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Direct access has been said to be the end-all, be-all for the healthcare issue of cost and quality when it comes to physical therapy. However, based on the concept of the iron triangle, this system can’t work as effectively and efficiently as they would like. The driving force behind my paper are these two questions: 1) can direct access put an end to the dilemma known as the iron triangle? and 2) is it possible for all areas of this model to benefit under the new system of direct access? I am interested in knowing and understanding what the iron triangle is, what direct access is, and how it can impact every corner of the triangle.

The iron triangle of healthcare depicts the idea that there are and must be trade-offs in the healthcare system for it to run efficiently. This model was developed in 1994 by William Kissick in the form of a book titled ‘Medicine’s Dilemmas: Infinite Needs Versus Finite Resources’. He wrote this book and presented these ideas as a method to address the concerns of the healthcare system. Cost, quality, and access are the three components of the triangle that influence one another. All three of these areas cannot be improved at once, and for there to be a significant improvement in one area, another must suffer. For example, if there is an increase in access, there must be an increase in cost to support the new demand. If there is an increase in quality, there would have to be a decrease in access to ensure that each patient seen is receiving the best care possible. In both these scenarios, one concept on the triangle must lack improvement. Increases in cost should, hypothetically, increase quality. However, we know this is not the case. The complete thought behind this model is to increase access while decreasing costs. It is very difficult to fulfill all aspects of the triangle in a manner that is beneficial to each realm. Low cost, high quality, and greater access are simply not attainable all at once.

Cost is one leg of the stool. This simply refers to the amount of money required for services to be provided. How much does health care cost? Is it affordable to the general population? The overall goal for the cost is for it to be lower to improve access and quality simultaneously. Unfortunately, reducing costs has been shown to have a direct effect on the quality of care provided. The extent of the meaning of quality is simply how good the services that are being provided are and do they meet the standards of the consumer when it comes to care. Quality is a difficult thing to measure due to it being subjective. Quality directly ties into cost in that you essentially ‘get what you pay for’. Access is probably one of the hardest areas to address. This term means is the consumer able to obtain the type of services desired in a reasonable location. With direct access, the patient gets the care they feel they need without having to go through several other healthcare providers. While looking into the aspects of the iron triangle, I was interested in learning more about direct access, its cost-effectiveness, and the quality of care that many direct access facilities provide.

Direct access to physical therapy services addresses the idea of accessibility. Direct access, by definition, is the patient’s ability to seek physical therapy without first seeing a physician for a referral to receive services. With the implementation of direct access, it is said that costs will decrease, and quality will improve. This means that each area of the iron triangle has an improvement, and neither of the three experiences a decline to benefit the other. With direct access, a patient can see a therapist as the first line of treatment for issues that they may feel they have. This improves the patient’s ability to receive quality and efficient care when they desire. It is important to note that some states do not grant direct access to therapists simply because of compensation issues. This limits patients in that they are not allowed to self-refer even if they feel they do not need the services of a physician. Patients with conditions that can be examined and treated by therapists have notable decreases in wait times and costs.

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When speaking of cost within the direct access system, the patient desires to have his or her needs fulfilled while reducing the burden that comes with treatment and wellness. It has been stated that cost is reduced in direct access due to a reduction in the number of visits and specialty consultations needed before receiving rehabilitative care. Physical therapy episode of care was less when patients saw a physical therapist directly versus through physician referral, likely due to less imaging ordered, injections performed, and medications prescribed. This study reveals that direct access to therapy services significantly decreased the overall cost of an episode of care. Cost is an important factor to consider in today’s society with the increase in demand and the decrease in supply.

Now that I have discussed the two areas of the iron triangle that seem to receive the most attention, let’s turn our attention to the most important aspect of this model, quality. This characteristic of care is used to prove overall treatment effectiveness. Quality of physical therapy by definition is an increase in the achievement of desired patient outcomes or desirable patient experience. This means that the care is patient-centered and has a focus on what the individual would like to achieve. For outcomes to display a significant increase, they need to be efficient and effective. Patient experience is defined as the customer service provided and the rapport the therapist builds with the patient through interaction during treatment sessions. Determining the quality of care can be measured using outcome measure scores. Direct access has been reported to provide better patient clinical outcomes at the time of discharge. Outcome measures focus on improvements in body structure and function, activity, and participation of individuals in the same population. Improvement in outcome measures and patient satisfaction with treatment is a good quality indicator.

