Another Economic Argument for Physical Therapy First

I just completed reading yet another research article to be published in Spine (accepted May 18, 2012) that examined the economic consequences of early physical therapy management for treating low back pain patients. Specifically, this study evaluated a large sample of low back pain patients (32,070) where a low percentage (7%) utilized physical therapy within 90 days of being examined by their PCP. Those patients referred to PT early (within 14 days) demonstrated decreased likelihood of consuming advanced imaging, additional physician office visits, surgery, injections, and opioid use. While the PT outcomes were not examined in this study, it can be assumed with some confidence that reduced subsequent medical service utilization was a function of condition improvements.

This study highlights several points that need to be raised. Firstly, there is absolutely too much variation in the management of low back pain. A recent data-set of UHC commercial claims shows that the greatest cost-driver in medicine today are orthopedic related and accounts for 17% of all expenditures (greatest percentage being spent on spine management). This demographic is largely driven by prevalence of back pain. When we assess health consumers treatment options for back pain there are literally 11 different provider options as access points. The above referenced study demonstrated that only 7% of patients were referred to a physical therapists for their low back pain. This referral percentage is entirely too low and is also supported by the research of Gellhorn, L. Chan et. al. 2010. They too concluded from their study that early PT management decreased downstream lumbar surgeries, spinal injections, and frequent physician office visits and suggested that generalists/ PCPs likely underutilize physical therapy referrals.

This brings me to the next point– all back pain is not the same. That is, the traditional medical model hasn’t effectively evolved to efficiently manage spine problems. Currently, the US treatment guidelines for the management of low back pain are generic and do not differentiate treatment subgroups based on clinical presentation. Being a physical therapist, this is a source of extreme frustration. How many times have you heard from patients suffering from low back pain, “Why hasn’t my doctor sent me to your earlier?” or “I wish my mother, sister, father had seen you prior to their back surgery”. The answer is simple; most physicians do not understand how to effectively perform an orthopedic spine examination and certainly don’t understand how to differentiate subgroupings of LBP patients. This is true for orthopedic surgeons, GPs, neurosurgeons, nurses, and physician assistants. Our physician colleagues have grown too dependent on imaging and too often conclude structural abnormalities are the definitive cause of a patients’ pain/problem. This is largely a function of defensive medical practices, and reduced time per patient that has been promulgated by a runaway fee for service remuneration model that rewards procedures and self-referral.

Also, this research article suggested reduced use of opioid utilization among LBP patients when they have been seen by a Physical Therapist within 14 days of seeing their PCP. This was also demonstrated by an earlier study published by J Fritz, J Cleland et. al. 2008 which concluded that early management of low back pain patients by physical therapists decreased likelihood of patients incurring high charges for subsequent healthcare to the tune of $1,304 or 37% less downstream costs. While it is difficult to quantify the economic impact of using narcotic prescriptions to manage low back pain, it is clear that this problem is growing and likely impacts in-direct costs much more than direct costs. I hate to rant, but I am appalled by the proliferation of pain clinics. Most are driven by ineffective management of pain syndromes that originate from the accumulation of undiagnosed movement dysfunction. Ultimately, many of these cases, who should be in our doors and under our care, are sent on a treatment path where there is no return. Treating chronic low back pain as an acute injury only facilitates more of the same.

Lastly, this study showed that medical resource utilization was actually higher when PT was initiated late (15 to 90 days) post initial PCP visit. In 2010, I was presented with similar data from the nation’s 3rd largest Medicare Replacement Plan asking me why there was so much variation in out-patient PT ($) spending per member per month among their many Independent Physician Organizations (IPA). After reviewing their physical therapy spend data among local, regional, and national IPAs it was clear that there was huge variation in how PT was being utilized from IPA to IPA.

