Last month, my company, WebPT, hosted its fifth-annual Ascend conference in the heart of Phoenix, Arizona, a mere stone’s throw away from our headquarters. This was truly a momentous occasion in WebPT’s history, not only because attendees got to meet us on our home turf and take a behind-the-scenes look at our inner workings, but also because it marked our 10-year anniversary. Amid the celebrating, there seemed to be an undercurrent of optimism and excitement. In addition to the plethora of valuable billing and compliance info brought to us by speakers like Rick Gawenda and Ellen Strunk, there was a tangible air of inspiration, which, as any past Ascend attendee can tell you, is not unique to this year’s event. But perhaps the most buzzed-about presentation came from David Elton, the Senior Vice President of Clinical Programs at Optum and a member of the UnitedHealth Group’s Opioid Task Force and Pain Management Work Group. During his keynote address, Elton laid the foundation for an open dialogue between rehab therapists and one of the top insurance payers in the biz: UnitedHealthcare (UHC).
Honest discussions between PTs and payers haven’t come easy.
Of course, I believe many attendees initially came to this session with much reproach and suspicion, and I certainly can’t fault them for that. After all, insurance payers don’t have the greatest reputation in the rehab therapy community, mainly because they’ve slashed payments for our services year after year while continually raising premiums for their beneficiaries. It’s frustrating, and it’s pushed many in our profession to explore alternative business models or opt to go out of network. (And this strategy breeds unique challenges in and of itself, namely, convincing patients to pay outright for PT services.) However, as Elton’s talk progressed, it became clear that he wasn’t there to justify low reimbursement, tell us how to treat our patients, or even convince us that we should love insurance companies. Instead, he highlighted some pretty incredible facts about our effectiveness in treating low back pain and how we can help combat the opioid epidemic, something that shouldn’t come as a shock to anyone in our profession. But what was perhaps even more striking were the implications these findings have on future relationships between payers and PTs.
The opioid epidemic is bad for patients and payers alike.
Elton shed light on UHC’s efforts to get at the heart of low back pain treatment, including a massive, soon-to-be-published study conducted by Boston University and jointly sponsored by UHC and the APTA. He revealed that claims for musculoskeletal episodes accounted for more than 16% of total spending, a percentage greater than that associated with any other condition. Furthermore, 75% of that spending went toward prescription medications. To put that into perspective, a little over 11% of UHC’s total spend went toward claims for cancer treatment. With numbers like those, it’s easy to see why UHC was interested in exploring ways to cut expenditures related to musculoskeletal conditions.
Physical therapy is a highly effective alternative to opioids and surgery.
The study also found that only about a third of eligible patients were sent to conservative treatments (i.e., physical therapy or chiropractic care) as a first option. At the same time, low back pain patients who accessed conservative therapies first were “75% to 90% less likely to have short or long-term exposure to opioids.” This stunning stat elicited a round of applause from the crowd, although I’m betting this isn’t news to most of us in the physical therapy profession. After all, we’ve seen firsthand evidence that physical therapy is a viable prescription drug alternative for certain populations of patients, including those suffering from low back pain.
Patients are more likely to seek less expensive treatment options.
Historically, there have been many barriers to patient entry into a PT practice, including cost. In fact, UHC found that beneficiaries are “10% to 25% less likely to see a PT, rather than a primary care provider, if their copay is more than $20 or deductible is more than $300.” And as many of you know, physical therapy copays and deductibles are often significantly higher compared to those for other types of care. This is largely due to our specialist designation, but in truth, physical therapists aren’t typical specialists. Sure, we specialize in the treatment of musculoskeletal conditions, but unlike most specialists, our patients see us relatively frequently, often as many as three or four times a week. And if a patient has to pay $50 out of pocket each time he or she comes to physical therapy, it can add up very quickly. We already know that opioids are a relatively cheap “solution” to chronic back pain, so this cycle seems very self-defeating.
These findings present an opportunity for increased access to physical therapy services.
But here’s the real question: considering the efficacy of physical therapy for the treatment of musculoskeletal conditions that often lead to long-term opioid use, why haven’t payers put forth the effort to make physical therapy services more accessible to patients? Simple: Until now, there was no real impetus for change. But with the opioid crisis wreaking havoc in patient lives (to the tune of 72,000 deaths from opioid overdoses in 2017 alone), and thus, creating headlines and prompting calls for regulatory shifts, the search for cost-effective, impactful solutions has become a top priority for many payers. UHC and other insurance companies are under greater pressure to find an alternative to prescription opioids for their beneficiaries, and fast. And now that payers have this research, physical therapy is perfectly poised to become an ideal, quick, and data-driven solution to this epidemic.
The change has begun, and it’s starting with a major player.
Our profession is standing in front of a huge opportunity to change the way payers view our services. In fact, this study has already sparked changes within UHC’s own benefits policies. Per Elton, starting in 2019, UHC will adjust its benefits packages to waive the copay and/or deductibles for each beneficiary’s first three physical therapy visits. He also mentioned the possibility of improving reimbursement based on patient outcomes. And if this data was enough to push one of the nation’s largest payers to make physical therapy more accessible, there’s no reason to think other payers wouldn’t make similar adjustments.
Change hinges on PTs breaking free of the siloed mentality.
So, how can we make that happen? If we want to improve patient outcomes, lower insurance premiums, and receive better reimbursements, then we can’t stay silent on this issue. We have the proof that PT is a safe, effective, and economical alternative to prescription opioids for the treatment of chronic pain; now, it’s time to take this data to our peers, payers, and patients.
This is a pivotal moment for our profession. The data is there, and PTs should be working together to make sure it gets the visibility it deserves. They should be shouting it from the rooftops, getting it covered in the media, whatever they have to do to get the attention of every single stakeholder in the opioid crisis, from referring providers to payers to patients themselves. The more these stakeholders demand a PT-first approach, the more pressure there will be to create the clinical pathways and insurance plans that support that approach.
Change is rarely easy, but it’s also often worth it. If we as a profession can decide today to rally around this opportunity to push the value of getting PT first, I believe we will see the positive change we crave within our profession. We now have the data in hand and the support of a major insurance company that is willing to change its clinical pathways to make it happen. We must cast aside our egos end seize the moment, not only for the good of our industry, but also for the health and wellbeing of our patients. After all, they are our most precious asset, and protecting their health and safety should be our number-one goal.