What’s driving comp medical costs

Two things – facility costs and pharmacy.
We’ll get to pharmacy next week (I’m finishing up the Seventh Annual Survey of Prescription Drug Management in Workers Comp), but for now here’s a couple quick hits on the growing problem in facility expenses.
Today’s WorkCompCentral [sub req] highlights the results of a recent WCRI study examining cost drivers in North Carolina. a study that indicates the “average hospital payment per claim was about $9500 in North Carolina, the highest among all the states examined. The average charge for inpatient procedures was 49% higher than the median.” [emphasis added]
Note this was back in 2007; while WCRI does good work, the nature of their process is such that the results are somewhat dated.
The fee schedule was changed back in mi-2009, lowering the cap on inpatient hospital reimbursement from 77.07% to 75%, a whole 2.07 percentage points and outpatient from 95% to 79%.
If anyone thinks this is going to make any difference at all, they’re not thinking.
Gaming the ‘percentage off charges’ ‘fee schedule’ is ridiculously easy; this nominal decrease will have zero effect on actual payments to hospitals, and thus will do nothing to lower payers’ medical costs in North Carolina, costs which, according to WCRI, wer up 9% in 2007.
The fee schedule reduction was a complete waste of time. That may not endear me to the folks who, I am sure, worked diligently to address the issue, but that’s a fact. What NC should have done was change the methodology from a percentage off charges to something much more certain and fair – a cost-plus based system would have been a good, albeit imperfect, alternative.
We need a reality check.
Workers comp will pay about $31 billion in medical expense this year.
Health care costs will total about $2.7 trillion this year
I raise this often-overlooked fact to point out that employers and insurers will not be able to rely on networks to control costs, as work comp networks have little buying power, and thus little ability to influence price per service.
Therefore, regulators have to step into the breach, and provide real, actionable, metric-based fee schedules based on something much more solid than the facility’s charges.
What does this mean for you?
Higher facility costs will drive medical expense which will drive up combined ratios – and premiums.


The cost of forgoing care

A new report documents the impact of the recession on the health care system, and for many Americans, the news is proof of what they know all too well – higher deductibles and copays are reducing their ability to access care.
The report [fee req] does not document whether the forgone care would have been necessary/appropriate/supported by evidence-based guidelines, and it is likely some of the forgone care was unnecessary. That said, it’s only ‘some’, and it is highly likely Americans with slimmer benefits, or no benefits at all, are skipping visits, medications, therapies, and operations that will over the long term will have very serious implications.
According to a piece in the NYTimes, the researchers reported “We find strong evidence that the economic crisis — manifested in job and wealth losses — has led to reductions in the use of routine medical care.” 26.5 percent of respondents reported reducing their use of routine medical care since the start of the global economic crisis in 2007.
The report adds more weight to the increasing evidence that the recession, coupled with the unique American health insurance system, has had a significant impact on Americans’ ability to access care.
The importance of primary care in prevention is well documented; [opens pdf] timely use of primary care tends to reduce the need for interventional procedures such as CABG, thereby reducing cost and improving long term quality of life. Delaying or forgoing primary care will likely have the opposite effect, increasing future health care costs.
Impact on workers comp
Over the short term, this ‘side effect’ of the recession will likely increase work comp costs
and extend disability duration, as more injured workers will have poor health status due to forgone care. If diabetics aren’t controlling their blood sugar, asthma sufferers have more acute episodes, and hypertensives are taking their meds every other day, it is going to be more difficult, costly, and time-consuming to help these claimants recover functionality.
Over the long term, health reform will reduce work comp costs as many more individuals will have coverage. But until 2015 (or so), we won’t see this positive influence.


Work comp pharmacy – one company’s experience

The work comp pharmacy benefit management industry is growing increasingly sophisticated, and the release of PMSI’s Annual Drug Trends Report this morning adds to the trend.
Many of the larger work comp PBMs produce similar reports, providing deep insights into cost drivers, the effectiveness of solutions, and trends that anyone with any responsibility for med loss would be well advised to read.
Here are the quick takes from my admittedly not in-depth read of PMSI’s effort.
1. Price was up significantly last year, climbing 4.7%. This is heavily influenced by the price increases pushed thru by big pharma on brand drugs last year in anticipation of health reform.
2. Utilization was up only slightly, driven by more days supply per script.
3. Mail order utilization was up 3.6%, which undoubtedly contributed to the higher utilization as mail order scripts tend to include more days’ supply than those dispensed by retail stores.
4. The average number of scripts per injured worker was 11.1 in 2009. Yep, eleven point one. That’s a lot of drugs.
5. The report includes an interesting chart graphically illustrating the impact of the age of the claim on scripts per claimant; claims a year old typically had around three scripts at an average price per script of thirty bucks or so; in contrast ten year old claims had 23 scripts averaging over $180 each.

