Insurers Move From "Sick Care" towards "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. TRICARE tells us in their summary of this demonstration what they mean by high vs 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."

Well Care
High-value care leads to better outcomes, is easy to access and is cheaper for both patients and insurers. Physical therapy fits into this category, but looking at other high-value treatments helps us start to see a theme. In 2017 the American College of Physicians released widely endorsed guidelines for treating low back pain. 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".

Sick Care
In contrast, low-value care tends to be "sick care" where the patient is a passive participant. TRICARE puts imaging before six weeks in the absence of red flag symptoms, surgery for nonspecific low back pain, opioids as the first or second-line treatment, and bedrest in the low-value category. Spinal injections also fall in this category for most people.

This isn't to say that imaging, surgery, or injections are always bad. For a small percentage of people with back pain, they're the right treatment. But, most people should start with treatments that have the best outcomes for the lowest cost. If those treatments tend to focus on putting the person in pain in power to actively participate in their care rather than making them dependent on someone to "heal" them, that's even better. Physical therapists know 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.

About The Private Practice Section of the American Physical Therapy Association
​Founded in 1956, the Private Practice Section of the American Physical Therapy Association champions the success of physical therapist-owned businesses. Our members are leaders and innovators in the healthcare system. The American Physical Therapy Association (APTA) represents more than 85,000 physical therapists, physical therapist assistants and students of physical therapy nationwide. For more information, please visit www.ppsapta.org.