without a referral, as well as clarifying who may refer a patient to physical therapy. Patients paying with cash don’t need a referral in any case. The sponsor did not provide a reason, but according to the American Physical Therapy Association, cash-based models let physical therapists work outside of insurance limitations, giving them more flexibility in caring for their patients.

Under the bill, physical therapists could not order or interpret medical imaging, such as X-rays or prescribe any prescription medication.

The bill would exempt referrers from civil and criminal liability any service or act by a physical therapist or other individual providing physical therapy services without a referral.

Sen. Tim Melson, R-Florence, the chair of the committee who sponsored a similar bill in 2023, said after the meeting that the bill is a compromise between physicians and physical therapists.

“It’s got some better safeguards in it that they didn’t necessarily want, but it wasn’t going to pass any other way,” Melson said.

Emmett Parker, co-chair of government affairs with the Alabama chapter of the American Physical Therapy Association, said that the care a physical therapist provides is different and complementary to medical care. For example, a physician would treat the injury, while the physical therapist would treat movement dysfunction associated with the injury.

Sometimes, Parker said, there are times that there is no injury associated with movement dysfunction.

“Those are people sometimes that we need to treat. They wouldn’t need physicians,” Parker said.

Kathy Miller, executive director of the Alabama Board of Physical Therapy, said after the meeting that the board does not have an official position on the bill, but when asked whether the compromises made the bill better or worse, she said, “I think it made everybody happy.”

The bill heads to the Senate for consideration.