6. Generic efficiency (the percentage of scripts that could have been filled with a generic version) remained at 92%. This is driven by several factors, including state regulations (some have mandatory generic language and others are considering adopting it), PBM and payer intervention and outreach, and the ‘macro’ pharmacy market’s introduction of new brands. Generic efficiency and ‘conversion’ is key to cost management; according to PMSI (and consistent with other reports) each one point increase in generic utilization reduces cost by 1.4%.
7. Pharmacy in comp remains primarily, and I’d argue overwhelmingly, driven by pain. PMSI’s data suggests over three-quarters of drug spend was for pain management – one of the key differences between work comp pharmacy and group/Medicare pharmacy.
8. Our old nemesis OxyContin again accounted for a lot of comp dollars, with 9.9% of spend allocated to the brand and generic versions. On the good news side, Actiq and Fentora usage declined significantly (type ‘actiq’ into the ‘search this site’ text box above and to the right for plenty of reasons why this is a very good thing).
9. Finally, the average days supply of narcotic analgesicvs was up 6.4% while the number of claimants getting those drugs actually declined. This may be due to those claimants who could use alternative meds getting off narcotics (or not starting on them in the first place). As a result, the claimants still taking these drugs are more likely to need more meds.
There’s a lot more meat in the report, lots of detail on which drugs are driving how much utilization, changes in utilization by class of drug, and most importantly, the impact of clinical programs on utilization and drug mix.
What does this mean to you?
Two things.
While PMSI is one of the largest PBMs, remember that these data refer to their customers’ experience and therefore may not be exactly equivalent to your book of business. That said, don’t use that as an excuse if your stats aren’t up to snuff – instead look for ways to get better.
As you pack for that summer vacation, grab a copy of your PBM’s report (go to their site and find it there, or call your rep and have them send it over) and perhaps a couple others.
You know you want to, and you can always hide it inside a Cosmo or Men’s Health to prevent mocking stares from the knuckleheads on the next beach towel.


Cost-shifting – the practice of seeking higher reimbursement from some payers and patients to cover shortfalls due to low or no reimbursement from others – is rampant in the US health care system. Having worked with providers, health care systems, and payers, I can attest to the pervasive nature of the beast – it happens all the time, everywhere.
More evidence came across my virtual desk yesterday in the form of a study by the Insurance Research Council entitled “Hospital Cost Shifting and Auto Injury Insurance Claims” [available for purchase thru IRC]. The study compared auto injury hospital costs in Maryland to those in 38 other states that don’t have the all-payer hospital rates mandated in Maryland. Thus, whether a patient is covered by a health plan or auto insurer in MD doesn’t matter – all are reimbursed at the same level.
Here are a few of the highlights.
– the “percentage of a state’s population without health insurance was found to be the strongest predictor of average hospital costs for auto injury claimants”
– “another important predictor of average hospital costs for auto injury claimants is the percentage of a state’s population covered by Medicaid”
– IRC estimated of the impact of cost shifting to auto insurers totaled $1.2 billion in 2007.
It is clear that cost shifting is rampant, particularly to property and casualty payers. Work comp payers are particularly vulnerable as their network arrangements are under growing pressure from hospitals seeking higher reimbursement.
What does this mean for you?
Your hospital costs are headed up. What are you going to do about it?

