Musculoskeletal complaints are among the most common reasons for outpatient visits among adults in the United States.1 At any time, approximately one-third of all US adults are affected by joint pain, swelling, or limitation of movement and about two-thirds of adults experience back pain at some point in their lives.2 The direct and indirect costs associated with low back pain are estimated between $96 billion and $238 billion annually,3,4 and expenditures for back pain are rising more quickly than overall health expenditures.5–7 Given that musculoskeletal complaints represent the second largest cause of short-term or temporary work disability, employers bear a disproportionate share of these costs, including approximately 290 million lost workdays annually.4
Employees with musculoskeletal complaints suffer from delays in obtaining physical medicine for their pain and overutilization of high-cost imaging procedures, orthopedic and neurosurgical specialist visits, and prescription pain medications including opioids.8–11 In contrast, a strategy of early access to physical therapy in employee populations has been associated with a 36% improvement in patient outcomes, 52% less imaging, 56% fewer spinal injections, 59% less lumbar surgeries, and 62% less opioid use.12
Employers are increasingly seeking solutions that provide their employees with rapid access to high-quality musculoskeletal care.13 A potential for serving this need is onsite physical medicine care. Although approximately 30% of employers with 5000 or more employees have onsite clinics,14 less than 50% of onsite clinics have integrated physical therapy,15 and very few have comprehensive physical medicine services that include physical therapy, chiropractic, and acupuncture care with onsite primary care.16
The purpose of this study is to evaluate the effects of employer-sponsored clinics that integrate a comprehensive physical medicine offering with primary care on key clinical and economic outcomes. Specifically, we hypothesized that employees with musculoskeletal pain cared for in an integrated clinic would have (1) increased access to physical medicine services, (2) equivalent or greater improvements in pain and functional status outcomes, (3) decreased opioid use, (4) improved patient experience, and (5) decreased total costs of care compared with similar patients cared for in the community.
Patients and Data Collected
We performed a retrospective evaluation of all patients (age ≥12 years) with musculoskeletal complaints seen in Crossover Health integrated physical medicine departments at 12 employer-sponsored clinics in the United States between December 12, 2016 and March 31, 2018. We excluded patients from this analysis if they had only one visit with a physical medicine provider or were unwilling to complete the outcomes survey.
We evaluated access to care by calculating the lag between when the patient called or accessed the scheduling portal to set up an appointment and their first visit. During their initial visit, patients identified the body part that was their primary reason for seeking care. They then responded to a standardized set of demographic and functional status questions specific to their condition using the well-validated Focus on Therapeutic Outcomes (FOTO) tool.17 FOTO uses the Intake Functional Status Score (where 0 indicates low function and 100 high function for a specific body part impairment) to assess baseline functional status.18 FOTO assesses functional status among patients with low back pain with computerized, adaptive versions of the Oswestry.19 If a patient did not follow up for subsequent visits, they were emailed the FOTO data collection survey.
Patients completed the Fear-Avoidance Belief Questionnaire (FABQ), which measures the extent to which a person suffering from musculoskeletal pain avoids physical activity because they fear that such activity will exacerbate their condition.20 On the FOTO-adapted version of the FABQ, scores of less than 44 suggest low pain fear avoidance and at least 44 suggest high pain fear avoidance.20 FABQ scores are predictive of workplace disability, especially for employees with low back pain.20
We emailed patients a satisfaction survey after their first visit and every fourth subsequent visit with a physical medicine provider. The satisfaction survey had nine questions: one to assess Net Promoter Score (NPS) (NPS was measured by asking each patient to rate, on a scale from 0 to 10, “How likely is it that you would recommend the Crossover Clinic to a friend or colleague?”) and eight additional questions on a five-point Likert scale that asked patients’ experience in the clinic (eg, ease of scheduling, confidence in care quality).
