Posts in health care costs
Individualized Physical Therapy Saves Money Compared to Usual Care for Low Back Pain

As healthcare costs continue to rise, all stakeholders (patients, providers, and payers) are looking for ways to reduce costs associated with common conditions.  In our field, we commonly see patients given generic, one size fits all exercise programs for common conditions including low back pain.  Our previous post highlights the limitations of this approach including providing incorrect, inadequate, and sometimes harmful exercises to patients without a proper Physical Therapy examination first.  In addition, patients provided these incomplete, generic exercise programs will often spend additional healthcare resources in the coming months looking for relief of their symptoms.  

A recent research article in the journal Spine compared the effectiveness of individualized Physical Therapy services to guideline based advice for patients with low back pain. (Hahne et al. 2016).  300 patients were randomized to one of the two groups then were followed for 1 year to determine the effectiveness and cost of each treatment group.  Patients treated with Physical Therapy reported higher levels of health benefits at a lower cost than the guidelines group.  Specifically, patients missed fewer work days at a savings of close to $2,000 per worker.  This study adds to the existing data on the importance of individualized Physical Therapy for patients with low back pain

Cost Effectiveness of Physical Therapy With or WIthout Primary Care

Health care costs have continued to outpace inflation each year.  Our previous posts have detailed the cost savings associated with seeing a Physical Therapist for many musculoskeletal conditions.  In addition to saving health care expenses, Physical Therapy produces excellent outcomes for many musculoskeletal conditions.  A recent review article summarized the cost effectiveness of Physical Therapy alone or with usual care for various health conditions.

Burge and colleagues reviewed the available literature from 1998-2014 and included 18 research articles in their review (Physical Therapy 2016).  The authors found Physical Therapy alone or added to usual care improved health outcomes in the vast majority of studies.  In addition, Physical Therapy alone or in combination with usual care was cost effective for many health conditions.  Patient are encouraged to pursue Physical Therapy interventions for their musculoskeletal complaints to improve outcomes and reduce health care costs.  

Cost Effectiveness of Physical Therapy for Low Back Pain

Low back pain continues to affect many Americans leading to pain, loss of function, missed work days, and higher health care expenditures.  Much of this cost is attributed to the often unnecessary utilization of advanced imaging and procedures such as injections and surgery.  Previous research has shown early access to Physical Therapy without a prior MD referral saves patients on average $1000 per episode of care.  Further cost savings are noted if patients are treated early with Physical Therapy compared to national guidelines advocating a "wait and see" approach for care prior to deciding on Physical Therapy.  

A recent study was conducted to determine the cost effectiveness of primary care management with or without the use of early Physical Therapy for patients with acute low back pain (Fritz et al. Physical Therapy. 2016).  Economic data was collected on 220 patients with acute low back pain who were all treated with primary care management (education, medication) and then randomized to either 4 sessions of early Physical Therapy or primary care management alone.  The authors collected costs (health care treatments, loss time at work) associated with this episode of back pain.  The authors concluded that Physical Therapy was associated with higher quality of life scores at 1 year and was sufficiently cost effective to support its' early use for patients with acute low back pain.

Patients with low back pain are encouraged to seek out the services of a local Physical Therapist to reduce health care costs and improve symptoms and function compared to primary care management alone.  

Hyaluronic Acid vs. Corticosteroid for Knee Osteoarthritis

Knee Osteoarthritis is a common condition affecting many middle aged adults which leads to pain, loss of range of motion, and decreased function.  Physical Therapy remains the primary choice for conservative treatment, but often these treatments are combined with injections to the knee joint.  Corticosteroids are an inexpensive injection designed to reduce pain and inflammation in the knee, but Hyaluronic Acid injections such as Synvisc are also on the rise.  These injections claim to cushion and lubricate the knee joint leading to reduced pain and improved function.  One downside of these injections is their cost ($250-$1000 per injection) which is often not covered by insurance.  In addition, the research on these injections has been compared to saline (placebo) injections instead of a head to head comparison with the corticosteroid.

Recently an article in the Journal of Bone and Joint Surgery examined the impact of a single corticosteroid or hyaluronic acid injection on 99 patients with knee osteoarthritis (Tammachote et al. 2016).  Patients were randomized to receive one of the two injections then followed over 6 months.  As you can see from the graph above both groups demonstrated similar outcomes in pain, function, and range of motion at 6 months.  Differences were noted in the short term with decreased pain and improved function noted in the first two weeks in the patients receiving the corticosteroid.  The authors called into question the cost of these expensive injections compared to the less expensive corticosteroid.  

Evidence Does Not Support Knee Surgery for Meniscal Tears

Tears in the meniscus, cartilage within our knees, can occur due to injury or degeneration attributed to the aging process.  The latter is a much more frequent scenario and often these tears are found on MRIs of patients without knee pain.  These false positive results cast doubt on the direct correlation between a picture of your knee and the symptoms you are experiencing. Thus, meniscal tears are found in patients without pain and those with pain can have a negative image.  Unfortunately, arthroscopic surgery for these age related tears is on the rise with 700,000 procedures performed in the United States each year (Cullen et al. 2009).  Interestingly, a previous randomized controlled trial in the New England Journal of Medicine found no difference in patient outcomes between this meniscal surgery and a sham surgery (Sihvonen et al. 2013).  

In the study, 70 patients were randomized to a partial menisectomy (removal of the meniscus) and 76 were randomized to a sham surgery (Sihvonen et al. 2016).  In the article published in the Annals of Internal Medicine the authors reported close to half of the patients in either group reported mechanical symptoms such as locking or catching prior to surgery.  Surprisingly, no differences were noted between the surgery and sham surgery for relief of pain or mechanical symptoms.  The authors concluded, "resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking".

Patients with meniscal tears are advised to work with a local Physical Therapist on an cost and clinically effective treatment plan before considering any surgical procedure.  

Timing of Physical Therapy and Patient Outcomes

Currently in the United States the majority of citizens can access their Physical Therapist without a prescription from their physician.  As shown in the map above, arbitrary restrictions on this access has been put in place through state legislatures with strong influences from special interest groups.  In Colorado, patients can access their Physical Therapist without restriction allowing them to enjoy the improved outcomes and decreased cost associated with this healthcare pathway.  On average these patients will save $1000 per episode of care and avoid the unnecessary and high risk pathway including medications, procedures, and surgery.  In addition to these benefits, research is now highlighting how this pathway can improve outcomes for patients with musculoskeletal problems.    

The majority of the musculoskeletal aches and pains are best treated early allowing the Physical Therapist to maximize outcomes in fewer visits.  A recent review article in the Journal of Sports and Orthopedic Physical Therapy highlights the importance of early vs. late access to Physical Therapy services (Ojha et al. 2016).  The authors reviewed 14 research articles to examine the impact of early Physical Therapy on health care outcomes.  Consistent with prior business and research articles, early Physical Therapy was associated with decreased costs and future health care utilization.  Patients who receive early Physical Therapy are likely to require fewer physician visits and avoid unnecessary and costly interventions including surgery.  

Patients are encouraged to round out their health care team of a physician and dentist by adding a Physical Therapist.  Seek out a local, knowledgeable Physical Therapist (early) for advice, questions, and treatment of your next ache or pain.