Does Unrestricted Access to Physical Therapy Reduce Health Spending?

1. Does Unrestricted Access to Physical Therapy Reduce Health Spending? ASHEcon 6th Biennial Conference Philadelphia, PA June 14, 2016 Presenter: Bianca K. Frogner, PhD Associate Professor, Department of Family Medicine Director, Center for Health Workforce Studies

2. The George Washington University Ken Harwood, PhD, PT Jesse Pines, MD, MBA, MSCE University of Washington Holly Andrilla, MS Malaika Schwartz, MPH Study Funded and Supported by: Co-Authors Health Care Cost Institute State Health Policy Grant Program Laura and John Arnold Foundation

3. Introduction • Back pain: $90.6 billion direct costs + $19.8 billion indirect costs1 • Opioids and imaging are common treatments for back pain, yet… • Opioids are associated with 36 to 56% lifetime prevalence of substance use disorder2 • Opioids are overprescribed leading to increase in emergency room visits3 • Imaging often inappropriately used and has limited evidence of providing accurate diagnosis4 • $300 million potential savings if imaging guidelines are followed5 • Limited evidence that early treatment by physical therapists (PTs) may reduce cost • PTs are trained to diagnosis and treat musculoskeletal conditions • Ritzwoller et al, 2006 found that only 24% of back pain patients received physical or occupational therapy6 • Flynn et al, 2011 found $1000 savings per person and 5 percentage point decrease in imaging if PT seen before a specialist4 • Limitations: These studies were focused on one medical center or one insurance plan 1. Dagenais et al, 2008, 2. Martell et al 2007, 3. Deyo et al 2009, 4. Flynn et al, 2011, 5. Srinivas et al, 2012, 6. Ritzwoller et al, 2006

4. Policy Concern • Many patients do not see a PT because: • Insurers may require a referral to see PT due to state law restrictions and provisions • Patients may be unaware of the full costs and benefits associated with PT services • Yet all 50 states and DC allow for direct access to PTs as of January 1, 20157 • 18 states allow unrestricted access • 25 states + DC have provisions • 7 states limit access • State advocacy work to increase PT access focus on: • Transparency of insurer referral and payment • Reduction or caps on co-payments • More robust evidence needed to inform debates on impact of restrictions on PT access and cost 7. “A Summary of Direct Access Language in State Physical Therapy Practice Acts,” American Physical Therapy Association. Available at: http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf

5. Data and Sample Study Question: Does allowing for unrestricted direct access to PT result in lower utilization and health care costs for patients with lower back pain? Data Source: Commercial health insurance claims data from Health Care Cost Institute, 2009-2013 Sample Selection: • Patients living in WWAMI+O region • Washington, Wyoming, Alaska, Montana, Idaho, and Oregon • Age: 18-64 years old • Non-Medicare Commercial population • Patients with primary diagnosis of lower back pain • 6 month “clean period” of no prior lower back pain diagnosis • Exclude patients with cancer diagnosis and selected severe illnesses

6. Variable Definitions (1) Outcome Variables (one-year post LBP diagnosis) • Utilization (binary): ER visit, opioid Rx, imaging (MRI/CT) • Cost: Total, Provider, Outpatient, Inpatient, Pharmacy, Out-of-Pocket • Patient + provider costs • Deflated to 2009 dollars Primary Independent Variable: Timing of Visit to PT • PTFirst v. Not PT First (e.g., No PT and PT later) • Any PT (e.g., PT first or PT later) v. No PT Where: • PT First: Visited PT at first point of lower back pain (LBP) diagnosis • PT Later: Visited PT, but not at first point of LBP diagnosis • No PT: Never visited a PT

7. Variable Definitions (2) Instrument to control for selection bias of seeing a PT: Differential distance between: • Distance between patient and PT • Distance between patient and other (counterfactual) provider Where: • PT First: Distance between PT seen and counterfactual closest provider of any kind within insurance network • PT Later: Distance between first provider seen and PT seen within insurance network • No PT: Distance between first provider seen and counterfactual closest PT within insurance network Control Variables: • Individual: gender, age bands, Elixhauser co-morbidity index, dummies for state and year

