DOD Establishes TRICARE Low Back Pain and Physical Therapy Demonstration

The Alliance for Physical Therapy Quality and Innovation (APTQI) applauds the Department of Defense (DOD) for approving the creation of a demonstration project to waive cost-sharing for a maximum of three physical therapy visits for TRICARE beneficiaries who suffer from low back pain (LBP).

Major provisions of the final rule read:

• TRICARE beneficiaries must have a primary diagnosis of LBP and receive physical therapy services in one of the selected demonstration states.
• Beneficiaries must be referred by a TRICARE- authorized provider to receive physical therapy services currently covered by TRICARE.
• Only new therapy episodes will be eligible for waived cost-sharing and provider reimbursements under this demonstration will follow current procedures for reimbursement.
• There is not a limit on the number of weeks from the onset of symptoms to receiving PT services under this demonstration, which supports the hypothesis that the increase of visits for therapy will reduce the proportion of beneficiaries who transition from acute to chronic LBP.

According to the final rule, licensed physical therapists and physical therapist assistants may provide covered physical therapy services to eligible beneficiaries. To comply with the existing requirements for TRICARE, physical therapy must be prescribed by a provider listed at title 32, Code of Federal Regulations, 199.6(c)(3)(iii)(K)(2). Appointments should also be scheduled immediately following the most recent visit, and services must be performed in the state in which the demonstration has been recognized.

The recent DOD announcement is in line with research commissioned by APTQI to demonstrate how the use of physical therapy early in the care of low back pain leads to reduced costs through less utilization of other types of healthcare services, including reduced use of downstream injections and surgeries, among others. According to APTQI data, beneficiaries who receive therapy within the first 15 days after diagnoses, compared to 45-90 days, are observed to have downstream costs that are, on average, 27 percent lower.

APTQI is pleased the DOD has recognized the value of physical therapy in the treatment of LBP. This change in demonstration regulations for TRICARE patients is long overdue and will assist in beneficiaries receiving proper care for their physical therapy needs.

The final rule will take effect on January 1, 2021.

To view the announcement in the Federal Register, click here.