I concluded that this company was “asking” the wrong questions when analyzing this data. I advise them and their actuarial department to compare overall orthopedic spends (Imaging and Surgery by ICD 9 Code) for those IPAs with high PT utilization with those IPA with low PT utilization. My hypothesis was that those IPA with high PT utilization would demonstrate much lower downstream orthopedic costs. After running the data that is indeed what we found. When PT was utilized early the downstream orthopedic spend was much less. The data suggested that the timing of PT strongly correlated to the downstream spending per patient per month—this data suggested that when PT was seen first the imaging and the surgical spend was significantly lower. This analysis also showed that IPAs who used PT aggressively also demonstrated lower in-patient and out-patient rehab costs within the patient populations they managed. See below a chart summarizing one facet of this analysis:




























ALL MARKET

885,691

mm

recd 97001 timing

Category

after

before

no 97001

same day

Grand Total

Knee Imaging

$ 0.00

$ 0.00

$ 0.02

$ 0.00

$ 0.03

Knee Surgery

$ 0.01

$ 0.00

$ 0.06

$ 0.00

$ 0.08

Low Back Imaging

$ 0.13

$ 0.09

$ 0.84

$ 0.01

$ 1.07

Low Back Surgery

$ 0.27

$ 0.14

$ 0.66

$ 0.04

$ 1.12

Neck Imaging

$ 0.06

$ 0.05

$ 0.51

$ 0.00

$ 0.63

Neck Surgery

$ 0.01

$ 0.00

$ 0.02

$

$ 0.03

Shoulder Imaging

$ 0.00

$ 0.01

$ 0.01

$

$ 0.02

Shoulder Surgery

$ 0.39

$ 0.17

$ 0.62

$ 0.00

$ 1.19

Grand Total

$ 0.88

$ 0.47

$ 2.74

$ 0.06

$ 4.15

HENDERSONVILLE IPA

33,257

mm

recd 97001 timing

Category

after

before

no 97001

same day

Grand Total

Knee Imaging

$

$ 0.00

$ 0.01

$

$ 0.01

Knee Surgery

$ 0.02

$

$ 0.03

$ 0.06

$ 0.11

Low Back Imaging

$ 0.08

$ 0.03

$ 1.09

$

$ 1.20

Low Back Surgery

$ 0.91

$

$ 0.26

$ 0.13

$ 1.31

Neck Imaging

$ 0.08

$ 0.01

$ 1.37

$

$ 1.46

Neck Surgery

$ 0.16

$

$ 0.06

$

$ 0.22

Shoulder Imaging

$

$

$ 0.01

$

$ 0.01

Shoulder Surgery

$

$ 0.23

$ 2.04

$

$ 2.26

Grand Total

$ 1.25

$ 0.27

$ 4.87

$ 0.19

$ 6.58

This table illustrates, that when PT was utilized before an orthopedic consult, downstream orthopedic resource use was much less. For “All Market” the overall orthopedic spend, when PT was accessed before orthopedic consult, the resource use was $.47 per member per month; while the orthopedic spend was $.88 per member per month when PT was accessed after an orthopedic consult. While there where several limitations to this claim based analysis, it did suggest that a more formal and highly controlled research approach should be conducted to examine closely the downstream orthopedic costs.

Collectively, our profession needs to use the clinical and the economic evidence (as highlighted above) to obtain receptive ears with legislators and health policy experts to discuss how physical therapists should play a primary care role in the management of all musculoskeletal problems. The above referenced studies clearly suggest a physical therapy triage first model may make good economic sense. A “PT First” approach would also assist with improving patient access to the right provider at the right time while delivering value to the consumer and to payors. The current system isn’t meeting the public’s needs or expectation with regards to managing musculoskeletal problems. We must use this data and be confident in demonstrating our value to the health delivery system and the public; use this data to assist with obtaining unrestricted direct access across all states, and educate our loyal patients to be advocates for the services we provide.

Dr. C. Jason Richardson, PT

Sr. VP of Clinical Operations

Results Physiotherapy Centers

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