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The American Journal of Managed Care June 2019
Reports of the Demise of Chemotherapy Have Been Greatly Exaggerated
Bruce Feinberg, DO; Jonathan Kish, PhD, MPH; Igoni Dokubo, MD; Jeff Wojtynek, PharmD; and Kevin Lord, PhD, MHS
From the Editorial Board: Patrick H. Conway, MD, MSc
Patrick H. Conway, MD, MSc
Association of Decision Support for Hospital Discharge Disposition With Outcomes
Winthrop F. Whitcomb, MD; Joseph E. Lucas, PhD; Rachel Tornheim, MBA; Jennifer L. Chiu, MPH; and Peter Hayward, PhD
US Care Pathways: Continued Focus on Oncology and Outstanding Challenges
Anita Chawla, PhD; Kimberly Westrich, MA; Angela Dai, BS, BA; Sarah Mantels, MA; and Robert W. Dubois, MD, PhD
Understanding Price Growth in the Market for Targeted Oncology Therapies
Jesse Sussell, PhD; Jacqueline Vanderpuye-Orgle, PhD; Diana Vania, MSc; Hans-Peter Goertz, MPH; and Darius Lakdawalla, PhD
Cancer Care Spending and Use by Site of Provider-Administered Chemotherapy in Medicare
Andrew Shooshtari, BS; Yamini Kalidindi, MHA; and Jeah Jung, PhD
Will 2019 Kick Off a New Era in Person-Centered Care?
Ann Hwang, MD; and Marc A. Cohen, PhD
Enhanced Care Coordination Improves HIV Viral Load Suppression Rates
Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
Impact of Care Coordination Based on Insurance and Zip Code
Jennifer N. Goldstein, MD, MSc; Merwah Shinwari, BS; Paul Kolm, PhD; Daniel J. Elliott, MD, MSCE; William S. Weintraub, MD; and LeRoi S. Hicks, MD, MPH
Changing Electronic Formats Is Associated With Changes in Number of Laboratory Tests Ordered
Gari Blumberg, MD; Eliezer Kitai, MD; Shlomo Vinker, MD; and Avivit Golan-Cohen, MD
Currently Reading
Health Insurance Design and Conservative Therapy for Low Back Pain
Kathleen Carey, PhD; Omid Ameli, MD, MPH; Brigid Garrity, MS, MPH; James Rothendler, MD; Howard Cabral, PhD; Christine McDonough, PhD; Michael Stein, MD; Robert Saper, MD, MPH; and Lewis Kazis, ScD

Health Insurance Design and Conservative Therapy for Low Back Pain

Kathleen Carey, PhD; Omid Ameli, MD, MPH; Brigid Garrity, MS, MPH; James Rothendler, MD; Howard Cabral, PhD; Christine McDonough, PhD; Michael Stein, MD; Robert Saper, MD, MPH; and Lewis Kazis, ScD
This study examined the association between health insurance design features and choice of physical therapy or chiropractic care by patients with new-onset low back pain.

Objectives: To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP).

Study Design: Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse.

Methods: We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics.

Results: Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy.

Conclusions: Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

Am J Manag Care. 2019;25(6):e182-e187

View an infographic of this abstract here.
Takeaway Points

Current guidelines for management of low back pain recommend early conservative treatment, such as physical therapy or chiropractic care, but patient choice of first-line treatment may be influenced by health insurance features. We examined the choice of a physical therapist or a chiropractor compared with a primary care physician as the entry-point provider for a large sample of commercially insured adults who received diagnoses of new-onset low back pain.
  • Patients covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy.
  • Higher patient out-of-pocket cost was associated with lower likelihood of choosing conservative therapy.
Low back pain (LBP) is among the most common medical conditions in the United States, with 70% of people experiencing symptoms at least once in their lifetime.1-3 The high prevalence of LBP translates into high healthcare costs for treatment, as well as considerable indirect costs associated with lost productivity.4,5 Current guidelines for treating LBP recommend noninvasive conservative management and avoiding more
aggressive and costlier options during earlier stages of care.6-8

