TRICARE, the health insurance system used throughout the U.S. military, is set to launch a demonstration project that waives cost-sharing for up to three physical therapy visits for patients with low back pain. (Read APTA’s summary). The demonstration will run from Jan. 1, 2021, through Dec. 31, 2023, in 10 states: Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, and Virginia.
This demonstration is important.
The concept behind the demonstration is simple: It's an effort to incentivize physical therapist services for patients with LBP in order to decrease the use of more costly, low-value, testing and interventions such as imaging, surgery, and opioids, reduce the overall cost of managing LBP, and improve patient outcomes. If the demonstration is successful, the Department of Defense may expand it to the entire TRICARE population.
Here's our guide to the demonstration and how best to seize this unique opportunity to establish the value of your care to this important population. Information is based on updated guidance issued by TRICARE on Oct. 27 within the TRICARE Operations Manual, Chapter 18, Section 9, which includes a list of eligible ICD-10 diagnostic codes.
Understand who's eligible.
To be eligible to receive waived cost-sharing for physical therapy visits, TRICARE Prime, TRICARE Select, and TRICARE For Life beneficiaries who have a cost-share for PT services must meet all the following requirements:
- Have a primary diagnosis of LBP as identified by the applicable ICD-10 diagnosis codes listed in TRICARE Operations Manual Chapter 18 Section 9.
- Reside and receive PT services in Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, or Virginia.
- Be prescribed or referred by a TRICARE-authorized provider to receive PT services.
- Have a new physical therapy episode, meaning their first physical therapy visit for LBP is on or after Jan. 1, 2021. The waived cost-sharing applies regardless of the time from onset of symptoms to when they begin to receive services.
Learn and follow TRICARE requirements for the demonstration.
Providers participating in this demonstration should note the following:
- Physical therapy must be provided by an in-network TRICARE-authorized provider. [Note: TRICARE for Life beneficiaries are exempt from the requirement to receive care from an in-network provider; services from any TRICARE-authorized provider will be eligible for the demonstration.]
- Physical therapy must be prescribed by a TRICARE-authorized provider, such as a physician, physician assistant, or nurse practitioner.
- PT services must be performed in one of the 10 demonstration states for a patient residing in one of those states. The provider also must be in a demonstration state.
- Payment for services will follow current TRICARE procedures for physical therapy.
- There is no limit on the time from onset of symptoms to the start of PT services, and visits for acute, subacute, or chronic LBP may be eligible for waived cost-sharing.
- Cost-sharing will be waived for up to three PT visits for patients with LBP. After the first three visits, cost-sharing will follow existing protocols specified in Chapter 2 of the TRICARE Reimbursement Manual.
These resources can also help you become familiar with TRICARE coding and billing:
Know TRICARE's coverage policies.
Become familiar with Chapter 7, Section 18.2 of the TRICARE Policy Manual — that’s where you can find information on the physical therapy services TRICARE covers. And be aware: TRICARE does change these policies from time to time. For instance, TRICARE no longer covers TENS for LBP.
Also review TRICARE Policy Manual Chapter 11, Section 3.16 for information about services furnished by PTAs.
Make sure care is evidence-based.
There's an ever-growing body of evidence around what works and what doesn't when it comes to LBP. If you're not already familiar, take the time to review what the evidence has to say. Here are three studies we recommend:
- LBP Clinical Practice Guidelines. The APTA Orthopaedic Section created this invaluable resource that evaluates the strength of evidence for nearly all facets of the PT’s involvement in the treatment of LBP, from differential diagnosis through examination and subsequent interventions.
- Impact of Physical Therapist Services on Low Back Pain Episodes of Care. This guidance, created by the APTA Private Practice Section, is an excellent overview of clinical considerations for the PT seeing a patient for LBP, either through direct access or early referral (as is the case in the TRICARE demonstration).
- VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain. This guideline provides recommendations related to the management of patients with LBP.
In addition, it's important to understand what doesn't work. Two of the biggest low-return treatments — use of superficial deep heat for long-term clinical outcomes and overuse of passive treatment — are addressed in APTA's "Choosing Wisely" recommendations published by the American Board of Internal Medicine Foundation.
It's also important to use the right tests for LBP. Among the test summaries available on APTA.org: the Oswestry Low Back Pain Disability Index, Oswestry Low Back Pain Disability Questionnaire, STarT Back Tool, Fear Avoidance Beliefs Questionnaire, and the Slump Test. Some of these tests are available on APTA's Tests and Measures webpage.
Finally, you may find it helpful to reinforce something you probably already know: Physical therapy for LBP improves outcomes and saves money, especially when provided early. These studies add to the strength of that assertion:
- The Timing of Physical Therapy for Low Back Pain: Does it Matter in Workers' Compensation?
- Health Insurance Design and Conservative Coverage for Low Back Pain
- An Observational Retrospective Study of the Association of Initial Health Care Provider for New-Onset Low Back Pain with Early and Long-Term Opioid Use
- Level of Direct Access to Physical Therapist Services: Association with Health Care Utilization and Costs in Patients with New-Onset Low Back Pain
Be aware of what the DoD will consider when deciding if it will expand the demonstration.
The Defense Health Agency plans to compare demonstration versus non-demonstration states through an analysis of various outcome measures, before the demonstration starts and again after a year. Here's what will be tracked:
- Total number of initial physical therapy visits.
- Average and median number of physical therapy visits among beneficiaries with LBP.
- Average and median number of opioid prescriptions filled by beneficiaries with LBP.
- Average and median number of imaging services (MRI, CT, X-ray, and ultrasound) provided to beneficiaries with LBP, stratified across the following time periods and measured from initial diagnosis: 0-6 weeks; 6-12 weeks; over 12 weeks.
- Proportion of beneficiaries with a diagnosis for LBP receiving back surgeries.
- Average and median cost of episode for LBP.
- Average and median cost of episode for LBP when the beneficiary attends at least three physical therapy visits.
- Average and median cost of episode for LBP when the beneficiary attends fewer than three physical therapy visits.
- Proportion of patients receiving services to treat LBP 12 weeks after onset.
- Average and median number of patients receiving injections.
Additionally, the demonstration will include a patient survey to measure reasons a patient begins and ends physical therapy visits, as well as access to care, quality of care, and overall health status. This information will supplement the outcome measures listed above and will provide important context for the data analysis. The survey will be administered electronically to TRICARE beneficiaries with a primary diagnosis of LBP who receive physical therapy in demonstration states. DHA will administer the survey, collect survey results, and evaluate survey data. Be sure to stress the importance of completing the survey to your patients.
Follow these tips to make the most of the demonstration opportunity.
Here are a few things you can do to ensure that your practice is helping to make participation in the demonstration a success:
- Use motivational interviewing, and work to engage the patient immediately in their rehabilitation in order to optimize early effectiveness. Ensuring early adoption of recommended exercises and a physical activity plan is critical.
- See to it that TRICARE beneficiaries participating in the demonstration are scheduled for their next visit at the conclusion of each visit.
- Emphasize the importance of contacting the PT if the beneficiary has questions.
- Clearly document any complexities, comorbidities, and barriers to patient engagement.
- At a minimum, use patient-reported outcome measures and performance-based outcome measures on initial evaluation and discharge.
- Identify and leverage the skills of the clinicians who produce the best outcome(s) for patients with LBP.