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  • Study: Entry-Point Physical Therapy for LBP Saves Money for Medicaid

    Editor's note: the following is a sneak peek at research that will be featured as part of Physical Therapy's (PTJ's) special series on health services research, beginning with the December issue.

    In an exploration of a payment area that could take on increasing prominence in physical therapy, researchers have found that Medicaid patients with low back pain (LBP) whose front-line treatment is provided by a physical therapist (PT) tend to generate lower costs over 1 year than patients who went to the emergency department (ED) or physician.

    Though the study's authors describe the number as "few" by proportion—75 Medicaid enrollees used a PT as their entry point—analysis showed that patients who began with physical therapy generated an average per-patient 1-year cost of $335, compared with $533 for primary care and $900 for patients who used the ED as an entry to care. Results were e-published ahead of print in Physical Therapy (PTJ), the journal of APTA. The study's authors include Julie Fritz, PT, PhD, FAPTA, and Anne Thackeray, PT, PhD.

    To conduct the research, authors analyzed care and expenditure data from 2,289 individuals in the University of Utah Health Plans "Healthy U" Medicaid program who received treatment for a complaint of LBP during 2012. Researchers separated the patients in terms of the setting in which they entered care—physical therapy, ED, primary care, or physical medicine and rehabilitation. They also looked at patients who did not enter by way of physical therapy but received physical therapy later, either within 14 days of the initial visit or 14 days or longer afterwards. Researchers also tracked the presence of comorbidities among all patients.

    In the end, primary care was found to be the most common entry point for the patients, with 70.8% of the population beginning their LBP care in a family medicine, internal medicine, urgent care, or obstetrics/gynecology setting. EDs were the second most-used entry point (17.6%) followed by physical medicine and rehabilitation (3.9%), and physical therapy (3.3%). "Other settings"—orthopedic or neurosurgeon, chiropractic, pain medicine, etc.—were selected by 4.4%.

    Regardless of the entry point, 20% of all patients received physical therapy at some point during the 1-year study period, with an average of 5.2 visits per patient. Of those patients who received physical therapy, 16.4% received physical therapy at entry, 19.5% received physical therapy after entry but within 14 days, and the remaining 65.1% received physical therapy at some point 14 or more days after entry.

    Other findings about patients who received physical therapy:

    • Physical therapy was less likely for patients with a substance abuse disorder who received opioids at the entry-level visit.
    • Physical therapy was more likely for patients with comorbid chronic pain or obesity.
    • Entry through the ED decreased the likelihood of later physical therapy.
    • Patients who received any prescription medication within 14 days of entry were less likely to receive physical therapy.
    • Women were more likely to receive physical therapy.
    • Entry into physical therapy decreased the likelihood of receiving radiographs, and no patients in the study who entered by way of physical therapy had surgery during the 1-year study period.
    • The 20% physical therapy use rate for the Medicaid patients in the study is consistent with rates outside the program, where an estimated 13%-34% of Medicare and private insurance patients receive physical therapy for LBP.

    Overall, the average cost for treatment of LBP over the 1-year study period was $626—less than the $900 average for patients who entered via the ED, but close to double the average costs associated with patients who went to a PT first. Authors noted that comorbidities—which occurred at a higher-than-average rate for the Medicaid patient studiedwere associated with higher costs.

    Researchers found that the group who entered care through physical therapy "tended to be younger, healthier, and more likely to be female" than the overall sample. While their study did not assess reasons for selecting physical therapy, they believe it's a topic worth pursuing. "Considering the relevance of the choice of entry setting on outcomes and costs in this sample, further research exploring reasons for patients' choices could lead to strategies to promote more effective and less costly options such as physical therapy rather than relying on the ED for entry," they write.

    While Medicaid enrollees may not make up a big portion of the physical therapy patient population at present, authors believe that the increases to the Medicaid rolls brought about the Affordable Care Act and the rise in the number of states that allow direct access to PTs (Utah is a direct access state) will mean that PTs could see this number grow in the near future. At least 1 state has taken the idea a step further; this summer Oregon adopted a change to its Medicaid provisions that lists physical therapy among the "first-choice" treatments for back pain.

    But it's not just a matter of numbers, according to authors of the Utah study, who write that more work needs to be done to address patient and other stakeholder assumptions about which treatments are the most effective.

    "Improving LBP care patterns for Medicaid recipients will require strategies addressing both system- and patient-level factors that drive ineffective and costly patterns," they write. "This may include everything from shifting hours of operation, educating patients and providers, and increasing the focus within physical therapy on providing self-management strategies for recurrent episodes and exacerbations. Knowledge of barriers and facilitators will be required … if effective strategies to promote more effective, less costly care patterns are to succeed."


    • Interesting….only 20% of all patients with LBP in the study received physical therapy at all. Of the 20% that received PT at all 65.1% of them received it AFTER 2 weeks. More interesting……treatment for LBP by way of the emergency department DECREASED the likelihood of later physical therapy and was also associated with the highest average cost per episode ($900). Even more interesting…..why were patients with substance abuse disorders MORE likely to receive opioids at their entry-level visit and LESS likely to receive physical therapy than patients WITHOUT a substance abuse disorder? Biggest take-a-way for me….out of all the patients in the study with LBP as their primary reason for seeking out medical care only 3-4% went by way of PT as the primary entry point which was associated with the lowest average cost per episode at $335. Btw….$335 per episode at an average of 5.2 visits is about $64 per visit. That figure would be substantially lower if it were state Medicaid patients in a private practice setting. That figure is more representative of the average cost per episode of ANY visit in the private practice setting....

      Posted by Darin on 9/15/2015 12:01 PM

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