Variation in High Value Care for Low Back Pain Among Older Adults Enrolled in Medicare Advantage Plans

IMPORTANCE: Low back pain (LBP) is a major cause of disability and poor quality of life among older adults. Clinical guidelines recommend non-pharmacological therapies, such as physical therapy (PT), as the first-line treatment for high-value care. Despite the fact that more than half of Medicare beneficiaries are enrolled in Medicare Advantage (MA), there is no knowledge about the patterns of high-value LBP care within this population. OBJECTIVE: To characterize high- and low-value LBP care among MA beneficiaries and identify factors associated with receipt of high-value care. METHOD: We conducted a retrospective cohort study using a 20% random sample of 2021 MA outpatient and carrier encounter data. Beneficiaries aged ≥ 66 years with a new LBP diagnosis between April 1 and September 30, 2021, were followed for 90 days. The study outcomes include high- and low-value care, defined by the timing and receipt of physical therapy, imaging, and spinal injections. RESULTS: Among 181,980 beneficiaries with newly diagnosed LBP, 87,305 received additional care within 90 days. Of these, 21.6% received high-value care and 78.4% received low-value care. Imaging without PT was the most common low-value care pattern, whereas PT alone was the most common high-value care pattern. Older age, Hispanic ethnicity, multiple comorbidities, lower MA plan ratings, and index visits with surgeons or pain specialists were associated with lower odds of receiving high-value care. County-level variation was observed, with rural residence and greater neighborhood socioeconomic deprivation associated with lower receipt of high-value care. CONCLUSIONS: Most older adults enrolled in MA plans with LBP did not receive guideline-concordant, high-value care. Geographic and socioeconomic disparities highlight opportunities to improve equitable access to evidence-based LBP management in older adults enrolled in MA plans.