Prior studies have found that patterns of care, including initial provider and timing of treatment, affect the cost of medical care for LBP. Patients with new-onset LBP who were referred to a physical therapist within 3 days9 or 4 weeks10 of onset had lower LBP-related healthcare utilization and costs during the following year. A similar study found lower follow-up costs over a 2-year period.11 Chiropractic care also was relatively cost-effective for treatment of chronic LBP.12-14 However, evidence is inconsistent. Results of a randomized clinical trial indicate that compared with referral to physical therapy from a primary care physician (PCP) after several weeks of persistent LBP, early utilization of physical therapy was associated with increased costs.15 A study of care management of LBP in a managed care organization found chiropractic management to be less costly than medical management when care extended beyond primary care but not when compared with primary care alone.16

Despite the availability of clinical practice guidelines for treating LBP, the current US healthcare system often fails to successfully engage patients and their providers in adherence to those guidelines.17 The relative value of different treatment options may be realized only over the course of an extended episode of illness and often is not aligned with patient cost-sharing policies imposed by payers. At the point of new symptom onset, patient preference for provider type may be strongly influenced by out-of-pocket (OOP) costs, which may be higher for patients who choose conservative therapy that involves repeated visits to a physical therapist or chiropractor. Hence, it is possible that financial barriers deter patients from seeking early conservative therapy despite its high value relative to other available treatment options.8

Health insurers offer a range of benefit designs with embedded financial incentives affecting patient choice.18 One feature is limitations on access to providers. Health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) are the most restrictive plan types, providing coverage only for providers included in network. HMOs and EPOs also require a designated PCP for each enrollee and PCP referrals to specialists. Preferred provider organizations (PPOs) are the least restrictive, generally offering a wide range of providers, with out-of-network coverage subject to higher cost sharing. Point of service (POS) plans are hybrid plans offering varying blends of HMO and PPO plan characteristics. We hypothesized that lower restrictions on provider access would be associated with higher likelihood of choosing conservative therapy for new-onset LBP.

Financial incentives also are present in patient OOP cost sharing at the point of service. Most health insurance plans have a deductible, which requires that a patient pay a fixed amount per calendar year before plan payment begins. Depending on the amount of the deductible and the amount already used at the time of a new episode of care, the deductible can require high patient OOP cost, strongly influencing patient choice of provider. A patient who does not expect to exhaust the deductible during the period of coverage faces full cost at the point of service and may be disinclined to choose conservative therapy involving multiple visits to a physical therapist or chiropractor.

Patient OOP costs also are affected by co-payments, which are fixed amounts charged to the patient, and/or by coinsurance, which varies as a percentage of the overall payment. Co-payments and coinsurance vary across health plans, and in the case of co-payments, there may be variation within plans across provider types. Relatively high co-payments or coinsurance for visits to physical therapy or chiropractic care present disincentives for patients with new-onset LBP to seek early conservative therapy, particularly if patients anticipate a number of visits requiring repeated charges.

The strongest financial incentives facing patients are encompassed in the growing system of consumer-driven healthcare, which couples high-deductible health plans with health reimbursement accounts (HRAs) or health savings accounts (HSAs).19 Premiums on these plans cost less, but the patient pays the full cost of care up to the level of the deductible using a prefunded spending account subsidized by employer contributions and/or consumer savings. The rationale behind consumer-driven healthcare is to provide patients with incentives to make high-value decisions about the healthcare they receive by managing their own healthcare budgets. Consumer-driven healthcare is a relatively new form of health insurance and evidence is mixed; however, although high-deductible health plans are associated with lower costs, this comes from reduction in inappropriate services but also in reduced utilization of appropriate preventive care and medication adherence.20

In order to better understand the impact of health insurance benefit design on provider choice, we examined the relationship between common features of commercial health insurance plans and patient selection of PCP versus physical therapist or chiropractor as first-line provider for new-onset LBP.

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