We compared the patients seen in the employer-sponsored clinic with two control groups. First, for the clinical outcomes (eg, functional status, FABQ), we compared patients receiving physical medicine care in the employer-sponsored clinic to those in the FOTO database. FOTO has the largest available dataset on outpatient physical medicine outcomes in the United States.17 Specifically, we compared patients of the employer-sponsored clinics to matched controls in the FOTO system (adjusted through a multiple linear regression model containing 13 variables including demographics, body part affected, acuity, medical/surgical history, functional status, and medication use).17
Second, to compare the health services utilization of patients cared for in the employer-sponsored clinic and those receiving care in the community, we compared the health care claims of eligible employees and dependents seen in the employer-sponsored clinic to other eligible employees and dependents seen by community providers. Specifically, we aggregated health care claims across multiple employers in multiple geographies to assess health services utilization for provider visits in the community, imaging, surgery, spinal injections, and opioid use.
As all data used in this analysis are routinely collected on all patients cared for by clinicians in the employer-sponsored clinics, this study was exempt from IRB approval.
The model of integrated care provided at the employer-based clinics includes five key elements (physical space, provider mix, technology, fee structure, and integrated processes) designed to remove barriers to accessing physical medicine services and improve communication and coordination among all providers. As conceptions of integrated care vary, both in terms of how to define it and how to implement it,21,22 a discussion of the integrated model in use in the employer-sponsored clinics included in this analysis follows.
Figure 1 presents a schematic of the clinic layout. Key design features include a central “Bullpen”: a large, open seating area where up to 60 clinicians sit at comingled workstations (not in groupings per specialty). The workstations were initially assigned to providers to purposefully integrate specialties and organize around patients’ needs,23 but now this integration persists organically. The open seating plan leads to a work environment conducive to “curbside consults” and feedback across specialties. A large monitor in the bullpen is used for weekly full team meetings, and similar monitors in the specialty areas are used for smaller team huddles.
Examination rooms surrounding the bullpen are designed specifically for their use (eg, primary care rooms feature a modern examination table, BP cuff, otoscope/ophthalmoscope; behavioral health rooms feature a sofa, chairs, and side tables; chiropractic rooms feature a table for manipulation and traction, charts of the musculoskeletal system, and TENS units; acupuncture rooms feature a large massage bed, heat lamps, and a relaxing ambiance). In addition to individual examination rooms, there are larger rooms used for group therapy and education (eg, diabetes education, group trauma therapy, back school, and injury prevention workshops). A large open area is dedicated to active physical therapy, chiropractic care, and fitness.
All of the included employer-sponsored clinics have these elements. However, each clinic's physical space differs slightly to reflect the size required to accommodate the eligible population (the number of eligible patients cared for at each site varied from 4,100 to 15,000).
Within each specialty, there is a purposeful mix of provider types: primary care staff include RNPs and physicians (MDs and DOs) with specialization in family medicine, internal medicine, and emergency medicine. Behavioral health staff include psychologists, social workers, and psychiatrists (MSWs, PhDs, MDs). Physical medicine staff include chiropractors, physical therapists, and acupuncturists. Additional clinical staff include dietitians, optometrists, massage therapists, health coaches, and nurses.
This provider mix enables both interdepartmental referrals (eg, patients can be referred by a primary care provider into physical medicine) and intradepartmental referrals (eg, physical therapists can refer to acupuncturists). In the community, physical therapists rarely refer patients for acupuncture or chiropractic care. Typically, physical medicine providers work in specialty-specific practices, do not have exposure to each other's modalities of care, and may fear a loss of revenue associated with cross-discipline referrals. In addition, primary care providers rarely refer patients to chiropractic or acupuncture, often due to lack of access to evidence-informed providers. However, in this integrated, employer-sponsored clinic model, such intradepartmental referrals are common.
All teams utilize the same, electronic health record that facilitates integrated care. Patients have access to a portal from which they can self-refer to any provider. In addition, patients use this portal to communicate with providers, check their laboratory results and biometric trends, and schedule appointments. Physical medicine staff deliver home exercise prescriptions through a web-based tool that patients and providers both access to monitor patient progress.
Patients’ fees for physical medicine encounters are dependent on their employers’ benefit designs; however, most have a copay or coinsurance in the employer-sponsored clinic that is either similar or lower cost than if they were to see a provider in the community.
