Insurance Coverage
TRICARE has decided to waive the cost-sharing requirement of up to three visits to a physical therapist for low back pain. They’ve said that the goal is to encourage more use of “high-value” treatments for low back pain. Understanding what they mean by “high-value” vs “low-value” treatment can help us see the direction healthcare payers are moving and how physical therapy is a part of that.
TRICARE tells us in their summary of this demonstration what they mean by high and low-value care: “Increasing the value of health care refers to improving patients’ quality of care and outcomes, improving patients’ access to care, and reducing overall costs of care. In contrast, low-value care refers to interventions that: are not proven to benefit patients; may harm patients; result in unnecessary costs; or waste health care resources.”
High-value care
High-value care leads to better outcomes, is easy to access and is cheaper for both patients and insurers. We already know that physical therapy fits into this category, but if we look at other things that fall into this category, a larger theme starts to emerge. In 2017 the American College of Physicians released guidelines for treating low back pain that have been widely endorsed. Initial treatment recommendations include exercise, stretching, tai chi, yoga, progressive relaxation, heat or ice, cognitive behavioral therapy, and motor control exercise. These are all active treatments, where the practitioner and the patient are working together to improve. This is “well care” or “let me help you get better.”
Low-value care
In contrast, low-value care tends to be “sick care” where the patient is a passive participant and the practitioner is saying “let me make you better.” TRICARE puts imaging before six weeks without red flag symptoms, surgery for non-specific low back pain, opioids as the first or second-line treatment, and bedrest in the low-value category. We would also place spinal injections in this category for most people. They’re expensive, only offer temporary relief, usually have a long wait before they’re available and include the risk of serious infection and damage to surrounding soft tissues like skin, cartilage, and ligaments.
This isn’t to say that imaging, surgery, or injections are always bad. For a small percentage of people with low back pain, they’re the right thing. But, most people should start with treatments that have the best outcomes for the lowest cost. If those treatments tend to focus on empowering the person in pain to actively participate in their care rather than making them dependent on someone to “heal” them, that’s even better. Physical therapists have known this and have been providing care that fits this model for years. TRICARE’s demonstration that waives cost-sharing clearly shows that insurers are recognizing the value of this type of care and that they are actively moving in this direction.
Resources/Author:
