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Licensed Unlicensed Requires Authentication Published by De Gruyter July 15, 2015

Physician Self-Referral of Physical Therapy Services for Patients with Low Back Pain: Implications for Use, Types of Treatments Received and Expenditures

Jean M. Mitchell, James D. Reschovsky, Luisa Franzini and Elizabeth Anne Reicherter


Prior research on treatment of low back pain has documented large increases in use of spinal surgery, MRIs and lumbosacral injections linked to physician self-referral arrangements. No recent research has examined whether physician ownership of physical therapy services results in greater use of physical therapy to treat low back pain. The objective of this study is to investigate whether physician ownership of physical therapy services affects frequency of use, visits and types of physical therapy services received by patients with low back pain. Using claims records from insured patients covered by Blue Cross Blue Shield of Texas (2008–2011) we compared several metrics of use of physical therapy services for low back pain episodes controlling for self-referral status. We identified 158,151 low back pain episodes, 27% met the criteria to be classified as “self-referral.” Only 10% of “non-self-referral” episodes received physical therapy compared to 26% of self-referral episodes (p<0.001). The unadjusted and regression adjusted self-referral effect was identical – about 16 percentage point difference (p<0.001). Among patients who received some physical therapy, self-referral episodes were comprised of 2.26 fewer visits and 11 fewer physical therapy service units (p<0.001). Non-self-referring episodes included a significantly higher proportion of “active” (hands on or patient engaged) as opposed to “passive” treatments (p<0.001). The regression-adjusted difference was 30 percentage points when measured as actual counts and 29 percentage points when measured in RVUs (p<0.001). Total spending on back-related care was 35% higher for self-referred episodes compared to their non-self-referred counterparts (p<0.001). Ownership of physical therapy services influence physicians’ referral to initiate a course of physical therapy to treat low back pain, but also affect the types of physical therapy services a patient receives.

Corresponding author: Jean M. Mitchell, Georgetown University – McCourt School of Public Policy, Old North 314, 37th & “O” Sts, NW Washington, DC 20057, USA, Tel.: +202-687-7038, Fax: +202-6897-5544

Funding source: National Institute on Aging

Award Identifier / Grant number: R01AG33646

Funding statement: Funding: Foundation for Physical Therapy, National Institute on Aging (Grant/Award number: R01AG33646).


Abraham, M., J. T. Ahlman, A. J. Boudreau, J. Connelly, L. Levreau-Davis, D. D. Evans, R. L. Glenn, D. Hayden, G. M. Kotowicz, J. Meggs, M. L. Mindeman, K. E. O’Hara, M. R. O’Heron, D. Pavloski, D. Rozell, L. Stancik, A. Walker, A. Watkins (2010) “Physical Medicine and Rehabilitation.” in 2011 Current Procedural Terminology (CPT): Professional Edition. Chicago: American Medical Association, 2010, pp. 509–511.Search in Google Scholar

Chatzitheodorou, D., C. Kabitsis, P. Malliou and V. Mougios (2007) “A Pilot Study of the Effects of High-Intensity Aerobic Exercise Versus Passive Interventions on Pain, Disability, Psychological Strain, and Serum Cortisol Concentrations in People with Chronic Low Back Pain,” Physical Therapy, 87:304–312.10.2522/ptj.20060080Search in Google Scholar

Croft, P. R., G. J. Macfarlane, A. C. Papageorgiou, E. Thomas and A. J. Silman (1998) “Outcome of Low Back Pain in General Practice: A Prospective Study,” British Medical Journal, 316:1356.10.1136/bmj.316.7141.1356Search in Google Scholar

Deyo, R. A., S. K. Mirza and B. I. Martin (2006) “Back Pain Prevalence and Visit Rates: Estimates from U.S. National Surveys, 2002,” Spine, 31(23):2724–2727.10.1097/01.brs.0000244618.06877.cdSearch in Google Scholar

Deyo, R. A., S. K. Mirza, B. I. Martin, W. Kreuter, D. C. Goodman and J. G. Jarvik (2010) “Trends, Major Medical Complications, and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults,” Journal of the American Medical Association, 303(13):1259–1265.10.1001/jama.2010.338Search in Google Scholar

Friedly, J., L. Chan and R. Deyo (2007) “Increases in Lumbosacral Injections in the Medicare Population: 1994 to 2001,” Spine, 32(16):1754–1760.10.1097/BRS.0b013e3180b9f96eSearch in Google Scholar

Fritz, J. M., J. A. Cleland and G. P. Brennan (2007) “Does Adherence to the Guidelines Recommendation for Active Treatments Improve the Quality of Care for Patients with Acute Low Back Pain Delivered by Physical Therapists?,” Medical Care, 45:973–980.10.1097/MLR.0b013e318070c6cdSearch in Google Scholar

Fritz, J. M., J. D. Childs, R. S. Wainner and T. W. Flynn (2012) “Primary Care Referral of Patients with Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and Costs,” Spine, 37(25):2114–2121.10.1097/BRS.0b013e31825d32f5Search in Google Scholar

Fritz, J. M., G. P. Brennan, S. J. Hunter and J. S. Magel (2013) “Initial Management Decisions after a New Consultation for Low Back Pain: Implications of the Usage of Physical Therapy for Subsequent Health Care Costs and Utilization,” Archives of Physical Medicine and Rehabilitation, 94(5):808–816.10.1016/j.apmr.2013.01.008Search in Google Scholar