Providers are either salaried or paid a flat daily rate. Patient satisfaction, NPS, and therapeutic outcomes are the primary metrics used to assess provider performance in the employer-sponsored clinic. This payment and provider evaluation model incentivizes practice patterns more consistent with value-based arrangement and contrasts with fee-for-service economics common in the community. Moreover, this payment model also facilitates intradepartmental referrals.
Referral and Integrative Processes
Patients can self-refer into any specialty (ie, directly schedule an appointment with any clinician including physical medicine providers), and can be referred to physical medicine from other health care providers in the employer-sponsored clinic, and from community referrals. The patient's preference for a specific type of physical medicine practitioner and their clinical need determine the type of practitioner to whom they are referred. Providers regularly discuss mutual patients. In addition, there are weekly full team meetings to discuss complex patients.
Spinal Care Pathway
Patients with spinal pain received highly standardized, evidence-based24–28 care in the employer-sponsored clinics, regardless of the type of physical medicine practitioner directing their care. The spinal care pathway was developed to take advantage of the integrated care model and to follow professional standards.24–26,29
During their baseline evaluation, physical medicine patients received a comprehensive assessment to rule out “red flags” suggestive of a serious condition (eg, history of cancer, significant neurological findings, bowel or bladder compromise, history of surgery). If a red flag was present, patients were referred for primary care. Diagnostic imaging was ordered for patients with neck or low back pain only when red flags were present.
Patients received individualized spinal care based on their clinical presentation. Physical medicine care informed by the biopsychosocial model30 involves approaching patients’ pain experience and biomechanics in a supportive environment that encourages movement and active therapy. During each follow-up visit, care plans were updated based on clinical progress. Therapeutic modalities included directional preference exercises (eg, flexion or extension biases), manual and instrument-assisted soft tissue therapies, manipulation and mobilization, and education on ergonomic strategies with a heavy bias towards exercise rehabilitation. Active modalities of care (ie, therapeutic exercise, active stretching) have been associated with improved outcomes when compared with passive modalities such as massage and ultrasound.31
Patients received pain neuroscience education (PNE) to improve their understanding of their symptoms and reduce their fear of movement. PNE significantly reduces pain, improves function, and reduces disability in patients with chronic musculoskeletal conditions such as low back pain.32 With PNE, patients identify and address factors that may contribute to their pain experience (eg, stress, relationship issues, poor sleep). If needed, patients were referred to an onsite psychologist and/or a health coach to develop coping strategies, stress management techniques, and foster a positive and proactive mindset to treat their back pain.
In addition to their individualized care, many spinal pain patients were encouraged to attend classes designed to teach patients to prevent reinjury, improve core strength, posture, and increase their overall resilience and performance. These group sessions focused on supporting restoring movement in patients’ daily lives with decreased pain fear avoidance.
To compare the access to and utilization of physical medicine services in the community with those in the employer-sponsored clinic, we first calculated a risk score for each patient using the 2015 Chronic Illness and Payment Disability System model33 based on patient demographics and comorbidities. We then compared the total number of physical medicine visits per patient by risk score.
To evaluate clinical outcomes (improvement in functional status and pain fear avoidance), we performed an analysis using the FOTO data. Specifically, we conducted a two-sided t-test on patients’ functional status and number of visits residuals (residuals are the difference between the FOTO-predicted value and what was actually observed for a patient). The null hypothesis was that the mean of the residuals is equal to zero (ie, that the outcomes achieved by our patients were indistinguishable from the expectations of the FOTO model). We used a confidence level of 95%. To better understand the characteristics of the sickest patients cared for in the employer-sponsored clinic, we performed a linear regression analysis on the Intake Functional Status score against the FOTO predictor variables.
To evaluate the rate of opioid prescribing in the employer-sponsored clinics for patients with noncancer related complaints, we identified all patients seen for any of the following visit types with a prescriber: annual physical, office visit, well woman visit, MD phone consult, travel visit, or fitness visit. We removed patients with a cancer diagnosis (defined as those with an active ICD10 code of C00—C96, D00—D49, or D3A. We then evaluated opioid prescriptions from claims for this population.
