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Do the Right Thing: Getting LBP Patients to Physical Therapy

The blog below was originally written by Richard Zhao, with contributions from Jerry Durham, and reflects a topic they discussed at PPS 2016. 

What challenges and opportunities are independent physical therapy clinics facing?

Healthcare expenses have been rising for the past decade, impacting all American consumers, hospitals, and governments. It seems that the upward trending of healthcare cost will stay, at least for some time.

There are a lot of factors that have an impact on healthcare cost for Americans. If we dive into the detail of medical expense by different medical conditions, musculoskeletal, aka MSK, related medical expense is the 3rd largest category, next to cardiac and cancer treatments. Within MSK treatment, spine-related medical expenses account for about 70 percent. Spine related medical treatment is obviously a huge expenditure for American families and the healthcare system.

Yet, the characteristics of spine related conditions are very different to cardiac and cancer treatments. Cardiac and cancer treatments rely heavily on medical centers. Those centers could be regional or national, but those centers are all equipped with multi-million dollar equipment to do the operations. MSK treatments on the other hand, are widely distributed among many medical disciplines and non-medical professions.

MCOs (Managed Care Origination) have been trying to bend the upward MSK related expense curve, or, at least, to keep this expense curve flat. But this effort has not been very successful for all MCOs. From claim data analysis, there are several scenarios that contribute to MSK treatment as one of the largest expenses in healthcare:

  1. High prevalence of lower back pain (LBP) among Americans
  2. Wide variety of point of entry to spine issues, some are not necessarily medical treatments.
  3. A relatively large portion of patients look for quick-fix for their spine issue, but they do not realize that spine related issues can be very complex
  4. Incorrect handling of treatment and escalation at the Point of entry (PoE) for LBP treatment can easily make the episodic cost much higher. This could happen either by holding the patient too long for conservative treatments that do not show results or by referring patients to other specialty providers too soon without proper conservative treatments.
  5. After patients get their MRI/CT scans, a relatively high percentage of patients ended up with expensive injections to manage the unbearable pain or invasive surgery procedures.
  6. All the medications that patients use to make them feel better is another expenditure for the patient.

Consumerism of Healthcare Is Giving Physical Therapy the Opportunity to Step Up as the Point of Entry (PoE) for Lower Back Pain

So, what is the right approach for patients with lower back pain if the spine care treatment is so complex? One solution is for physical therapists to be the Point of Entry (PoE) for all lower back pain patients.

All the white papers and discussions in the past have been based on medical reimbursement data. After studying social media data, which is the detailed comments from patients, we have realized that there were a lot of LBP treatments happening before the patient sought medical professional help. Those treatments are all cash based. For working Americans, high-deductible health plans (HDHP) with Healthcare Saving Accounts (HSAs) are very common today. HSA spending is cash equivalent. If physical therapists have not realized that, it is time to rethink your market approach strategy.

The deepest fundamental change occurring is the consumerism or “Uberism” of healthcare. During the time with low deductibles, most clinical decisions were made by PCP (Primary Care Provider). But, with the shift to a cost-sharing healthcare model,  patients have had to shoulder part of the cost. This leaves many patients with the decision between which provider to see, how much money they can spend, what type of service to get, when they will reach the deductible, etc.  With the consumerism of healthcare progressing and all the characteristic of LBP treatment available, it makes perfect sense for Physical Therapists to be PoE for LBP treatment. Physical Therapists can help patients get to the right solution for their long-term well being. All of this will require patient engagement at the front-end.

Currently, only 7 percent of all LBP patients use physical therapy as PoE. And, most physical therapy clinics still rely on MDs’ referral for getting new patients. This current business model is not a patient-centric solution. It is HMO or health system centric solution, based on what the MD thinks is best for the patient. With the purchase decision power shifting to the patient more, this old approach is late in the treatment process for conservative treatment.

The right thing to do is to engage your patient at the front-end, addressing patients’ needs, answering patients’ questions about treatment, payment, and insurance options. This will require strong clinical guidelines and a referral process so that physical therapy can be the point of entry to put LBP patients on conservative care first before other expensive and invasive procedures. If patients use physical therapy more as the PoE (7% to ??) then patients, payers, and physical therapists will all WIN.

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Author

Richard Zhao

Business Process Consultant, Wells Fargo Insurance

Richard Zhao, independent healthcare consultant and healthcare economist. Previous consulting at OptumHealth on musculoskeletal insurance program product development. And, consulting to Preventice, which is a Merck subsidiary, on home care for ACO market. With many years experience from technology and financial services industry, Richard is keen to build innovative business models, financial model building and data analytics. Previous medical device startup and payer product development experience puts Richard in a unique position, which has good to insight of current healthcare delivery and forward looking attitude.

2 thoughts on “Do the Right Thing: Getting LBP Patients to Physical Therapy

  1. Can’t go wrong with the honorable J Durham, and to be joined by Mr Zhao is a win! Won’t be at PPS this year but get to join Jerry in Seattle in 4 weeks.

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