General Accountability Office (2014) Medicare Physical Therapy: Self-Referring Providers Generally Referred More Beneficiaries But Fewer Services per Beneficiary. United States: United States Government Accountability Office; Report No.: GAO-14-270.Search in Google Scholar

Hillman, B. J. and J. Goldsmith (2010) “Imaging: The Self-Referral Boom and the Ongoing Search for Effective Policies to Contain It,” Health Affairs, 29(12):2231–2236.10.1377/hlthaff.2010.1019Search in Google Scholar

Koes, B. W., M. W. van Tulder and S.Thomas (2006) “Diagnosis and Treatment of Low Back Pain,” British Medical Journal, 332(17):1430–1434.10.1136/bmj.332.7555.1430Search in Google Scholar

Koes, B. W., M. W. van Tulder, C. W. Lin, L. G. Macedo, J. McAuley and C. Maher (2010) “An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care,” European Spine Journal, 19(12):2075–2094.10.1007/s00586-010-1502-ySearch in Google Scholar

Malmivaara, A., U. Häkkinen, T. Aro, M. Heinrichs, L. Koskenniemi, E. Kuosma, S. Lapp, R. Paloheimo, C. Servo, V. Vaaranen and S. Hernberg (1995) “The Treatment of Acute Low Back Pain – Bed Rest, Exercises, or Ordinary Activity?” New England Journal of Medicine, 332:351–355.10.1056/NEJM199502093320602Search in Google Scholar

Martin, B. I., R. A. Deyo, S. K. Mirza, J. A. Turner, B. A. Comstock, W. Hollingworth and S. D. Sullivan (2008) “Expenditures and Health Status among Adults with Back and Neck Problems,” Journal of the American Medical Association, 299(6):656–664.10.1001/jama.299.6.656Search in Google Scholar

Medicare Payment Advisory Commission (June 2010). Report to Congress: Aligning Incentives in Medicare, chapter 8 Addressing the Growth of Ancillary Services in Physicians’ Offices in the United States. Medicare Payment Advisory Commission.Search in Google Scholar

Mitchell, J. M. (2007) “The Prevalence of Physician Self-Referral Arrangements after Stark II: Evidence from Advanced Diagnostic Imaging,” Health Affairs, 26(3):W415–W424.10.1377/hlthaff.26.3.w415Search in Google Scholar

Mitchell, J. M. (2008) “Do Financial Incentives Linked to Ownership of Specialty Hospitals Affect Physicians’ Practice Patterns?,” Medical Care, 46(7):732–737.10.1097/MLR.0b013e31817892a7Search in Google Scholar

Pengel, L. H., R. D. Herbert, C. G. Maher and K. M. Refshauge (2003) “Acute Low Back Pain: Systematic Review of Its Prognosis,” British Medical Journal, 327(7410):323–327.10.1136/bmj.327.7410.323Search in Google Scholar

Pillastrini, P., I. Gardenghi, F. Bonetti, F. Capra, A. Guccione, R. Mugnai and F. S. Violante (2012) “An Updated Overview of Clinical Guidelines for Chronic Low Back Pain Management in Primary Care,” Joint Bone Spine, 79(2):176–185.10.1016/j.jbspin.2011.03.019Search in Google Scholar

Shreibati, J. B. and L. C. Baker (2011) “The Relationship between Low Back Magnetic Resonance Imaging, Surgery, and Ppending: Impact of Physician Self-Referral Status,” Health Services Research, 46(5):1362–1381.10.1111/j.1475-6773.2011.01265.xSearch in Google Scholar

Stanton, T. R., J. M. Fritz, M. J. Hancock, J. Latimer, C. G. Maher, B. M. Wand and E. C. Parent (2011) “Evaluation of a Treatment-based Classification Algorithm for Low Back Pain: A Cross-sectional Study,” Physical Therapy, 91(4):496–509.10.2522/ptj.20100272Search in Google Scholar

Swedlow, A., G. Johnson, N. Smithline and A. Milstein (1992) “Increased Costs and Rates of Use in the California Workers’ Compensation System as a Result of Self-Referral by Physicians,” New England Journal of Medicine, 327(21):1502–1506.10.1056/NEJM199211193272107Search in Google Scholar

Waterman, B. R., P. J. Belmont and A. J. Schoenfeld (2012) “Low Back Pain in the United States: Incidence and Risk Factors for Presentation in the Emergency Setting,” The Spine Journal, 12(1):63–70.10.1016/j.spinee.2011.09.002Search in Google Scholar

Webster, B. S., Y. Choi, A. Z. Bauer, M. Cifuentes and G. Pransky (2014) “The Cascade of Medical Services and Associated Longitudinal Costs Due to Non-adherent MRI for Low Back Pain,” Spine, 39(10):1433–1440.10.1097/BRS.0000000000000408Search in Google Scholar

Weinstein, J. N., J. D. Lurie, P. R. Olson, K. K. Bronner and E. S. Fisher (2006) “United States’ Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003,” Spine, 31(23): 2707–2714.10.1097/01.brs.0000248132.15231.feSearch in Google Scholar

Published Online: 2015-7-15
Published in Print: 2016-12-1

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