8. Empirical Specifications Instrumental Variable: 2 Stage Residual Inclusion (2SRI) approach with bootstrapped residuals of: IV1: Pr(PT First v. Not PT First) = γ0i + γ1iDifferentialDistance + γ2i X IV2: Pr(Had PT v. No PT) = γ0i + γ1iDifferentialDistance + γ2i X Outcomes: Y = β 0i + β 1i IV1 + β 2i X + β 3i e2SRI Y = β 0i + β 1i IV2 + β 2i X + β 3i e2SRI • Utilization outcomes used probit • Total costs used GLM with Gamma Distribution and Log Link • Provider, OP, IP, Rx, and OOP costs used Two Part Model • First stage: Probit • Second stage: GLM with Gamma Distribution and Log Link

10. Demographics ofLBP Patients by PT Access

11. Utilization and Costs ofLBP Patients by PT Access

12. Regression Results for Utilization Margins dy/dx from probit using 2SRI

13. Regression Results for Costs Margins dy/dx from GLM for total cost, two part model for all other costs using 2SRI

14. Findings • Patients with LBP who saw a physical therapist (any or first) had significantly lower probability of having an ED visit, lower imaging rates, and lower probability of an opioid prescription compared to patients who saw another provider first. • Patients with LBP who saw a physical therapist (any or first) had significantly lower outpatient, pharmacy and out-of-pocket costs than patients who saw another provider with the exception of: • Patients with any PT had significantly lower inpatient costs but this was not significantly different among those who saw PT first • Patients with PT first had significantly lower total costs but this was not significantly different among those who had any PT • Patients with any PT or PT first had significantly higher provider costs

15. Conclusions • Seeing a physical therapist as the first point of care compared to seeing a physical therapist at a later point in time may reduce utilization of potentially costly services, which have an impact on health care costs across most settings. • Removing restrictions on access to PT may result in better imaging, opioid, and ED outcomes among select populations.

16. References 1. Dagenais Simon, Caro Jaime, Haldeman Scott, “A Systematic Review of Low Back Pain Cost of Illness Studies in the United States and Internationally,” The Spine Journal, 2008, 8(1): 8-20. 2. Martell BA, O’Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, Fiellin DA, “Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction,” Annals of Internal Medicine, 2007, 146(2): 116-127. 3. Deyo Richard A, Mirza Sohail K, Turner Judith A, Martin Brook I, “Overtreating Chronic Back Pain: Time to Back Off?” Journal of the American Board of Family Medicine, 2009, 22(1): 62-68. 4. Flynn Timothy W, Smith Britt, Chou Roger, “Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder that Unnecessary Imaging May Do as Much Harm as Good,” Journal of Orthopaedic and Sports Physical Therapy, 2011, 41(11): 838-846. 5. Srinivas Shubha V, Deyo Richard A, Berger Zackary D., “Application of “Less is More” to Low Back Pain,” Archives of Internal Medicine, 2012, 172(13): 1016-1020. 6. Ritzwoller Debra P, Crounse Laurie, Shetterly Susan, Rublee Dale, “The Association of Comordities, Utilization, and Costs for Patients Identified with Low Back Pain,” BMC Musculoskeletal Disorders, 2006, 7: 72. 7. “A Summary of Direct Access Language in State Physical Therapy Practice Acts,” American Physical Therapy Association. Available at: http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf

17. Questions? Contact: Bianca K. Frogner, PhD Associate Professor, Department of Family Medicine Director, Center for Health Workforce Studies bfrogner@uw.edu UW Center for Health Workforce Studies http://depts.washington.edu/uwchws/ @uwchws

18. Distribution of Instrumental Variable

19. Demographics of LBP Patientsby PT Access Instrumental Variable

20. Utilization and Costs of LBP Patientsby PT Access Instrumental Variable