predictive modeling
artificial intelligence


Ethics, clinical guidelines and profits

On Thursday I’ll be speaking at the Geisinger Clinic in Danville, PA on Comparative Effectiveness; the Payer’s ethical dilemma.
This is one of those ‘honored to be asked’, followed almost immediately by ‘I’ve a lot of work to do’ things. And a lot of work it indeed has been, but the deeper I’ve gotten into this, the more…gratifying it has become.
One example. In my research I came across Jim Sabin, MD. Dr Sabin, clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School; he also directs the ethics program at Harvard Pilgrim Health Care and writes an excellent blog, Health Care Organizational Ethics.
Here’s a few of the things I’ve learned from Dr Sabin.
1. Harvard Pilgrim may be the only health insurer in the country that has an inhouse ethics program that includes members, employers, brokers, community members, administrators and physicians. (If there are others out there I’d love to hear about them)
2, This isn’t a program set up merely for PR; rather it has studied significant issues, taken tough stands, and been public about its role and results.
3. The issue of ethics in medical research on effectiveness has another dimension, one that I hadn’t thought thru or explored in enough detail – health plans and health systems can be and in many cases are ‘sites’ for research; there are several ethical issues inherent in that role, issues that involve informed consent, public involvement and education, funding sources and use of those funds, the balance of cost and effectiveness, and the potential impact on the physician-patient relationship inherent in many research efforts.
4. Perhaps the most helpful discussion was around the not for profit status of HPHC. As a not for profit, Harvard Pilgrim doesn’t have to deal with the primacy of stockholder returns inherent in the for profit world; that’s not to say it doesn’t have to ensure financial stability and long-term viability. The difference is in what’s most important – profits or patients.
The primacy of stockholder returns influences ethical and business decisions, or rather should. For profit companies must consider shareholder returns first and foremost; to do otherwise would be an ethical problem. There are for-profit health plans and insurers that work diligently to deliver services ethically and responsibly, bending over backwards to do the right thing. Aetna is one that comes first to mind. And there are others that don’t bend at all.
Which is ‘right’? A compelling argument could be made for either position.


The ethics of clinical guidelines – the payers’ dilemma

In preparing for a talk on the ethics of comparative effectiveness I’m to give at the Geisinger Clinic in Danville PA in April, I’ve been interviewing medical directors from several health plans and workers comp insurers, along with physicians – both practicing and managing, in an effort to get their views on guidelines.
I’ve been somewhat surprised at what I’ve learned.
The real problem may not be payers’ efforts to deny medical care, but their willingness to ‘go along to get along’; to avoid making tough coverage decisions, and when in the slightest doubt, to approve the procedure/drug/treatment/therapy rather than run the risk of upsetting someone.
One would think payers would be keenly interested in supporting and using evidence-based clinical guidelines; costs would be reduced and outcomes improved, benefiting both patients and profits. And one might very well be wrong.
Payers operate in a market where public opinion matters a lot; if the payer has a negative image, it will be harder to convince employers and their employees to sign up for their health plan. It may also be harder to convince physicians and other providers to join and stay in their provider networks. And families may well be reluctant to carry an insurance card from a payer known for their tight controls on medical care.
We all know that restricting unnecessary care is not bad or immoral, but to the general public, it can certainly look like a profit-driven effort to cut costs, regardless of the effect on patients. To be sure, payers’ public efforts to terminate patients on the flimsiest of excuses and refuse coverage to anyone who might actually get sick haven’t helped their image. But the sense I get from the medical directors and practitioners I’ve spoken with is they are quite reluctant to deny treatment.
Part of this may be influenced by reality – when claims costs go up, so do premiums, and so does the health plan’s top line. There are few industries where built-in inflation results in near-double-growth same-store growth every year; health insurance is certainly one. This ‘reality’ is closely related to health plans’ motivations. Wall Street demands revenue growth, and for those health plans that are for-profit, their primary obligation is to their stockholders.
Allowing questionable treatments drives up revenues which benefits stockholders.
Of course, it isn’t anywhere near that simple or straightforward in the real world. Health plans’ profits are higher if medical costs are lower – at least over the short term. And most of the health plan execs I know are honestly trying to ensure their members get the care they need, care that they can’t afford if they approve any and all treatments no matter how ineffective.
But there is no question payers face an ethical dilemma, one complicated by patient demand, provider relations, market influences, and the obligation to their owners. (I’m not addressing the not for profits in this post)
A lot of Federal (taxpayer) dollars are going to be spent on comparative effectiveness research over the next few years, and if there’s a better use of my money I’m not aware of it. It is widely acknowledged that much of what we spend is wasted on unnecessary tests, advertising-driven consumer demand, unproven treatments and procedures that benefit device companies, specialists, and facility owners far more than patients.
It’s also equally clear that reining in those costs is going to be incredibly difficult, because much of it occurs in the somewhat grey area between procedures that are clearly useless or harmful, and those that are undeniably appropriate. And that grey area is where hundreds of billions are spent every year.
What does this mean for you?
Perhaps an ethical dilemma.


