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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.
RESULTS

In the Table, we present descriptive data on the distribution of benefit features and choice of entry-point provider for the 117,448 patients included in the analyses. Of the 82,052 patients in the PCP versus physical therapist sample, 2.8% chose the latter provider. POS was the dominant plan type, followed by EPO, PPO, and HMO. Approximately 31% of patients in this sample had zero co-payments and 23% had zero deductibles. Patients in CDHPs made up only about 20% of the total. Regression results for all logistic models are contained in eAppendix D Tables 1 to 8.

Choice of conservative therapy was higher for the 115,144 patients in the chiropractor versus PCP sample; 31% of patients chose a chiropractor as their entry-point provider. The distribution among plans differed little, with the largest portion also enrolled in a POS plan, followed by EPO, PPO, and HMO plans. The percentages of patients with zero co-payments, zero deductibles, or CDHP participation were similar to those in the previous sample.

Physical Therapy

Figure 1 depicts odds ratios generated from results of the physical therapy logistic regressions. Among plan types, PPO plans were associated with the highest odds of seeing a physical therapist first; PPO patients had a 32% higher likelihood of seeing a physical therapist than a patient enrolled in a POS plan. EPO plans were associated with the lowest odds; these patients were 16% less likely than POS patients to see a physical therapist first.

The odds of seeing a physical therapist as first provider decline steadily as co-payment increases. Those in the highest category, patients with a co-payment of greater than $30, were 29% less likely to see a physical therapist first than patients whose co-payment was zero. The association of physical therapist first with OOP costs is also observed with deductibles, for which we observe a general decline in the odds of seeing a physical therapist first as the deductible increases. In the deductible range of $1001 to $1500, the odds are 19% lower than for zero deductible, and for deductibles greater than $1500, the odds are 11% lower. The regressions that included CDHPs produced mixed results. Patients with HRAs are 16% less likely to see a physical therapist first compared with patients without CDHPs; however, those with HSAs are 25% more likely.

Chiropractic Care

We present odds ratios obtained from the results of the logistic regressions in which the outcome variable was chiropractor versus PCP in Figure 2. With regard to plan design, there are some similarities to the physical therapist regression results. Patients in PPO plans had the highest likelihood of seeing a chiropractor first; the odds were 21% higher than for those in POS plans. As was the case for the analysis of physical therapists versus PCPs, EPO patients are less likely to choose chiropractors; the odds were 14% lower than for POS patients. However, unlike the analyses for physical therapists versus PCPs, HMO patients also were less likely to choose chiropractors; the odds ratio is the lowest, indicating a 28% lower likelihood of choosing such providers.

Results reveal little association between co-payments and choice of chiropractor first. Relative to $0 co-payment, the odds were only slightly lower for the categories of $1 to $20 and $21 to $30 and were not different for the highest co-payment category (>$30). Except for the highest category of deductibles (>$1500), other categories, relative to a $0 deductible, actually showed a slightly higher likelihood of seeing a chiropractor. Patients with a deductible of greater than $1500 were 7% less likely to choose a chiropractor as entry-point provider. With regard to CDHPs, those with HRAs, in comparison with those without CDHPs, had slightly higher odds of seeing a chiropractor, whereas there was no significant association for HSAs.


 
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