Physical Therapy First: WCRI Study Highlights How Early Implementation Can Spare Workers and Their Insurers Unnecessary Pain and Costs
For workers’ comp, lower back pain is a common workers’ injury. It can occur among industrial workers who are lifting heavy workers and office workers who may not have the ergonomic resources they need.
A recent study from WCRI found that early physical therapy could help reduce the costs of these injuries.
In a recent webinar, “The Timing of Physical Therapy for Low Back Pain: Does It Matter in Workers’ Compensation?” WCRI went over their findings which revealed that initiation of physical therapy within the first two weeks post-injury is associated with lower medical utilization and costs and shorter duration of temporary disability.
Speakers for the webinar included Dongchun Wang, Economist at WCRI, Dr. Randy Lea, Senior Research Fellow at WCRI, an orthopedic surgeon, and a hospital chief medical officer in Columbus, Ohio, and Dr. Kathryn Mueller, Professor at the Colorado School of Public Health and School of Medicine, former Medical Director for Colorado’s Division of Workers’ Compensation.
Wang emphasized that the study is focused on physical therapy treatment as defined by “workers who had three or more visits for PT services and by PT services we mean broadly speaking, physical modalities, manual therapies, and therapeutic exercise.”
WCRI excluded workers with only one or two visits, as this is likely only an evaluation and instructions for home exercises. Chiropractic care was also excluded, as were claims with red flag characteristics such as nerve involvement.
The Study at a Glance
To analyze the effect of physical therapy timing, WCRI broke the data out into five “buckets” based on date of injury: within three days, 4-7 days, 8-14 days, 15-30 days, and after 30 days. In the 27 study states, 68 percent of low back pain (LBP)-only claims received PT treatment and close to half of them received seven or more visits.
Additionally, large variation existed between states, with only 44 percent of LBP-only claims in Louisiana receiving PT to 80 percent in Delaware. Back to the timing, 48 percent of claims across the 27 study states started it late, meaning after two weeks. The difference in services associated with late PT is staggering.
“Workers with late PT, after 30 days, were more likely to receive medical services, specifically, they were 46 percent more likely to receive opioid prescriptions, 47 percent more likely to receive MRI, 29 percent more likely to receive pain management injections,” Wang explained.
“For low back surgery, for this particular set of claims, the surgery rate is low, but when you’re comparing the early group and the late group, workers in the late PT group after 30 days were 89 percent more likely to have low back surgery.”
Overall, workers in the late PT group had 24 percent higher medical costs and 58 percent longer temporary disability duration. “This study does not address optimal timing for PT initiation, but we do look at patterns in the results and we see evidence that led us to conclude that 14 days is a pretty good marker for late PT,” Wang continued.
Early PT Correlates with Better Outcomes
While the study shows correlation and not causation, Lea and Mueller laid out some clear implications for providers and employers.
“For employers, providing early access and intervention to decrease costs and utilization – that’s been a prominent theme in discussions around work related injuries and illnesses for better than 20 years,” Lea said.
“Our findings align with that concept. Early PT intervention is beneficial from a cost and a clinical standpoint.” Lea also emphasized that payors can do themselves a favor by incorporating a 14 day watch in their typical predictive analytics program.
Lea also perceived some elements of the study for patients to consider. “For a variety of reasons, patients at times might avoid or even refuse care. Let’s say for whatever reason they don’t trust the care being offered, here I think making a concerted effort to include shared decision making in the care plan is important. Specifically to let them know that research is suggesting outcomes are less favorable with delayed care,” he explained.
Lea also commented on the fact that sometimes treatment guidelines are insufficiently detailed on the timing of PT, but that the study can help flesh out those guidelines.
Advocate for State Legislation
For her part, as a long tenured state regulator, Mueller sees a strong call to action in the data for states to implement policies encouraging early PT.
“Of states that had 60 percent of all of their PT cases occur after 30 days, there’s five states like that, if I were one of those states I’d take a look at that, because the prediction is not very good,” she said.
“From a state regulatory point of view, I’m going to look at that and say ‘where am I and if I have that many late cases, is there something in my system that somehow is contributing to this? Is there too much prior authorization, are they not seeing a provider soon enough after the injury?’ ”
Mueller also encouraged state agencies and individual regulators to focus on the supplementary charts addressing patients with 3-6 PT visits, as opposed to those with seven or more.
About a third of those patients got opioids, and about a third got an MRI. “That doesn’t comport well with what most guidelines say should happen with patients that just have low back pain and have none of the red flag factors,” Mueller said.
Lea indicated that this study suggests numerous other avenues for research, including an assessment that digs into the difference between a cohort that receives no PT and how that establishes certain patterns. He also hinted at a future study that will identify and examine PT patterns of care and then determine their impact on utilization, costs, and TD duration.
This study is based on nearly 26,000 LBP-only claims with more than seven days of lost time from 27 states, with injuries from October 1, 2015, through March 31, 2017, and detailed medical transactions up through March 31, 2018.
The data was statistically controlled for factors such as worker and injury characteristics, state-specific factors, attorney involvement, and timing of initial care.
The 27 states are Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin. &