TRICARE to Begin Pilot That Waives Cost-Sharing for Physical Therapy for LBP
Back pain is a huge problem in developed nations worldwide. It has or will affect most of us. The current estimate is that 80% of people will experience back pain at least once. It is the single biggest cause for disability, the third most common reason for doctor visits, and one of the most common reasons for missing work.
It's also expensive. Back and neck pain makes up the biggest healthcare expense in the US, totaling $134 billion spent in 2016. The next two most expensive conditions were diabetes — $111 billion in spending — and ischemic heart disease at $89 billion.
Why is back pain so expensive?
The first reason is that it's so common. The second reason is that our current system isn't very good at treating it. Current recommendations include starting with activity modification, and active treatments like physical therapy. Research backs this up, showing better outcomes and lower costs with early PT. Unfortunately, only 2% of people with back pain start with PT, and only 7% get to PT within 90 days. At the same time, a study looking at about 2.5 million people with back pain in The Journal of the American Medical Association showed that 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. Both of these things go against current practice guidelines for treatment of back pain.
A new pilot program being rolled out by TRICARE, the insurance system used throughout the US military is waiving the payment owed by the patient for up to three PT sessions in an attempt to improve the use of what the Defense Health Agency calls "high value" treatment for low back pain. The theory is that once a person sees some benefit from PT treatment, they're likely to go back for more. This is the "try it before you buy it" approach - think of the 7-day free trial Netflix offers, free samples poured in wineries and craft breweries, or the folks you see standing around in supermarkets with food on toothpicks. TRICARE's data seems to indicate that it works just as well for healthcare as it does for other businesses. In a press release they state that once people attend one session of physical therapy, they're likely to go back for more, no matter what their co-pay is. But TRICARE found that higher co-pays could be a barrier to people trying that first visit. For the group of patients with the highest co-pays in the system, only 38% of the people prescribed PT attended the first visit. That's about half the rate of attendance found in the lowest co-pay group.
Here are the details you need to participate.
- This demonstration applies to new PT episodes of care only. TRICARE patients who were receiving PT services before Jan. 1, 2021, may not receive waived cost-shares for services received after the start of the demonstration.
- A TRICARE-authorized provider must refer beneficiaries to treatment.
- A network provider must provide the PT services. (Exception: TRICARE For Life beneficiaries may receive PT services from a non-network TRICARE-authorized provider.)
- There is no time limit between the onset of symptoms and receiving PT services under this demonstration.
- Visits for acute, subacute or chronic LBP may be eligible for this benefit.
- After the third, cost-share waived PT session, beneficiaries will be responsible for standard cost-shares for future sessions.
If you fit these requirements, contact your primary care provider and have them send us a referral for low back pain.
The fact that such a major insurer is looking into the value of PT is great news for everyone. If TRICARE can show that lowering the cost of PT for patients can improve outcomes and save insurance companies money, other major insurers will likely follow. This could improve the lives of millions of people every year while reducing the huge cost of treating low back pain for the country. That seems like a win for everyone involved.