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By Margot Walthall, MHA, Vice President, Translation, OptumLabs; and Joelle Zaslow, MS, Communications & Translation Manager, OptumLabs

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Low back pain (LBP) can happen to anyone at any age.

Take a new mom for example. She’s 27 years old and hadn’t experienced LBP until the birth of her child two months ago. 

Since then, she has felt pain in her back that radiates down her leg on a daily basis. The pain has started limiting her ability to hold and care for the baby and is taking a toll on her mental health. 

Or imagine a 45-year-old construction worker. He has had recurring episodes of LBP since he began working in construction 20 years ago. 

While most LBP episodes only last for a few weeks at a time, the pain became prolonged and so debilitating when he was 34 that he had to go on disability leave and take unpaid time off from work. 

These are just two of the millions of people who experience low back pain — LBP is among the most common medical conditions.

Nearly 70% of people experience symptoms at least once in their lifetime, and approximately one quarter of adults in the United States report experiencing LBP in the past 3 months.1,2,3

Such statistics show the clear need to improve quality of life for people with LBP through treatments that adhere to clinical guidelines, which recommend first-line treatments of exercise, time and noninvasive therapies like physical therapy and chiropractic care, and discourage the use of opioids.

Recent research conducted by OptumLabs and Boston University School of Public Health provides insight into opportunities for better care options.

The research finds that a patient’s initial choice in health care provider (i.e., seeing a non-invasive therapist first vs. a primary care physician [PCP]) for a new episode of LBP results in much lower odds of early and long-term opioid use.

The findings also suggest that health plans could play an important role in making it easier for consumers to consider noninvasive therapies for LBP.

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Current treatment methods

Most episodes of LBP improve substantially within six weeks through active treatments, such as exercise-based therapies that focus on returning to regular function. And by 12 months, average pain levels are low.

Still, LBP has remained one of the top reasons for physician visits,5 which prompted the American College of Physicians (ACP) to develop guidelines for providing clinical recommendations on the treatment of LBP. The guidelines were originally published in 2007 and updated in 2017.

The guidelines recommend exercise and time as a first line of treatment. 

If LBP persists, the ACP encourages the use of nonpharmacologic and nonsurgical approaches including physical therapy, spinal manipulation (chiropractic care), acupuncture and nonsteroidal anti-inflammatory drugs (NSAIDs). 

It is important to note that for “red-flag” symptoms, such as fever, loss of weight, or loss of bladder or bowel control, immediate testing and intervention by a physician may be required. 

Evidence shows that both physical therapy and chiropractic care may yield positive results for treating LBP. 

A systematic review from the ACP concluded that physical therapy has a moderate effect on reducing pain, and chiropractic care has a small effect on lessening pain and improving level of function.

Other studies have found that patients with new-onset LBP who were referred to a physical therapist within three days to four weeks of occurrence had lower LBP-related health care utilization and costs during the following year.6,7

A similar study found lower follow-up costs over a two-year period.⁸

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Managing pain amidst the opioid epidemic

Despite the guidelines clearly recommending against pharmacologic treatment, insight from an OptumLabs key performance indicator related to opioid prescribing for new-onset back pain reveals that opioids are still prescribed for nearly 9% of new LBP cases.10

And LBP is the most common reason for an opioid prescription in general — 52% of prescribed opioids are for LBP. 

This is especially troubling considering that over-prescribing of opioids is now well-understood to have contributed to the dramatic increase in opioid dependence in our country.

Today, almost two million people in the United States suffer from opioid use disorder (OUD), and, in 2017, more than 47,000 Americans died from overdoses related to prescription and/or illicit opioids.11,12  

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Investigating how noninvasive therapies for LBP impact patient care

Seeking better care options for people with LBP motivated UnitedHealthcare® and the American Physical Therapy Association to sponsor research on how well noninvasive — also known as “conservative” — therapies such as physical therapy and chiropractic care could serve affected patients.

A team from OptumLabs and Boston University School of Public Health designed a project in this area with two objectives: 

  1. Investigate nonpharmacologic therapies for LBP and their association with opioid use.
  2. Examine health outcomes and costs associated with various provider types who treat LBP.

Investigating the association of initial health care provider with opioid use

This collaborative team's paper — recently published in BMJ Open — compared early and long-term opioid use among patients seeking initial treatment for LBP from various providers, including primary care physicians, specialist physicians, chiropractors, physical therapists and acupuncturists.

Using de-identified administrative claims data from the OptumLabs Data Warehouse (OLDW), the research team conducted a retrospective study of 216,504 individuals aged 18 or older who were seen by a health care provider for new-onset LBP and were opioid-naïve at the time of the initial visit. 

Short-term opioid use was defined as an opioid fill within 30 days of the initial visit. 

Long-term opioid use was defined as an initial opioid fill within 60 days of the initial date and either 120 or more days’ supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months.

Individuals who received initial treatment from chiropractors or physical therapists had decreased odds of short- and long-term opioid use compared to those who received initial treatment from primary care physicians (PCPs). 

The odds of early opioid use for those who saw a physical therapist first were 85% lower than those who saw a PCP first. The odds of early opioid use were even lower for those seeing a chiropractor and acupuncturist (90% and 91%, respectively). 

See the table below for the all odds of early and long-term opioid use by initial provider.