To evaluate the predictors of patient experience as measured by NPS, we performed ordinal regression analysis of patient satisfaction survey responses for physical medicine visits with NPS (detractor, neutral, or promoter) as the outcome variable.
To estimate the cost of physical medicine care in the community, we first removed all claims from patients with total medical expenses greater than $50K in the past 12 months. We then calculated the average cost of outpatient physical therapy and chiropractic visits.
We conducted all statistical analyses in R version 3.4.1 (2017-06-30).
Table 1 presents the demographic and clinical characteristics of the 2493 unique patients included in this analysis: 56% were male with a mean age of 38.5 years (SD 11.3 years). Their Intake Functional Status Score (mean 60.5, SD 14.4) suggests good baseline functional status (0 indicates low function and 100 high function for a specific body part impairment).18 Their pain fear avoidance (FABQ score) at baseline was 47.5 (SD 21.9), where FABQ scores at least44 suggest high pain fear avoidance.20 Neck and lumbar spine complaints accounted for 54.7% of all cases, among these.
The following characteristics were significantly associated with worse functional status at baseline: older age (P < 0.001), female gender (P < 0.001), history of prior surgeries (P < 0.001), exercise regimen of less than once or twice a week (P = 0.007), and medication use (P < 0.001).
Overall, physical medicine was the second most utilized service in the integrated employer-sponsored clinic (42.9% of patients) (Figure 2A). Patients (21.2%) seen in the employer-sponsored clinic received physical medicine services without any other type of care. These patients self-referred directly into physical medicine services (Figure 2A).
The integrated model facilitated care by more than one clinical department: 16.5% of patients were seen in primary care and physical medicine, 1.6% were seen in behavioral health and physical medicine, and 3.6% were seen in all three departments.
Across all physical medicine practitioners, there are approximately equal proportions of physical therapists and chiropractors (about 40% each of the total physical medicine staff), and approximately 20% acupuncturists. Therefore, it is not surprising that most patients received care by either a chiropractor (35.4%) or a physical therapist (29.9%) (Figure 2B). However, it is notable that 19.6% of patients saw two different types of physical medicine practitioners and 4.4% saw all three types.
Patients accessing physical medicine care in the employer-sponsored clinics had shorter wait times for physical medicine care than is typical for patients receiving care in the community: the median time between when a patient scheduled an appointment and when it occurred was 6 days for physical therapists and chiropractors and 8 days for acupuncturists compared with 14 to 30 days in the community.
Patients in employer-sponsored clinics achieved significantly greater improvements in functional status and pain fear avoidance in fewer clinic visits than control patients (Figure 3). Specifically, the average FOTO functional status residual (which measures the difference in the functional status at the end of treatment between patients seen in employer-sponsored clinics and FOTO controls) was 3.8 for spine patients and 3.6 for neck patients (P < 0.01 for both) (Figure 3A). This demonstrates that patients in employer-sponsored clinics had statistically and clinically significant improvements in their functional status compared with FOTO controls.
The average pain fear avoidance for all patients seen by physical medicine providers decreased significantly from 47.5 (SD 21.9) (classified as high pain fear avoidance) to 40.2 (SD 21.4) (classified as low pain fear avoidance) (P < 0.00001). Similar significant improvements were found for lumbar and neck pain patients (lumbar pain patients: pretreatment FABQ 49.4 (SD 22.8); posttreatment 40.9 (SD 21.9), P < 0.00001; neck pain patients pretreatment FABQ 44.6 (SD 20.5); posttreatment 39.5 (SD 20.8), P < 0.00001).
Patients in employer-sponsored clinics required eight fewer clinic visits than patients receiving care in the community: on average, the risk-adjusted difference between the number of physical medicine visits in the community (mean 11.9, SD 14.9) was 3× greater than in the employer-sponsored clinic (3.9, SD 5.6) (P < 0.0001).
