Insurers Are Moving From “Sick-care” to “Well-care”

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

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.”

Low-value care

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 secondline 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, and ligaments.

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.

Patients Reap the Benefits of Playing a More Active Role in Physical Therapy

Patients can no longer be passive players in the game of health. Studies show that informed patients are not only more engaged during physical therapy but also reap the benefits in overall health and well-being.

Those who understand why they’ve been referred to physical therapy, are actively engaged in the process, and develop useful self-management skills are more likely to achieve lasting results. With a few pointers, building one’s health literacy doesn’t have to be an overwhelming prospect.

To get the most out of your rehabilitation, it’s important to keep an open line of communication with your physical therapist. Your physical therapist is a wealth of knowledge and is there to help you regain mobility and relieve pain. The interaction should be positive, informative, and collaborative. Here are a few questions to ask your physical therapist so you may understand the rehab approach and how it impacts your injury or illness:
Why have I lost function/why do I hurt?
Your physical therapist has been trained to determine why a particular injury causes a loss of mobility or interferes with your ability to complete a task. It’s helpful for patients to gather information and understand the body’s mechanics as it relates to an individual injury.
Did my lifestyle contribute to this issue?
Your physical therapist will gather information about your lifestyle in order to identify habits that might be contributing to the problem. Perhaps the patient needs to wear shoes with support and limit time in flip flops. Or maybe the patient is experiencing low back pain due to poor posture at work.
How will physical therapy help me?
Physical therapists work with patients to devise an individualized and concrete care plan. You should feel comfortable asking your physical therapist why a specific goal has been chosen, how it will help you, and what you personally need to do to succeed.
What can I do to make sure I get better?
Showing up for appointments is only half the battle. Being ready to participate and understanding what you should be doing in between appointments is critical. You should be prepared to carry over goals at home and make modifications to habits at home and work to change contributing behavior.

It’s important that you feel comfortable asking your physical therapist questions and continue to understand how you can contribute to your care plan. Advocating for your own care and maximizing educational opportunities will give you the confidence and tools to succeed in physical therapy and beyond.