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TRICARE, the health insurance system used throughout the U.S. military, is set to launch a pilot project that waives cost-sharing for up to three physical therapy visits for patients with low back pain.

The program is part of a U.S. Department of Defense effort to test its theory that once patients begin physical therapy for LBP, they'll tend to continue as they experience the positive results.

According to an announcement from the U.S. Defense Health Agency, or DHA, the program will be available in Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, and Virginia, and will run from January 1, 2021, through December 31, 2023. Under the program, cost-sharing will be waived for up to three physical therapy visits for TRICARE beneficiaries who have a primary diagnosis of LBP and are referred by a TRICARE-authorized provider to receive PT services. If this demonstration is successful, it could be rolled out to the entire TRICARE population.

Only new physical therapy “episodes” will be eligible for waived cost-sharing, meaning that a patient who is receiving PT services before the beginning of the demonstration won't qualify for the waivers. Provider reimbursement will follow current TRICARE reimbursement procedures for physical therapy; similarly, after the third therapy visit with waived cost-sharing, beneficiary cost-sharing will follow regular TRICARE policies.

As for the requirement that beneficiaries be referred to physical therapy by a TRICARE-authorized provider, Kara Gainer, APTA's director of regulatory affairs, says it is a current coverage requirement in the TRICARE system — but it may evolve, thanks in part to advocacy by APTA and other organizations.

"DHA recognizes that the TRICARE referral requirements for therapy are overly restrictive, and last year it issued a proposed rule that would allow coverage for physical, occupational, and speech-language therapy when prescribed by what DHA defines as 'other allied health professionals,'" Gainer said. "We are hopeful that the proposal, if adopted, would essentially allow PTs, OTs, and SLPs to prescribe therapy in accordance with state law, and we have urged DHA to finalize the rule with that understanding."

The final rule isn't out yet, Gainer says, "but I think it's likely that with the final rule, DHA will expand physical therapy referral sources throughout TRICARE, and I would expect the expanded list to be applied to this demonstration project."

The adoption of the pilot is the result of an analysis by TRICARE that found beneficiaries who attended physical therapy for LBP did so at similar rates across all beneficiary classes and age groups — provided they attend the first session. TRICARE uncovered that rates of attendance to at least one physical therapy session varied significantly, ranging from active duty beneficiaries at a 65% attendance rate to non-active duty dependents only reaching 38% attendance. As it turns out, the low-attending group happens to have the highest cost-sharing requirements for physical therapy and occupational therapy. DHA thinks the cost-sharing waivers could help to increase participation in what it calls "high value" treatment for LBP.


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