On average, patients with spinal pain seen in employer-sponsored clinics required 5.7 fewer visits to restore their physical function than FOTO control patients (P < 0.01). Similarly, patients with neck pain cared for in employer-sponsored clinics required 6.3 fewer days than FOTO controls to achieve resolution of their symptoms (P < 0.01). Notably, the most complex patients (those who received more than 15 visits in the community) were able to have their clinical situation managed in about a third the number of visits (Figure 3B).
Neck pain patients, who were seen by more than one type of physical medicine provider, achieved better functional status (mean functional status residual 6.8 [SD 12.5]) than patients seen by only one type of provider (mean functional status residual 2.8 [SD 11.3]) (P = 0.01) without an increase in total number of physical medicine visits (mean number of visits residual for patients seen by more than one provider type −6.4 [SD 2.1] vs −6.4 [SD 2.5] for patients seen by only one provider type, P = 0.91).
Patients with lumbar spine pain cared for by more than one physical medicine provider type (mean functional status residual 5.5 [SD 10.1]) also tended to have greater improvement in functional status than patients seen by only one type of provider (mean functional status residual 3.4 [SD 13.1]), albeit not statistically significantly so (P = 0.056). However, patients with lumbar spine pain treated by more than one physical medicine provider type achieved resolution of symptoms in fewer visits than those seen only by one provider type (mean number of visits residual for patients seen by more than one provider type −6.1 [SD 1.8] vs for patients seen by only one provider types −5.6 [SD 3.2] P = 0.01).
Primary care providers recommended nonpharmacologic approaches to pain when possible and actively referred patients to the physical medicine department to manage pain conservatively. Noncancer patients received far fewer opioid prescriptions from providers in employer-sponsored clinics than are typical in the community (2.8% [1 in 36] in the employer-sponsored clinic compared with 20% [1 in 5] in the United States).34 The vast majority (70.3%) of opioid prescriptions in the employer-sponsored clinics were for cough suppressants. Overall, 1.3% of patients cared for in physical medicine received an opioid prescription.
Patients seen by physical medicine providers at employer-sponsored clinics were highly likely to recommend that care to others (NPS 84.7). Patients who were most likely to recommend the employer-sponsored clinic found practitioners easy to talk to, had confidence in the quality of care delivered, felt that the visit helped their health, reported getting an appointment that fit their needs, and considered the clinic their medical home (P < 0.01 for all).
The average cost to the employer was $85.40 for a physical therapy visit and $73.05 for a chiropractic visit in the community. Assuming a similar mix of visits to physical therapists and chiropractors in the community, the average cost of a visit in the community was $78.70. Given that patients seen in employer-sponsored clinic required on average eight fewer visits (11.9 visits [SD 14.9] in the community vs 3.9 visits [SD 5.6] in the employer-sponsored clinic), employers saved $630 per patient episode overall.
From the FOTO analysis, patients with neck and spine pain were seen on average six fewer visits than controls. Employers saved $472 on patients with these conditions.
This study has five key findings regarding the clinical and economic outcomes of providing physical medicine in employer-sponsored clinics. First, integrating physical medicine practitioners in employer-sponsored primary care clinics can decrease wait times for seeing these practitioners to about a week—considerably faster than in the community.35 Utilization of physical medicine onsite was high—second only to utilization of primary care services. The importance of this increased access is underscored by the data, demonstrating that early access to physical medicine services is associated with reductions in imaging, spinal injections, and surgeries.12,36,37 The patients in this analysis could directly schedule with physical medicine providers (at least 22% of patients seen in the employer-sponsored self-referred for physical medicine services). Employers interested in offering onsite or near-site physical medicine services should consider policies to reduce barriers to access these services such as direct patient access, sufficient availability of appointments, and benefit designs that incentivize use of physical medicine services before elective imaging and specialist visits.
