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The American Journal of Managed Care June 2019
Reports of the Demise of Chemotherapy Have Been Greatly Exaggerated
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Cancer Care Spending and Use by Site of Provider-Administered Chemotherapy in Medicare
Andrew Shooshtari, BS; Yamini Kalidindi, MHA; and Jeah Jung, PhD
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Ann Hwang, MD; and Marc A. Cohen, PhD
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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.

The study involves a retrospective analysis of claims data from the OptumLabs Data Warehouse,21 which includes deidentified claims data for privately insured and Medicare Advantage enrollees in a large, private US health plan. The database contains longitudinal health information on enrollees, representing a diverse mix of ages, ethnicities, and geographical regions across the United States. The health plan provides comprehensive full insurance coverage for physician, hospital, and prescription drug services. Overall, findings demonstrate that patients’ selection of entry-point provider was responsive to the incentives that they faced. Patients covered under health plans with the most restrictions on provider choice were less likely to choose a physical therapist or chiropractor over a PCP, and those under the least restrictive plan type were more likely. We also observed a pattern indicating that the likelihood of choosing a physical therapist declined as patient OOP cost increased. This result was less evident for choice of chiropractor. Results exploring the relationship between choice of conservative therapy and participation in a CDHP were largely inconclusive.

CDHP designs couple high-deductible plans with health spending accounts and have become increasingly prevalent since the 2000s. The rationale is that requiring patients to shoulder a greater share of the cost of their care will encourage them to reduce unnecessary utilization. However, studies have shown that reductions in spending are not necessarily accompanied by improvement in value, particularly if patients bypass routine care that would prevent higher downstream costs.20,25 Patients who were enrolled in HRAs were somewhat less likely to choose physical therapy, but those enrolled in HSAs were more likely. It may be that incentives placed by HRAs, which are accounts funded by employer contributions, differ from those placed by HSAs, which are funded by both consumers’ personal savings and employer contributions. Consumer sensitivity to the cost of care may be higher when their personal contributions are at stake. Affordability may also play a role, as individuals in HSAs may have higher available income compared with individuals in HRAs.26 Future studies that explore these possibilities would be a useful direction for research on consumer-driven healthcare.

In designing insurance products, managed care organizations make use of various financial incentives and management strategies aimed at controlling expenditures. These range from supply-side controls that place restrictions on utilization to looser demand-side approaches that affect patient OOP costs. Of late, 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.27,28 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.18 In this scenario, a patient with new-onset LBP covered under a health plan with a relatively low or zero OOP 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.11,29,30 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.


This study analyzed only patients who sought medical care for LBP and whose entry-point provider was either a physical therapist, a chiropractor, or a PCP. We did not consider patients who chose other providers for first-line treatment, and we had no information on severity of the patients’ pain, their incomes, or other sociodemographic information that might affect provider choice. Although selection effects of providers cannot be ruled out, we attempted to mitigate the risk of observed effects being driven by selection through stringent exclusionary criteria. Still, the conclusions drawn are associations between benefit design and first provider, and they do not demonstrate a causal connection.

Finally, we examined benefit design features individually, but there may be complex interactions among features that could confound our results. A useful future research direction aimed toward improving the value embedded in health insurance plans would be to investigate the joint impact of various features of benefit designs.


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.31 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.18,32 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.

Author Affiliations: Department of Health Law, Policy, and Management (KC, OA, BG, JR, MS, RS, LK), and Department of Biostatistics (HC), Boston University School of Public Health, Boston, MA; OptumLabs (OA), Cambridge, MA; University of Pittsburgh School of Health and Rehabilitation Sciences (CM), Pittsburgh, PA; Department of Family Medicine, Boston Medical Center (RS), Boston, MA.

Source of Funding: This project was supported by United Healthcare, OptumLabs, and the American Physical Therapy Association.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KC, OA, JR, CM, RS, LK); acquisition of data (OA, LK); analysis and interpretation of data (KC, OA, BG, JR, HC, CM, MS, RS, LK); drafting of the manuscript (KC, OA, HC, MS, RS); critical revision of the manuscript for important intellectual content (KC, OA, BG, JR, HC, CM, MS, RS, LK); statistical analysis (OA, HC); obtaining funding (RS, LK); administrative, technical, or logistic support (BG, LK); and supervision (LK).

Address Correspondence to: Kathleen Carey, PhD, Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Boston, MA 02118. Email:

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