March 26, 2021
TRICARE has decided to waive the cost-sharing
requirement of up to three visits to a physical therapist for low back pain.
They've said that the goal is to encourage more use of "high-value"
treatments for low back pain. Understanding what they mean by "high-value"
vs "low-value" treatment can help us see the direction healthcare
payers are moving and how physical therapy is a part of that.
TRICARE tells us in their summary of this demonstration what they mean by high
and low-value care: "Increasing the value of health care refers to
improving patients’ quality of care and outcomes, improving patients’ access to
care, and reducing overall costs of care. In contrast, low-value care refers to
interventions that: are not proven to benefit patients; may harm patients;
result in unnecessary costs; or waste health care resources."
High-value care leads
to better outcomes, is easy to access and is cheaper for both patients and
insurers. We already know that physical therapy fits into this category, but if
we look at other things that fall into this category, a larger theme starts to
emerge. In 2017 the American College of Physicians released guidelines for
treating low back pain that have been widely endorsed. Initial treatment
recommendations include exercise, stretching, tai chi, yoga, progressive
relaxation, heat or ice, cognitive behavioral therapy, and motor control
exercise. These are all active treatments, where the practitioner and the
patient are working together to improve. This is "well care" or
"let me help you get better."
In contrast, low-value
care tends to be "sick care" where the patient is a passive
participant and the practitioner is saying "let me make you better."
TRICARE puts imaging before six weeks without red flag symptoms, surgery for
non-specific low back pain, opioids as the first or second-line treatment, and
bedrest in the low-value category. We would also place spinal injections in
this category for most people. They're expensive, only offer temporary relief,
usually have a long wait before they're available and include the risk of
serious infection and damage to surrounding soft tissues like skin, cartilage,
This isn't to say that imaging, surgery, or injections are always bad. For a
small percentage of people with low back pain, they're the right thing. But,
most people should start with treatments that have the best outcomes for the
lowest cost. If those treatments tend to focus on empowering the person in pain
to actively participate in their care rather than making them dependent on
someone to "heal" them, that's even better. Physical therapists have
known this and have been providing care that fits this model for years.
TRICARE's demonstration that waives cost-sharing clearly shows that insurers
are recognizing the value of this type of care and that they are actively
moving in this direction.