Health Insurance Design and Conservative Therapy for Low Back Pain

Most Americans will struggle with low back pain (LBP) at some point in their life. Current clinical guidelines recommend noninvasive, conservative treatment first — physical therapy, chiropractic care, exercise, etc. — before moving to surgical treatments or opioids. Not only does this save the patient from more aggressive intervention, it may save money overall.

But saving money overall is not the same thing as saving the patient money. Repeated visits to the physical therapist or chiropractor can be expensive to patients, as copayments add up. They’re also time consuming. Patients in plans with more narrow networks of those kinds of providers might have to spend more time finding and traveling to one.

A recent paper by Kathleen Carey and colleagues studied these two components of a patient’s insurance coverage — cost sharing and network — and how they affect LBP treatment decisions. They hypothesized that a broader provider network would be associated with a higher likelihood of initially choosing conservative treatments for LBP. They also predicted increased out-of-pocket (OOP) costs would be associated with a lower likelihood of initially choosing conservative treatments for LBP. (The authors hold positions with the Departments of Health Law, Policy, & Management and Biostatistics at Boston University School of Public Health; the Department of Family Medicine at Boston Medical Center; OptumLabs; and the University of Pittsburgh School of Health and Rehabilitation Sciences.)

Each analysis in the paper included four sub-analyses based on particular plan characteristics: plan type, co-pay, deductible, and health savings account (HSA) or health reimbursement account (HRA) enrollment. The reference groups for each sub-analysis were, respectively: POS plan (a managed care plan that blends characteristics of both HMO and PPO plans), zero co-pay, zero deductible, and no HSA or HRA.

Four plan types were included, representing a range of provider networks: point of service (POS), exclusive provider organization (EPO), health maintenance organization (HMO), and preferred provider organization (PPO).

The study population included adults with private insurance and a new diagnosis of LBP during 2008-2013. Patients were excluded if they had a prior LBP diagnosis, prior back procedures, or an LBP diagnosis that would not typically be treated with conservative treatment.

Physical therapist v. PCP

Over 82,000 patients were included in the physical therapist versus PCP analysis and less than three percent chose a physical therapist as their initial treatment provider. The authors compared patients with all four plan types and found those with a PPO plan — the least restrictive plan with a wide range of providers and out-of-network coverage options — were the most likely to initially see a physical therapist. Those with an EPO plan — one of the most restrictive plans with in-network coverage only and required referrals for specialists — were the least likely.

Regarding OOP costs, the researchers found that as co-pays or deductibles increased, patients became less likely to initially see a physical therapist. Patients with an HRA were also less likely to initially see a physical therapist while patients with an HSA were more likely.

Overall, these findings support the authors’ hypotheses. A less restrictive provider network and lower OOP costs made it more likely patients would seek LBP treatment from physical therapists before PCPs.

The HRA/HSA analysis was particularly interesting. Carey, et al. posited the incentives and financial responsibilities for each account differ. HRAs are employer-funded, meaning patients have less financial liability. The authors speculated that patients with HSAs, to which employees also contribute, may have more at stake.

Chiropractor v. PCP

Over 115,000 patients were included in the chiropractor versus PCP analysis. More than 30 percent chose a chiropractor as their initial treatment provider. The authors again compared patients with all four plan types and patients with a PPO plan were the most likely to initially see a chiropractor. Those with an HMO plan — another very restrictive plan with in-network coverage only and required referrals for specialists — were the least likely.

There was little association between co-pays and provider choice. Interestingly, deductibles were found to be associated with an increased likelihood of initially seeing a chiropractor (except for deductibles over $1500). Patients with an HRA were a bit more likely to initially see a chiropractor but an HSA had no effect.

These findings do not support the researchers’ hypotheses as clearly as those from the physical therapy analysis. A less restrictive provider network still made it more likely for a patient to initially choose a chiropractor over a PCP, but the OOP cost analysis was less conclusive. Their findings on deductibles do not support their theory because patients who paid more OOP in the form of deductibles were more likely to see a chiropractor before a PCP for LBP than those who didn’t.


Carey, et al. found that both provider network and individual financial responsibility can affect a patient’s likelihood to seek conservative therapy for LBP before visiting a PCP. (The authors caution these findings are associations and do not demonstrate causation.) However, the impact of provider network was much more apparent. If a patient had an insurance plan with a bigger provider network, such as a PPO plan, she was more likely to choose physical therapy or chiropractic care before visiting her PCP.

Understanding how insurance policies impact a patient’s treatment choices is helpful for both patients and providers to ensure each patient receives the highest value care possible within his individual plan limitations, be it provider availability or cost.

It’s also important for patient safety. Evidence suggests that patients who seek conservative treatment for LBP first through a physical therapist or chiropractor have lower odds of both early and long-term opioid use. In light of the current opioid crisis, reducing the number of patients who use opioids for LBP when there are better, more conservative treatments available is critical. (The authors recently published a separate paper on this, specifically studying this relationship in comparison to patients who see their PCP first.)

Lastly, these findings are helpful for insurance plan design as companies move towards value-based coverage. Ideally, insurance companies should encourage patients to choose conservative, lower cost treatments for LBP first whenever possible before turning to surgical treatments or opioids. One way to do this is to make physical therapy, chiropractic care, and the like easily accessible and available at low or no cost to the patient so she and her provider choose them first in line with clinical guidelines.

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