Discussing Updated CDC Guidance on Pain Management, Coverage for Physical Therapy

Chuck Thigpen, PhD, PT, ATC, clinical research scientist, ATI Physical Therapy, reviews the updated guidance on pain management from the Centers for Disease Control and Prevention, as well as how patients and payers typically cover the costs of physical therapy.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

In this episode, Dr Chuck Thigpen discusses coverage for physical therapy in the wake of the CDC's recently updated guidance on pain management.

I’m Chuck Thigpen, vice president of care delivery for ATI Physical Therapy. I lead quality and innovation of our clinical services to prevent and treat musculoskeletal disorders, which are primarily joint- and muscle-related. We have over 900 clinics, 200 sports medicine affiliates, and 200 employers for which we provide physical therapy, and then early intervention services to across the country. I'm really excited to be here today.

Can you discuss how the CDC has shifted its guidance on pain management? How might this impact stakeholders?

There's really 3 important items that they've changed in their recommendations. Two are a point of emphasis, and the other is a policy change.

For the policy change, they removed the arbitrary dosing limits. In the original guidelines that came out in 2016, the CDC had hard stops on how many pills you could prescribe and how long a patient could take them, which then created some barriers for providers regarding the patients that benefited from opioids in managing their pain. It put some handcuffs unintentionally on the providers.

Of the 2 decisions that come behind the policy change, one is a strong recommendation to promote integrated pain management. I'm going to quote exactly from the guideline. It said medications should ideally be combined with non-pharmacologic therapies to provide greater benefits, improving pain and function. That's music to our ears in physical therapy, because that's what we do: improve pain and function.

The other important guideline recommendation is policy-related, to improve payer limitations because the reimbursement policy is the principle barrier to why these non-pharmacologic therapies aren't integrated into a more comprehensive approach to pain management.

How does physical therapy compare to opioid use for pain management?

Physical therapy has long been a principle non-pharmacologic therapy, especially for musculoskeletal-related pain. Studies show up to a 20% to 50% reduction in opioid use when you start and continue physical therapy. When you've been using opioids, and then you come to therapy, you see a reduction. The largest benefit, up to 80% reduction in opioid use, is when you start therapy early in a course, typically within 30 to 60 days of the initial onset of musculoskeletal pain.

We feel physical therapy has a strong impact by improving range of motion and strength, and doing that on a personalized basis to reduce patients’ dependence on medication for the long term. It allows patients, as needed, to use opioids to help manage their pain, but then hopefully bridges them to a new place in life to not be dependent upon the medications for long-term pain management.

Thank you, Dr Thigpen. How is physical therapy typically covered by payers?

It's very traditional. Typically, physical therapy is lumped under specialist, just like an orthopedic surgeon or other specialist that you would go see in your health plan. The challenge with that is this usually comes with a hefty copay. For other services, like seeing a surgeon or maybe a heart specialist, you only go 1 or 2 times, so the $50 copay isn't that big of a deal. But if you're coming to therapy a couple of times per week over 4 to 6 weeks, now that becomes a pretty significant burden.

When you think about the evolution of high deductible plans—which are good because they come with a lower premium on your regular check—it actually shifts all that burden upfront. Now the patient is left with a choice. Can I spend $2000 for physical therapy, to go for 8 to 12 visits over 6 to 8 weeks, to get a full course and likely resolve my issue, or are opioids are covered for $10? It’s the choice between paying a $50 copay for a specialist, or $10 every 2 weeks.

There is just a disparate difference in how those services are covered, ,which has been a barrier to access for physical therapy as a key non-pharmacologic treatment for musculoskeletal pain.

And given the recently updated guidelines and the current state of the opioid crisis, where do you see future payment models headed for physical therapy?

Physical therapy is now being recognized as an important early, non-invasive treatment for patients with musculoskeletal disorders, in particular around musculoskeletal pain. As we move into this era of bundled payments, I think physical therapy will continue shift toward the early portion of care where, preferentially, a lot of payers are removing copays, doing pilots, and leveraging virtual therapy for easy access to physical therapy so patients can get a prognosis, diagnosis, and a plan of care early.

We will see shared savings because of the reduction in opioids, imaging, and surgery that are reduced downstream when you get early non-pharmacologic care.

Thank you, Dr Thigpen. Is there anything else you would like to add today?

We're really excited at ATI to be the leader in prevention and treatment of musculoskeletal disorders. As these policies continue to evolve, we're excited as a national provider of physical therapy to be able to partner with payers, physicians, and patients to limit musculoskeletal pain and return patients to the function that they're hoping to achieve.

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This transcript has been edited for clarity.