Care pathways

Odds of Physical Therapy as Entry-Point Provider (compared with PCP)

Odds of Chiropractor as Entry-Point Provider (compared with PCP)

“under pressure to reduce growing healthcare expenditures, health insurers and employers have been increasing the level of patient cost sharing at the point of service, elevating the role of benefit design in shaping patient preferences. This development is part of a larger movement toward redesigning benefits in order to encourage patient decision making that aligns the prices of medical services with the value of those services. Value-based insurance design is based on the notion that the value of a treatment to a patient depends not only on the perceived therapeutic effect but also on the price of the treatment relative to other options. In this scenario, a patient with new-onset LBP [low back pain] covered under a health plan with a relatively low or zero OOP [out-of-pocket] cost for physical therapy or chiropractic care may be more likely to choose early conservative therapy, in harmony with the clinical guidelines.

In addition to the economic value of potentially avoided downstream costs, policies that encourage patients with LBP to choose early conservative therapy may have a particular social advantage. Mounting evidence suggests that initial conservative treatment of LBP by a physical therapist, chiropractor, or acupuncturist decreases the odds of early and long-term opioid use. Hence, we postulate that benefit redesign that is successful in realizing initial conservative treatment for LBP may also indirectly have a positive bearing on restraining the growing problem of overprescribed opioids. [..]

Evidence-based guidelines for treatment of LBP recommend early conservative therapy with referral to other providers for patients who do not improve within a few weeks. Yet many patients experiencing a new episode of LBP turn to other nonconservative, first-line treatments that may involve greater cost and/or advanced testing and medications such as opioids. Our study has demonstrated that patients experiencing LBP are moderately responsive to network restrictions and cost sharing in their choice of entry-point provider. This suggests that innovative modifications to insurance benefits offer an opportunity for increased alignment with clinical practice guidelines and greater value. To date, incentive-based insurance benefit design has been applied mainly to prescription drug pricing through mechanisms such as tiered formularies and, more recently, through the Affordable Care Act, requirement of zero cost sharing for preventive services covered by insurance sold on the exchanges. Moving forward, benefit managers and regulators need to advance such principles more broadly by developing new designs and policies aimed at encouraging behaviors that will result in the largest long-term economic and social benefits.”

Health Insurance Design and Conservative Therapy for Low Back Pain (2019.6.7)