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This week, UnitedHealthcare (UHC) announced a pilot program in 5 states that will waive the cost of copays and deductibles for 3 physical therapy sessions for patients with low back pain (LBP) living in Connecticut, Florida, Georgia, North Carolina, and New York. The pilot, which could affect as many as 1 million enrollees, goes into effect July 1, 2019. Other states will join the program in 2020 and 2021.

Specifically, the pilot will be available to UHC enrollees with new onset of LBP when receiving care from an outpatient in-network provider. This benefit change will not extend the enrollee’s physical therapy or chiropractic benefit maximum, and will apply only to services related to treating back pain. Enrollees must have physical therapy or chiropractic benefits remaining in order to use this benefit.

UHC will send emails about the benefit change on a quarterly basis to enrollees in the 5 states as they gain access to the benefit. Information also will be included on myuhc.com in the enrollee’s benefit information under Rehabilitation Services - Outpatient Therapy and Chiropractic (Manipulative) Treatment.

This pilot follows a multiyear collaboration between APTA, OptumLabs, and UHC that included publication of a study in the American Journal of Managed Care (subscription required). This study affirms that higher copays and payer restrictions on provider access may steer patients away from more conservative treatments for LBP, including physical therapy and chiropractic services. "Innovative modifications to insurance benefits," authors write, "offer an opportunity for increased alignment with clinical practice guidelines and greater value."

"This type of collaboration between a professional association and a private insurer is key to advancing the essential role of the physical therapy profession in improving outcomes for patients," says Carmen Elliott, MS, APTA's vice president of payment and practice management. "APTA continues to advocate for benefit design that is validated by data and meets the needs of patients, providers, and payers.”

The study's authors, which include APTA member Christine M. McDonough, PT, PhD, hypothesized that patients with LBP who had easier access to a wider array of providers and lower out-of-pocket costs would be more likely to first seek out conservative approaches such as physical therapist (PT) or chiropractic services.

Researchers looked at 5 years of claims data from OptumLabs Data Warehouse for 117,448 adult patients to determine the relationship between health plan benefit design and patient choice of primary care physician (PCP) versus a physical therapist or chiropractor as the first-line provider for new-onset LBP.

Patients were excluded if they were not enrolled 2 years before and after the onset of LBP with no prior diagnosis of LBP or back procedures, or if they had filled opioid prescriptions within a year of LBP onset. Included patients could not have had any neoplasm diagnosis in the previous year or recent LBP-related diagnoses, such as spinal fractures, that would require more intensive treatment.

For the analysis, authors divided the patients into 2 groups: those who first sought treatment from either a PCP or a PT, and those who first sought treatment from either a PCP or chiropractor.

Their findings include:

Only 2.8% of the 82,052 patients in the PCP-versus-physical therapist group chose to see a PT first, while 31% of the 115,144 patients in the PCP-versus-chiropractor group chose to see a chiropractor first. The majority of patients had a point-of-service (POS) health plan, and approximately 30% had no copayment or deductible to meet.

Fewer restrictions on provider access was associated with higher likelihood of seeking out physical therapy or chiropractic treatment. Compared with patients with a POS plan, patients enrolled in a preferred provider organization (PPO) plan—the least restrictive option—were 32% more likely to see a physical therapist first. Patients in exclusive provider organization (EPO) plans were 16% less likely than POS patients to see a physical therapist first. These findings were similar for choosing a chiropractor versus a PCP.

Higher copayments decreased the likelihood of a patient seeing a physical therapist as first provider. Patients with a copayment over $30 were 29% less likely to see a physical therapist first than were patients with no copayment. This association was not evident for chiropractic.

As deductibles increased, the odds of a patient seeing a PT first declined; this association was not consistent for chiropractic. Patients with a deductible between $1,001 and $1,500 were 19% less likely to see a PT first (as opposed to seeing a PCP) than were those who had no deductible, while patients in this level were more likely to see a chiropractor first. Patients with a deductible of $1,500 or more were 11% less likely to see a PT first and 7% less likely to see a chiropractor first.

There were mixed results for consumer-driven health plans (CDHPs) such as health reimbursement accounts (HRAs) and health savings accounts (HSAs). Patients with HRAs were 16% less likely to see a PT first compared with patients without CDHPs, but they were slightly more likely to see a chiropractor first. Patients with HSAs were 25% more likely to see a PT first compared with patients without CDHPs. HSAs had no effect on the chiropractic group.

"Our study has demonstrated that patients experiencing LBP are moderately responsive to network restrictions and cost sharing in their choice of entry-point provider," authors write. "Reductions in spending are not necessarily accompanied by improvement in value, particularly if patients bypass routine care that would prevent higher downstream costs."

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


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