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  • APTA Cosponsored Study: Direct Access to Physical Therapy for LBP Saves Money, Lowers Utilization Better When It’s Unrestricted

    In this review: Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain
    (e-published ahead of print in PTJ, November 2019 )

    The message
    Does unrestricted direct access to a physical therapist (PT) make a difference compared with "provisional" direct access systems that include restrictions such as visit limits and referral requirements for specific interventions? A new analysis of insurance claims records from nearly 60,000 adults across the US says yes.

    The study, cosponsored by APTA, reveals that for patients with new-onset low back pain (LBP), seeing a PT first in states with unrestricted direct access resulted in lower health care costs and use compared with patients seeking care in provisional access states. And the differences don't end there: researchers found that patients in provisional access states who saw a PT first tended to incur higher costs than those who saw a primary care provider (PCP) first, while data from unrestricted direct access states showed relatively equal, if not slightly lower, costs for seeing a PT first compared with PCPs.

    The study
    Researchers reviewed private and Medicare Advantage insurance claims from 59,670 adults with new-onset LBP between 2008 and 2013 to explore health care cost and utilization from 2 perspectives: first, in terms of differences between patients who saw a PT first for LBP in states with unrestricted direct access versus those who sought PT care in states with provisional direct access provisions; and, second, in terms of differences between patients who saw a PT first versus those whose first meeting was with a PCP.

    The deidentified data was provided by OptumLabs®, which worked collaboratively with APTA and UnitedHealthcare to produce this and 2 other research articles related to access to PTs first for LBP. Authors of this study included APTA member Christine McDonough, PT, PhD.

    Findings

    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, no patients diagnosed with neoplasm 12 months prior and 3 months after the first visit, and insurance enrollment for at least 12 months before and after the index date), nearly 98% initially met with a PCP. Overall, more women than men sought care for LBP, with around 21% of all patients reporting prior physical therapy use. Among patients who sought treatment from a PCP, experience with physical therapy was much lower—about 2.1%.
    • Among patients who saw a PT first, those in provisional-access states recorded 31% more physician visits and had 58% higher odds of having imaging in the first 30 days of the index visit, compared with patients from unrestricted states.
    • Average 30-day costs were lowest for patients in unrestricted states who saw a PT first for LBP, at $511. The next-to-lowest costs were associated with patients who saw a PCP first in unrestricted-access states ($556), followed by patients in provisional-access states whose first visit was with a PCP ($632). The highest costs were for patients in provisional-access states whose index visit was with a PT, at $726. After 90 days, the rankings shifted, but only slightly: seeing a PT first in a provisional-access state was associated with the highest costs ($1,269), followed by index visits with a PCP in provisional-access states ($1,046), PT-first visits in unrestricted states ($1,032), and PCP-first visits in unrestricted states ($948).
    • Patients in provisional-access states who saw a PT first averaged LBP-related costs that were 19% higher than PCP-first patients at 30 days. It was a different story in unrestricted-access states, where patients who visited a PT first averaged costs that were 4% lower than PCP-first patient costs, a difference that authors call "insignificant."

    Why it matters
    This large-scale retrospective study—authors believe it's the first to analyze how state limits on PT access affect utilization and costs—adds to the evidence that direct access to a PT for LBP (and seeing a PT first) achieves effective results. The cost differences alone are potentially significant, given the estimate that as many as 70% of people will experience LBP in their lifetimes, making it "the third most costly medical condition in the United States," according to authors.

    More from the study
    Authors were particularly interested in the findings that patients in provisional-access states who saw a PT first tended to incur higher cost and utilization than those whose index visit was with a PCP. Authors believe the explanation for the difference may have something to do with the way the restrictions tend to increase the need to visit physicians following the initial PT visit to comply with requirements around, for example, imaging or specific procedures.

    Similarly, authors theorize that the cost ratio—in other words, the magnitude of the differences—may also be due to the pressures provisional-access systems bring to bear on LBP treatment.

    "Given that patients in provisional-access states often are required to see a PCP after a certain number of physical therapist visits or required a PCP shortly after the initial physical therapist visit, these additional visits likely increase the cost of care in provisional-access states," authors write. "Since physician gatekeeping does not occur in unrestricted-access states, which would increase the cost of care, we would postulate that this restriction accounts for the differences in 30-day costs between provisional-access states and unrestricted-access states."

    APTA's role
    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP as well as the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and the investigation included in this review. APTA cosponsored all 3 studies

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients and were limited to evaluation of only "certain variables." Additionally, data from patients in states that changed their access regulations between 2008 and 2016 were excluded, reducing sample size.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    [Editor's note: McDonough is the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant and of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]