TRICARE Archives - Freedom Physical Therapy

Insurers Are Moving From “Sick-care” to “Well-care”

TRICARE has decided to waive the cost-sharing requirement of up to three visits to a physical
therapist for low back pain. They’ve said that the goal is to encourage more use of “high-value”
treatments for low back pain. Understanding what they mean by “high-value” vs “low-value”
treatment can help us see the direction healthcare payers are moving and how physical therapy
is a part of that.

TRICARE tells us in their summary of this demonstration what they mean by high and low-value
care: “Increasing the value of health care refers to improving patients’ quality of care and
outcomes, improving patients’ access to care, and reducing overall costs of care. In contrast,
low-value care refers to interventions that: are not proven to benefit patients; may harm patients;
result in unnecessary costs; or waste health care resources.”

High-value care

High-value care leads to better outcomes, is easy to access and is cheaper for both patients
and insurers. We already know that physical therapy fits into this category, but if we look at
other things that fall into this category, a larger theme starts to emerge. In 2017 the American
College of Physicians released guidelines for treating low back pain that have been widely
endorsed. Initial treatment recommendations include exercise, stretching, tai chi, yoga,
progressive relaxation, heat or ice, cognitive behavioral therapy, and motor control exercise.
These are all active treatments, where the practitioner and the patient are working together to
improve. This is “well care” or “let me help you get better.”

Low-value care

In contrast, low-value care tends to be “sick care” where the patient is a passive participant and
the practitioner is saying “let me make you better.” TRICARE puts imaging before six weeks
without red flag symptoms, surgery for non-specific low back pain, opioids as the first or secondline treatment, and bedrest in the low-value category. We would also place spinal injections in
this category for most people. They’re expensive, only offer temporary relief, usually have a long
wait before they’re available and include the risk of serious infection and damage to surrounding
soft tissues like skin, cartilage, and ligaments.

This isn’t to say that imaging, surgery, or injections are always bad. For a small percentage of
people with low back pain, they’re the right thing. But, most people should start with treatments
that have the best outcomes for the lowest cost. If those treatments tend to focus on
empowering the person in pain to actively participate in their care rather than making them
dependent on someone to “heal” them, that’s even better. Physical therapists have known this
and have been providing care that fits this model for years. TRICARE’s demonstration that
waives cost-sharing clearly shows that insurers are recognizing the value of this type of care
and that they are actively moving in this direction.

TRICARE Thinks PT is so Valuable, They’re Covering the Whole Cost!

TRICARE, one of the nation’s largest insurers wants their members to get physical therapy for
back pain. They think that treating back pain with PT is so important that they’re willing to waive
the cost to their members. That’s a huge deal. When’s the last time you remember an insurance
company covering the entire cost of anything? Let’s dive into back pain treatments and see why
TRICARE likes PT so much.

You probably already know that back pain is a common problem. What you might not know is
that the medical system isn’t very good at treating it. “Non-drug treatments like physical therapy”
are the first treatment recommended for back pain. Unfortunately, many providers don’t follow
this and treatments are often recommended based on opinion rather than research. This means
insurance companies and patients often end up spending a lot of money for outcomes that are
less than stellar.

Here’s how it usually goes: You go see your doctor with back pain. They might give you
medication, recommend rest, some stretches, send you for x-rays or an MRI. Next will likely be
a referral to a specialist like an orthopedic surgeon. Chances are you won’t be having surgery
right away, so the specialist will either refer you to PT, or back to your PCP where you’ll end up
with a PT referral. The path will look different for each person, but the end result is usually the
same – multiple failed treatments, imaging you probably didn’t need and a delay of weeks or
months to get to a physical therapist.

Multiple large studies have looked at the effects of early physical therapy on low back pain with
impressive results. One of them was done in 2006 in Seattle by Virginia Mason Health Center.
They teamed up with Aetna and Starbucks to send workers with back pain to see both a
physical therapist and physician for their first treatment. Use of MRI dropped by 1/3, people got
better faster, missed less work and were more satisfied with their care. The cost savings was so
great, that Virgina Mason was losing money on treating back pain and Aetna ended up paying
them more for PT treatments because Aetna was saving so much money.

Intel ran a similar program with their employees, getting people with back pain to a PT within 48
hours. Previously it took about 19 days for people to get to a PT. With the earlier access,
patients completed their care in 21 days, compared with 52 days previously and costs dropped
between 10 and 30%. Intel also found more satisfaction with care and a faster return to work.

The data is out there that proves physical therapy is the cheapest and most effective treatment
for most people’s low back pain. It’s clear that people with back pain should start treatment with
their physical therapist, but most don’t. TRICARE’s pilot program that waives copays for up to
three PT visits aims to change that. If successful it will lead to lower costs for both TRICARE
and their members while delivering better outcomes in less time.

Finally, Some Good News About Back Pain

Back pain is a huge problem in developed nations worldwide. It has or will affect most of us. The
current estimate is that 80% of people will experience back pain at least once. It is the single
biggest cause for disability, the third most common reason for doctor visits, and one of the most
common reasons for missing work.

It’s also expensive. Back and neck pain makes up the biggest healthcare expense in the US,
totaling $134 billion spent in 2016. The next two most expensive conditions were diabetes —
$111 billion in spending — and ischemic heart disease at $89 billion.

Diabetes and heart disease being so expensive to treat doesn’t surprise most folks – they can
both lead to other major problems, require long term medication, could require surgery, and
both can be fatal. Back pain won’t kill you, usually doesn’t require long term medication, and
usually doesn’t require surgery either. Why is it so expensive?

The first reason is that it’s so common. The second reason is that our current system isn’t very
good at treating it. Current recommendations include starting with activity modification, and
active treatments like physical therapy. Research backs this up, showing better outcomes and
lower costs with early PT. Unfortunately, only 2% of people with back pain start with PT, and
only 7% get to PT within 90 days. At the same time, a study looking at about 2.5 million people
with back pain in JAMA showed that 32.3% of these patients received imaging within 30 days of
diagnosis and 35.3% received imaging without a trial of physical therapy. Both of these things
go against current practice guidelines for treatment of back pain.

A new pilot program being rolled out by TRICARE, the insurance system used throughout the
US military is waiving the payment owed by the patient for up to three PT sessions in an attempt
to improve the use of what the Defense Health Agency calls “high value” treatment for low back
pain. The theory is that once a person sees some benefit from PT treatment, they’re likely to go
back for more. This is the “try it before you buy it” approach – think of the 7-day free trial Netflix
offers, free samples poured in wineries and craft breweries, or the folks you see standing
around in supermarkets with food on toothpicks. TRICARE’s data seems to indicate that it works
just as well for healthcare as it does for other businesses. In a press release they state that
once people attend one session of physical therapy, they’re likely to go back for more, no matter
what their co-pay is. But TRICARE found that higher co-pays could be a barrier to people trying
that first visit. For the group of patients with the highest co-pays in the system, only 38% of the
people prescribed PT attended the first visit. That’s about half the rate of attendance found in
the lowest co-pay group.

The fact that such a major insurer is looking into the value of PT is great news for everyone. If
TRICARE can show that lowering the cost of PT for patients can improve outcomes and save
insurance companies money, other major insurers will likely follow. This could improve the lives
of millions of people every year while reducing the huge cost of treating low back pain for the
country. That seems like a win for everyone involved.