The iron triangle, or the three-legged stool, is a great way to assess how effective a new method of treatment is and whether or not it proves to be successful. When speaking about direct access, research has shown that there is a benefit to this form of practice. Findings of lower cost and higher quality with the ability to access services whenever an issue or injury presents itself prove that the iron triangle is a malleable structure when approached from a patient-centered standpoint. The patient-centered method in this situation is providing the population with unrestricted access to services that they desire with the ability to bypass services that may be more costly. The ability to decrease cost is directly correlated to less of a need for diagnostic imaging and procedures that may be found to be unbeneficial in the long run. Along with decreased cost, patients expect the quality of care to remain at a certain standard. They expect good, timely outcomes with a return to the prior level of function as the sole focus.

In conclusion, conversion over to direct patient access to therapy services seems to be the most advantageous method of managing all aspects of the healthcare system. The iron triangle receives improvements in all areas and manages to keep the patient as the center of focus. Ensuring that patient satisfaction and improvement are the hub of all practices performed provides a greater representation of what this profession values. Focus on continually improving cost, access, and quality within the practice of physical therapy is pivotal to the success of this profession.

References

  1. Badke M.B., Sherry J., Sherry M., et al. Physical Therapy Direct Patient Access Versus Physician Patient-Referred Episodes of Care: Comparisons of Cost, Resource Utilization & Outcomes. Physical Therapy Journal of Policy, Administration and Leadership. 2014; 1(43).
  2. Bredow A.V. Outcome Measures in Patient Care. APTA. http://www.apta.org/OutcomeMeasures/ Published June 5, 2017. Accessed July 27, 2019.
  3. Carroll A.E. Health Reform and the Iron Triangle of Health Care. KevinMD.com. https://www.kevinmd.com/blog/2011/08/health-reform-iron-triangle-health-care.html Published January 27, 2016. Accessed July 27, 2019.
  4. Delaronde S. The Iron Triangle of Health Care: Access, Cost and Quality. 3M Inside Angle. https://www.3mhisinsideangle.com/blog-post/the-iron-triangle-of-health-care-access-cost-and-quality/ Published February 6, 2019. Accessed July 27, 2019.
  5. Lewis W. What Is the Iron Triangle of Health Care? Medium. https://medium.com/more-health/what-is-the-iron-triangle-of-health-care-9ce6f5276077 Published May 20, 2017. Accessed July 27, 2019.
  6. Ojha H.A., Snyder R.S., Davenport T.E. Direct Access Compared with Referred Physical Therapy Episodes of Care: A Systematic Review. Physical Therapy. 2013;94(1):14-30. doi:10.2522/ptj.20130096.
  7. Piscitelli D., Furmnanck P., Meroni R., DeCaro W., Pellicciari L. Direct Access in Physical Therapy: A Systematic Review. View of Direct Access in Physical Therapy: A Systematic Review. http://www.clinicaterapeutica.it/ojs/index.php/ClinicaTerapeutica/article/view/266/117 Accessed July 27, 2019.
  8. Raising the Bar: Tips to Measure and Improve the Quality for PT Practices. APTA Learning Center. http://learningcenter.apta.org/student/MyCourse.aspx?id=b954832c-7dd4-4c8c-8d1c-9aa3e3da73a0&programid=dcca7f06-4cd9-4530-b9d3-4ef7d2717b5d Accessed July 27, 2019.
  9. Westby M.D., Klemm A., Li L.C., Jones C.A. Emerging Role of Quality Indicators in Physical Therapist Practice and Health Service Delivery. Phys Ther. 2016;96(1):90–100. doi:10.2522/ptj.20150106.

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