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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.

Study Population

We studied commercially insured adults 18 years or older with an outpatient diagnosis of new-onset LBP during 2008-2013 as recorded in claims from the OptumLabs Data Warehouse.21 (See eAppendix A [eAppendices available at].) Inclusion criteria required 24 months of continuous enrollment before and following the index event with no prior diagnosis of LBP or back procedures, including spinal surgery, spinal injections, or spinal cord stimulators, and no filled opioid prescriptions during the 12 months prior to the index event. Also excluded were those with any neoplasm diagnosis in the 12 months prior to and 3 months on or following the index date and, additionally, in the 3 months on or following that date, LBP-related diagnoses that would typically not be amenable to conservative therapy (ie, spinal fractures, vertebral dislocations, inflammatory spondyloarthropathies, intraspinal abscess).

Based on the index LBP date, we selected 117,448 patients whose entry-point providers were characterized as a physical therapist, chiropractor, or PCP and for whom benefit design information was available. (The benefit design criteria excluded Medicare Advantage enrollees.) PCPs included family medicine practitioners, pediatricians, internists, obstetricians, gynecologists, hospitalists, and geriatricians. We focused on 2 samples: (1) 82,052 patients whose first encounter was with either a PCP or a physical therapist and (2) 115,144 patients whose first encounter was with either a PCP or a chiropractor (see eAppendix B).

Descriptive Analysis

Descriptive statistics were reported as counts and proportions for categorical variables representing plan type (POS, EPO, HMO, PPO), co-payment, deductible, and consumer-driven health plan (CDHP) by sample. We included the number and percent of patients whose entry-point provider was a physical therapist or a chiropractor overall and by category within each benefit design feature. We omitted analysis of coinsurance; more than 95% of patients had no coinsurance for 90 days following the index date, with little variation among patients who did.

Statistical Analysis

Our main analyses consisted of 2 sets of multivariable logistic regressions. The dependent variable in the first set was physical therapist versus PCP as entry-point provider. We estimated 4 logistic regressions with this dependent variable, 1 for each benefit design feature: plan type, co-payment, deductible, and CDHP. The key independent variables were categorical variables measuring the benefit design feature, and reference groups were POS plan type, zero co-payment, zero deductible, and neither type of CDHP. The second set of 4 logistic regressions was structured similarly, with the dependent variable being choice of chiropractor versus PCP as entry-point provider. For all logistic models, we calculated adjusted odds ratios with 95% Wald CIs. We also evaluated overall model fit, model discrimination (C statistic), and calibration (Hosmer–Lemeshow test) for all logistic models (see eAppendix C).

Although our main interest was in the association of benefit design features with the likelihood of patients choosing a physical therapist or a chiropractor as entry-point provider, all regression models included a broad range of covariates. Patient demographic characteristics included age, gender, race/ethnicity, and US region. (Race and ethnicity are based on imputation and are not separately defined in the OptumLabs Data Warehouse.21 The specified categories are black, Hispanic, Asian, and white.) We included a modified Elixhauser index (in which mental health conditions were excluded) to account for physical comorbidities, treated as a continuous variable.22 We also included 9 binary variables to control for individual mental health comorbidities, 8 selected from the CMS list of chronic health conditions23 and a single condition representing fibromyalgia, chronic pain, and fatigue. For the physical therapy regressions, we also included a categorical variable that measured the level of direct access to physical therapy afforded to insured patients according to various state regulations, as categorized by the American Physical Therapy Association: limited, provisional, or unrestricted.24 Other covariates are listed in eAppendix D Tables 1 to 8.

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