Does Unrestricted Access to Physical Therapy Reduce Health Spending?

Introduction: Back pain results in $90.6 billion in direct costs and $19.8 billion in indirect costs in the US. Opioids and imaging are common treatments for low back pain (LBP), but have been found to contribute to higher costs through inappropriate use of imaging and over prescription of opioids leading to substance use disorders.  Limited evidence suggests that early treatment by physical therapists (PT) may reduce costs as a result of earlier accurate diagnosis and lower use of imaging. Although all 50 states and DC allow direct access to PTs, over 32 states still have referral and diagnosis requirements in place that prevent unrestricted access to PTs.

Objective: We investigated whether states allowing for unrestricted direct access to PTs have lower utilization and healthcare costs for patients with lower back pain.

Data and methods: We used 2009-2013 commercial health insurance claims data for a non-Medicare population between the ages of 18 and 64 provided by the Health Care Cost Institute. We identified patients living in one of six states in the northwest region with variation in state restrictions and other healthcare market factors. We identified patients with a primary diagnosis of LBP with at least six months of a “clean” period of no prior LBP diagnosis, and no diagnosis of cancer or other selected severe diseases. Patients were divided into three cohorts: 1) visited PT at first point of LBP, 2) visited PT but not at first point of LBP diagnosis, and 3) never visited a PT. We used an instrumental variables approach using distance between the patient and first provider providing a LBP diagnosis to predict: 1) access to PT at any point, and 2) access to PT as first point of care. We then predicted whether access to PT at any point or access to PT at first point was associated with significant differences in cost of care, imaging, and number of prescriptions within one-year post LBP diagnosis.

Results: We found that accessing PTs at any point in time resulted in significantly (p<0.001) lower likelihood of receiving any MRI scan, CT scan or radiography, fewer prescriptions, and lower total cost of care. Lower total cost of care appears to be driven by significantly (p<0.001) lower outpatient costs and to a lesser extent (p<0.05) inpatient and pharmacy costs. Accessing PTs first significantly (p<0.001) reduced the likelihood of receiving imaging and prescriptions, but had no impact on cost of care. Living in a restricted state was not related to any significant differences in imaging or prescriptions, but significantly (p<0.001 for any PT, and p<0.01 for PT first) increased total cost of care via physician costs.

Conclusions: Use of PT at any point appears to significantly decrease use of imaging and number of prescriptions for patients with LBP, which appears to lead to lower costs of care. States with restrictions on PT access significantly increase physician costs. Removal of barriers to PT may lead to lower cost of care through lower use of expensive treatments and fewer prescriptions.