David Elton, senior vice president of clinical programs for Optum Health, describes the opioid epidemic as a lit match—the crisis that sparked payers to sit up and take notice of physical therapy's ability to not only reduce later opioid use, but to lower downstream health care costs for a variety of conditions. It didn't take long for the 2018 Rothstein Roundtable to reflect that same heat, as a discussion initially focused on increasing the use in physical therapy as an alternative to opioids spread to an exchange on both the promise of physical therapy to become more broadly supported by private payers, and the factors that could get in the way.

The roundtable, a regular part of APTA's 2018 NEXT Conference and Exposition, held true to its reputation for facing hot topics in the profession head-on. This year, the title of the discussion was "Physical therapy decreases opioid use: what will it take to change policy?"

The answer, more-or-less agreed upon by Elton and his fellow panelists: policy is already changing, but not as quickly—or as broadly—as some in the physical therapy profession might prefer.

Moderator Anthony Delitto, PT, PhD, FAPTA, launched the discussion by asking, “What’s taking so long?” for payers to act on the evidence that shows physical therapy's efficacy in treating chronic pain, as many payers impose restrictions, high copays, and other barriers that make it hard for patients to get nondrug care.

It's not simply a matter of payers being unaware of physical therapy's effectiveness, explained panelist Kenneth Schaecher, MD, associate chief medical officer for the University of Utah Health Plans—it's also that most clinicians don't think of physical therapy as an option for their patients. "And even if they do,” he said, “they're not aware of the evidence."

Stephen Hunter, PT, PhD, physical therapy administrator at Intermountain Health Care, said that financial implications play a role, too. Often, he explained, physical therapy presents a disincentive for patients: multiple visits, with multiple copays—providing, of course, that the patient has made it past her or his high deductible in the first place. "Due to the historical approach to physical therapy … payers have created the circumstances that have pushed people away from physical therapy," Hunter said.

Elton largely agreed with Schaecher and Hunter, but was more hopeful about the future. The evidence, he said, can no longer be ignored, particularly when an estimated 50% of all health insurance claims are related to back pain, and 75% are related to musculoskeletal conditions—the exact areas in which physical therapy has been demonstrated to be most effective. But, as panelists pointed out, change can't really start happening until payers and the profession itself do a better job of making the case for physical therapy to the public.

Hunter explained that at Intermountain, it was commonly assumed that the reason patients weren't seeing physical therapists (PTs) is that physicians weren't referring them. That does happen sometimes, he explained, but when they looked closer they found the real problem was with the patients themselves.

"Patients were referred to PTs but would never show up," Hunter said. "They don't see the value."

Charles Thigpen, PT, PhD, clinical research scientist for ATI Physical Therapy and director of observational clinical research with the Center for Effectiveness Research in Orthopaedics at the University of South Carolina, agreed, saying that the issue is about "getting in front of the patient."

"A lot of patients don't understand why they're coming to therapy," Thigpen said. "We have a messaging issue."

Schaecher thinks it's not simply about better marketing to consumers—those within the physical therapy profession need to rein in unwarranted variation in practice and truly commit to value-based care.

From a payer perspective, Schaecher said, the practice of physical therapy can seem broad and inconsistent, which can lead to a perception that PTs "are not engaged in a value-based approach to care—they're engaged in making money."

"You need to start seeing therapists that are looking at their services as a value and not a revenue generator," Schaecher added.

Elton only partially agreed. The variability issue is present in physical therapy, he countered, but is not nearly as bad as it is in some of the medical specialties.

Thigpen added that the variability issue in physical therapy may have to do with issues other than revenue generation, such as payer variation and patient market factors that can add to variability in treatment.

Thigpen said he also worries that for some PTs, their commitment to their profession and a belief in the good it can do can morph into a maybe-unconscious willingness to please the patient at all costs. "You feel obligated to give the patient what the patient wants," he said. "In that way, we sometimes don't do a great job in shared decision-making," he said, which leads to unwarranted variation in practice.

Delitto acknowledged that the current payer landscape for physical therapy was created at least in part in reaction to what he described as the "free-for-all" days of the 1980s and 1990s, when payers were much less restrictive. Returning to a place where physical therapy receives the level of support warranted through evidence will require PTs to better track and report outcomes, but that begs other questions: will the administrative burden be too heavy? Are there simpler approaches to supplying the needed data?

Elton pointed out that APTA is already attempting to respond to these questions by way of the Physical Therapy Outcomes Registry. According to Elton, profession-driven data collection efforts could make a key difference.

But, he added, turning the corner toward value-based care that will open payment doors will also require collaborative efforts between payers, PTs, and other professions. "What we need to be asking is, how do payers and groups like APTA come together to get a total view of this?" he said. APTA and Optum are currently pursuing a joint initiative that will be announced in the coming months, he added.

It could be possible that payers just don't care about data, Delitto said.

Oh, but they do, countered Schaecher, because data show where the money's going, and payers care very much about that.

Elton agreed, but framed the issue differently.

"Cost is really a proxy for clinical outcomes," he said. The problem is that data are often limited to what happens during and at the end of treatment, with no tracking of what happens over time—if, for instance, the physical therapy patient eventually winds up getting other treatments, undergoing surgery, or pursuing imaging at some point down the road. That's what's known as "the tail" of a particular provider's treatment. The lack of sufficient data on physical therapy's tail is the "Achilles' heel" of the profession, Elton said.

Still, with all the internal and external challenges in place, Elton believes that for physical therapy, the bottom line is the bottom line.

"The fact is, there's a 10-to-1 [return on investment] with physical therapy," Elton said. "More physical therapy equals less cost."