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Odds of early and long-term opioid use by initial provider

Table
Initial provider Early use, OR (95%CI)  Long-term, OR (95%CI)
PT (n=3499) 0.15 (0.13 to 0.17)  0.27 (0.15 to 0.48)
DC (n=50014) 0.10 (0.09 to 0.10 0.22 (0.18 to 0.26) 
Acupuncture (n=1839) 0.09 (0.07 to 0.12) 0.07 (0.01 to 0.48) 
Ortho (n=9335) 0.63 (0.60 to 0.67) 1.10 (0.92 to 1.30) 
Emerg Med (n=8746) 2.66 (2.54 to 2.78) 0.92 (0.77 to 1.10)
Neurosgn (n=578) 0.58 (0.47 to 0.71)  1.50 (0.88 to 2.58)
MD other (n=4422) 0.50 (0.46 to 0.54) 2.03 (1.70 to 2.41)
Rehab (n=3246) 0.54 (0.49 to 0.59)  1.78 (1.40 to 2.26)
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Examining health outcomes and cost associated with various provider types

A related paper from this team — recently published in the American Journal of Managed Care — investigated the association between several health insurance benefit design features and choice of early, noninvasive therapy for patients with LBP. 

Using de-identified data from the OLDW, researchers looked at commercially insured adults ages 18 or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013.

The team found that benefit design plays a key role in whether patients choose to see their PCP when first seeking LBP care instead of a provider who offers nonpharmacologic and nonsurgical treatments like a physical therapist or chiropractor. 

People covered under health plan designs with the most restrictions on provider choice (e.g., health maintenance organization [HMO] vs. preferred provider organization [PPO] plans) were less likely to choose a physical therapist or chiropractor over a PCP. 

They found that PPO plan patients had a 32% higher likelihood of seeing a physical therapist — and a 21% higher likelihood of seeing a chiropractor — than a patient enrolled in a point of service (POS) plan. 

And EPO (exclusive provider organization) plan patients were 16% less likely than POS patients to see a physical therapist first, and 14% less likely to choose a chiropractor. 

Higher patient out-of-pocket cost was associated with a lower likelihood of choosing conservative therapy for LBP. Patients with a copay of more than $30 were 29% less likely to see a physical therapist than patients whose copay was $0.

There was a similar association between deductible and choice of physical therapy as the service provider for back pain.  

The chart below outlines the likelihood that patients will choose a physical therapist first before consulting a PCP, based on plan type, copay, deductible, and consumer directed health plan (CDHP).13

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Figure 1: Odds of physical therapist as entry-point provider
(compared with PCP)

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Taken together, these findings suggest that incentivizing use of conservative therapists may be a strategy to reduce risks of early- and long-term opioid use.

They also suggest that modifying health insurance benefit designs could be one way to encourage patients to use these noninvasive (conservative) therapies as a first line of treatment for their LBP.

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Translating the findings

Analyses that identified barriers to convenient and affordable access to conservative therapies for LBP, in tandem with the results of this study, contributed to UnitedHealthcare’s recent decision to offer new benefit designs.

The new benefit design improves patient access to physical therapy and chiropractic care for people in eligible UnitedHealthcare employer-sponsored plans. 

People covered by eligible plans with this benefit design will pay $0 out-of-pocket costs for the first three visits if they choose to receive physical therapy or chiropractic care for their LBP*. 

These three visits (with the potential for variability in the number of free visits offered in the future) may be to any network provider who offers these services. 

UnitedHealthcare began offering out this benefit design to employers in July 2019 in a few states, and is expanding to employers with self-funded plans and more markets in 2020 and 2021. 

This is a great example of how evidence from rigorous research triggers innovation, leading to meaningful changes that positively impact members’ health care journeys. 

For patients like the new mom and construction worker mentioned above, this means fewer barriers to the sorts of treatments that can improve quality of life and enable them to get back to their normal routines. 

The work from OptumLabs and Boston University looking at both costs and outcomes has provided some of the evidence to enable and incentivize better care options for people with LBP. 

In a few years it will be exciting to examine whether these changes are associated with other long-term health, economic and social benefits.

 

* Eligible plan participants must have remaining physical therapy or chiropractic visits under the plan; the new benefit design does not increase the maximum number of physical therapy/chiropractic visits.   

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Citations

1. Hurwitz EL, Randhawa K, Yu H, Côté P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. European Spine Journal. 2018 Sep 1:1-6.

2.  Kassebaum NJ, Arora M, Barber RM, et al. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2015;388:1603–1658. 

3. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014; 73(6):968-74. 

4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet 2018; 391: 2356–67. 

5. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530.

6. Liu X, Hanney WJ, Masaracchio M, et al. Immediate physical therapy initiation in patients with acute low back pain is associated with a reduction in downstream health care utilization and costs. Phys Ther. 2018;98(5):336-347. 

7. Gellhorn AC, Chan L, Martin B, Friedly J. Management patterns in acute low back pain: the role of physical therapy. Spine (Phila Pa 1976). 2012;37(9):775-782.

8. Childs JD, Fritz JM, Wu SS, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs [erratum in BMC Health Serv Res. 2016;16(1):444. BMC Health Serv Res. 2015;15:150. 

9. Low back pain series. Lancet. 2018 Mar 22. https://www.thelancet.com/series/low-back-pain 

10. OptumLabs. 2018 Opioid KPI Metrics.

11. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 2017. 

12. National Institute on Drug Abuse. National drug overdose death through 2017. January 2019.

13. Carey K, Ameli O, Garrity B, et al. Health insurance design and conservative therapy for low back pain. Am J Manag Care. 2019 June 7;25(6):e182-e187.

 

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