Why Direct Access Alone Isn’t Enough: The Next Step for Physical Therapists

The physical therapy profession has long fought for direct access—the ability for patients to seek treatment from a PT without a physician referral. Today, all 50 states have some form of direct access, a hard-earned victory that expands patient choice and accelerates care. But now that PTs have won this battle, the question remains: is marketing directly to patients enough? Or should PTs be thinking bigger—leveraging direct contracting, cash-based services, and subscription models to build more profitable and sustainable practices?

A Brief History of Direct Access

The push for direct access began in 1957, when Nebraska became the first state to allow patients to see PTs without a physician’s referral. For decades, restrictive laws kept PTs under physician gatekeeping, limiting their ability to serve as primary musculoskeletal (MSK) providers. The American Physical Therapy Association (APTA) made direct access a central advocacy issue, emphasizing its benefits:

• Earlier intervention for pain and injuries
• Lower healthcare costs by reducing unnecessary imaging, medications, and surgeries
• More autonomy for PTs, enabling them to fully apply their expertise

By 2015, all 50 states had enacted some form of direct access, though with varying levels of restrictions. Some states still impose limitations like visit caps or physician involvement in certain cases. However, the foundation for independent PT practice is stronger than ever.

The Next Challenge: Making Direct Access Work for PTs

While direct access has removed referral barriers, it hasn’t solved the financial and operational challenges of running a PT practice.

• Insurance still dictates reimbursement rates, often undervaluing PT services.
• Administrative burdens remain high, with prior authorizations and claims denials consuming time and resources.
• Many patients don’t realize they can go straight to a PT, requiring significant education and marketing.

Marketing directly to patients is essential—but it isn’t the only path forward. PTs who want to thrive must think beyond referrals and embrace alternative business models that create financial stability, reduce administrative burdens, and improve patient outcomes.

Expanding Beyond Traditional Models

1. Direct Contracting with Employers

One of the most promising opportunities is partnering directly with self-funded employers. Many companies are looking for cost-effective ways to manage employee health, especially as MSK conditions drive up healthcare expenses. Direct contracting allows PTs to:

• Eliminate insurance barriers (no prior authorizations, denials, or visit limits)
• Increase revenue through predictable payments (e.g., case rates or per-employee-per-month models)
• Provide preventative and early intervention care, reducing long-term costs for employers

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2. Cash-Based and Hybrid Models

Cash-based PT services have grown in popularity, offering freedom from insurance constraints. While full cash-pay models work well for some, hybrid approaches—where PTs accept cash while maintaining selective insurance contracts—allow for a balanced revenue stream. Benefits include:

• More personalized care without insurance-mandated restrictions
• Higher patient satisfaction by reducing bureaucratic delays
• Improved financial stability by setting fair, transparent pricing

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3. Subscription and Membership Plans

A growing number of PTs are implementing membership models, offering ongoing care for a monthly fee. This prevents the cycle of episodic care and allows patients to maintain consistent MSK health. Potential offerings include:

• Regular PT check-ins and screenings
• Access to digital resources and exercise programs
• Discounted or included in-person visits

Subscription models provide predictable income for clinics while ensuring patients receive continuous care, not just treatment for acute issues.

The Future of PT: Beyond Direct Access

Direct access was a necessary step forward—but it’s not enough on its own. To build a sustainable and rewarding PT practice, clinicians must expand their vision beyond traditional marketing and insurance-based models. Direct contracting, cash-based services, and subscription plans provide the next evolution in PT business strategy.

By taking control of revenue streams and reducing dependence on insurance, PTs can: 

• Earn fair compensation for their expertise
• Reduce administrative burdens and reclaim time for patient care
• Improve access to care through flexible, patient-centered models

Direct access opened the door—it’s time for PTs to walk through it and take full control of their profession.

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