By: Tom Carroll, CFO, and Tom Davis, VP of Clinical Operations-Physical Therapy
In order to understand the benefits of the PT First and Chiropractic First approach to musculoskeletal (MSK) care—where physical therapists and chiropractors are the first stop on the patient’s care journey—it’s important to understand what MSK care looks like today and how we got here.
In the United States, with the best of intentions, insurers have asked Primary Care Physicians (PCPs) to be the gatekeepers for nearly all non-emergency conditions. For many conditions, this approach works well. The problem is that patients who have back or shoulder pain are not really sick in the traditional sense. They have MSK issues that need to be quickly diagnosed and treated before they get worse. Unfortunately, because PCPs are increasingly overwhelmed, it often takes an inordinate amount of time for someone in pain to get an initial appointment with a PCP which often results in the patient going to the emergency room for treatment.
The big enemy for a patient with an MSK condition is time. With time, unaddressed conditions get worse, and mobility and strength decrease while pain increases. Or sometimes, if a patient has to wait too long to see a PCP or specialist, the pain might temporarily go away. This is not necessarily a good thing. When pain subsides, the patient might decide to cancel an appointment and ignore the problem as the underlying condition worsens. When pain reappears, mobility might be more compromised, and the condition may be more difficult and expensive to treat. In this broken system, expensive interventions that could have been prevented with an immediate and targeted course of physical therapy become the norm, not the exception.
Of course, many PCPs do refer their patients relatively quickly for a course of PT or chiropractic treatment. However, getting immediate access to a PT or chiropractor only solves part of the problem. The other problem is cost.
Over the past twenty years, patients seeking physical therapy and chiropractic care are on the hook for more of the cost. If you roll back to how things were twenty years ago, patients were paying on average $10 in copays. For those of us who were practicing then, patient engagement was terrific. Patients came in for their care. They followed through with and completed their plan of care. For patients, there weren’t the financial barriers that we’re seeing today. Now, it’s not uncommon to see patients who have a $75 co-pay. And on top of that co-pay, they might have a $5,000 deductible. The end result is that a physical therapy or chiropractic plan of care that cost a patient around a hundred dollars twenty years ago can now run into the thousands of dollars. Even in the hundreds of dollars, that patient payment burden is too much for many to bear, which means they often choose to forego the most cost-effective, and non-invasive path of care for their MSK issue.
Payers and employers rationalize that they need to increase patient payment obligations because of the burgeoning cost of health care and the need to have patients engage in their care decisions. This argument has some validity when you consider that health care costs have risen at an annual pace of 3.5% a year (or close to 100% over 20 years) far exceeding the 2.1% annual rise in the consumer price index (CPI). Matter of fact, Hospital costs have risen even faster, averaging an annual growth of 4.5% over the past ten years—more than double the CPI. However, the argument does not work across all sites of service. For instance, physical therapy reimbursements have only increased by 2.2 % annually over the past twenty years, roughly the same as the CPI. So, factoring in inflation, physical therapy reimbursement is costing payers the same as it cost them twenty-five years ago, but they are charging patients far more.
Although arguably unfair to both patients and physical therapists, this shift in payment burden by payers might make sense if it saved them money in the long run. But the opposite is true. Studies show that MSK patients who forego physical therapy are far more likely to end up in the ER, requiring costly imaging and surgery that could have been avoided. Acute care is always more costly for payers than preventative care. Fortunately, some of the more enlightened insurers are starting to tune in to this reality. Recognizing that lowering patients’ cost-burden, as recent studies have shown, increases the likelihood that they will seek out and complete a PT plan of care, some payers are eliminating or reducing patient cost sharing. For instance, TRICARE, the health insurance system used throughout the U.S. military, has launched a three-year demonstration project that waives cost-sharing for up to three physical therapy visits for patients with low back pain. Others like Humana have their own pilot projects.
We hope that more payers will follow suit — and that these projects will quickly move from the pilot stage to the standard of patient payment. We are convinced that this will ultimately save patients, employers, and payers money, and most importantly, save patients from unnecessary pain and invasive interventions. In addition, by giving patients with MSK conditions direct access to PTs and chiropractors, the overall patient load for PCPs is reduced, allowing them to focus on patients who need their expert care the most. The result is a win-win for patients, primary care physicians, and health care overall.