Low Physical Therapy Referral Rates for Knee Osteoarthritis Present a Barrier to Care for Patients With Medicaid

OBJECTIVE: To evaluate the rates of physical therapy (PT) referral for knee osteoarthritis (KOA) and factors associated with referral patterns, including insurance status, provider specialty, year, and patient demographics and comorbidities. DESIGN: This retrospective cohort study included 41,373 patients diagnosed with KOA at an integrated health system in Arizona and Colorado, USA between January 2020 and February 2023. PT referral rates were stratified by insurance type. Multivariable logistic regression assessed predictors of referral including insurance type, age, BMI, sex, race/ethnicity, provider specialty, year of visit, and comorbidities. RESULTS: Crude PT referral rates at the initial visit were 12.06% for Medicaid, 6.83% for Medicare, 10.29% for commercial insurance, and 8.33% for uninsured patients. Adjusted analysis showed that Medicaid patients had higher referral odds (OR, 1.20; 95% CI [1.10, 1.30]; p < 0.001), whereas Medicare patients had lower odds (OR, 0.76; 95% CI [0.66, 0.88]; p < 0.001) compared to those with commercial insurance. Female (OR, 1.21; 95% CI [1.14, 1.29]; p < 0.001) and Hispanic patients (OR 1.18; 95% CI [1.09, 1.29]; p < 0.001) demonstrated increased referral odds. Provider specialty was associated with PT referral, with non-operative sports medicine providers having the highest referral odds (OR, 3.00; 95% CI [2.72, 3.31]; p < 0.001) relative to orthopaedic surgery. CONCLUSION: Despite strong clinical practice guidelines recommending PT, formal referral rates for patients with KOA remain low regardless of insurance type, patient characteristics, and referring healthcare provider specialty. Low formal PT referral rates may represent a barrier to evidence-based KOA care.