Second, early access to physical medicine interventions is associated with improved patient outcomes at lower cost to the employer. The magnitude of clinical improvements in both functional status and fear of pain avoidance among employees with musculoskeletal pain cared for in integrated employer-sponsored clinics was remarkable compared with controls. We hypothesize that the standardization of care for patients with spinal pain through the use of the spinal care pathway was a key driver of the observed clinical improvements. This hypothesis is supported by the work of others that show that multidisciplinary, evidence-based standardized spine care pathways have been associated with cost savings and improved outcomes, including pain reduction and improved patient satisfaction.38 However, the sample size of patients presenting with other types of musculoskeletal complaints (eg, shoulder pain) for which a specific care pathway has not been implemented was too small to test this hypothesis.
The finding that employees had greater improvements in functional status and decreased fear of pain avoidance should be of particular interest to employers with populations for whom low back pain is a prevalent. In this population, fear of pain avoidance is predictive of workplace disability.20 An important extension of the work described in this study will be to compare workplace absenteeism and disability claims associated with musculoskeletal complaints among populations with and without access to physical medicine services in employer-sponsored clinics.
The decrease in number of visits required to treat patients’ musculoskeletal complaints resulted in a cost savings to employer sponsors of $472 to $630 per patient episode. The savings described in this study warrant a more detailed economic analysis—one that directly compares total costs for patient episodes seen in the employer-sponsored clinic with those cared for in the community. Such analysis would facilitate a deeper understanding of both the drivers of total cost of care for employees with musculoskeletal issues (eg, physical medicine office visits, specialist visits, imaging, medications) and suggest opportunities to further reduce them.
Third, 24% of patients receiving physical medicine care in employer-sponsored clinics were seen by two or more different types of physical medicine providers. Interestingly, despite receiving care from more than one type of physical medicine provider, patients with neck and spinal pain required, on average, six fewer visits than risk-adjusted FOTO controls. Intradepartmental referrals are supported by the physical layout, provider mix, spirit of collegiality, and fee structure of the employer-sponsored clinic. We speculate that the use of multiple modalities of physical medicine care may be a contributor to the fewer overall number of visits required for patients to resolve their clinical issue and patients’ satisfaction with their care.
Fourth, providers in employer-sponsored clinics prescribe about 10 times fewer opioids than clinicians in the community.39 Multiple factors influence prescribing practices in the employer-sponsored clinics included in this analysis including improved access to nonpharmacologic treatments of musculoskeletal pain including physical medicine care and strict opioid prescribing guidelines In addition, patients may feel reluctant to seek opioids in an employer setting. In light of the national opioid crisis, this finding warrants consideration among employers with significant prevalence of noncancer pain in their populations.
Finally, on average, patients receiving care in integrated employer-sponsored clinics appeared to be highly satisfied with their care. The NPS of 85 compares favorably with other health care entities (eg, CVS Health [−10], Cigna [−1], Walgreens , Kaiser health care).40,41 All patients included in this analysis chose to receive their care in the employer-sponsored clinic but could have been seen in the community. This freedom of choice may have contributed to improved satisfaction with their experience.
Kindermann and colleagues found that onsite chiropractic services were associated with lower utilization of radiology services (55.5% vs 38.2%; P < 0.001), outpatient visits (47.3% vs 30.2%; P < 0.001), and emergency department use (19.0% vs 13.1%; P = 0.022) than off-site care.42 Taken together, our findings highlight the potential clinical and economic benefits of integrating physical medicine services into employer-sponsored clinics.
The limitations of this study include that the integrated model of care provided in the 12 employer-sponsored clinics include a set of features such as physical space, provider mix, technology, fee structure, and integrative processes. These features have evolved over time and together represent the intervention evaluated in this study. It is not possible from this analysis to determine which aspects of this multimodal intervention where the key drivers of the outcomes described. In addition, the patients evaluated in this analysis were somewhat younger and healthier than many patients who receive physical medicine care. Although all of the comparisons to FOTO controls and patients in the community adjusted for multiple demographic and clinical characteristics, there may have been systematic differences between the populations seeking onsite care than those seeking care in the community.
Our results suggest that employers with populations in whom musculoskeletal complaints are common and have or are considering an onsite or near-site clinic should evaluate integrating a physical medicine services in their offering.
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