Time for more science in medicine – and less marketing

Prostate cancer may be one of the most over-diagnosed and over-treated conditions in the nation. It is also one of the most over-publicized, with ex-politicians (Bob Dole) and sports figures (Ed Randall) encouraging all men over 50 to get a test that is no more accurate than a flip of the coin, costs big bucks, and may well lead to costly, unnecessary, and painful surgery.
In an editorial in today’s NYTimes, Richard Ablin, who discovered PSA (the enzyme that is the target of the test), publicly disavowed the test, calling it a “hugely expensive public health disaster”. He went on to detail the statistics: “American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That’s because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.” [emphasis added]
The cost of prostate hysteria comes to about $3 billion a year for the tests, plus the pain and discomfort and sexual dysfunction – and cost – of men treated unnecessarily.
One study found “1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer.”
Another study found “94% of the cancers detected with the routine PSA blood test would not cause death before the age of 85.”
What’s really disturbing about this is the evidence was there 15 years ago. I wrote a paper for a now-defunct journal describing the results of AHCPR’s Prostate Outcome Research Team which documented much of the problems described by Dr Amblin today. Yet the science is hard-pressed to overcome the marketing muscle behind the test, muscle that has been used to develop fake grassroots organizations supporting the testing (aka astroturf). These organizations are funded by companies who benefit not only from the test, but the devices and seeds used to ‘treat’ positive results.
Here’s one example.

Michael Milken, the principle founder of the Prostate Cancer Foundation, is a significant investor in the venture capital industries. Are you aware that Michael Milken founded Proquest Investments, a $1 billion venture capital fund, with a specific investment thesis centered around prostate cancer after founding the Prostate Cancer Foundation? If you review the board members to ProQuest, you will find that six of the seven scientific advisors to ProQuest Investments are executives or member doctors to the Prostate Cancer Foundation. It seems clear that ProQuest Investments operates as a for profit extension of the Prostate Cancer Foundation, a 501(c)(3) designated non-profit

This not for profit encourages testing and screening, resulting in millions of unnecessary tests, thousands of impotent and incontinent men, and billions in revenue for the physicians, device and pharma companies, and facilities providing the testing and treatment.
What does this mean for you?
Payers are wasting money, patients are getting unnecessary treatment, and physicians are violating their oath to do no harm. Which category are you in?
Note – I’ve contacted Ed Randall, the host of the popular (and very good) Talking Baseball radio program several times in an effort to encourage him to stop promoting PSA testing. He’s never responded. I encourage you to contact Mr Randall yourself here – http://www.erbatforthecure.org/ and ask him to reconsider his advocacy that harms patients and increases costs while benefiting for profit companies.


The ethics of clinical guidelines

Next month I’m going to be speaking at the Geisinger Clinic on the subject of Comparative Effectiveness – the payer’s ethical dilemma. I’m fascinated by this issue as it strikes at the heart of the problems with, and perhaps solutions for, the health insurance crisis.
If we are to solve the access and cost problem, payers, providers, and patients must be comfortable with the decision process and methodology. Today, there’s precious little ‘comfort’ with the current ‘system’. And that’s understandable.
There’s a lot of ‘art’ in medicine; physicians diagnose conditions and recommend specific treatments based on what they think will help, often without much in the way of peer-reviewed research supporting their views. Much is based on their own training and experience and the knowledge passed on to them by their medical school professors and colleagues, provided in specialty society and other medical journals, passed on by medical device and pharmaceutical firms, and learned at conferences and symposia.
Most of the time this knowledge delivers the ‘right’ outcome; the patient gets better. But in some instances there are at least a couple different treatment options for the patient’s condition. Physicians recommend what they think will work based on the patient’s unique characteristics (physical, emotional, financial, history), and these ‘recommendations’ may be several. For example, chronic lower back pain treatment options may include surgery, physical therapy, medications, some of the above, all of the above, and variations of each of the above.
Sticking with the back pain issue, think of this from the payer’s perspective. The wide variation in back surgery rates is well-documented, with Medicare data indicating a 500% variation between Ft Myers and Miami Florida. We don’t know why there’s such a wide difference, but it is safe to assume that the rate is too high in Ft Myers, too low in Miami, or perhaps both.
When a physician in Ft Myers recommends surgery for a patient with a back condition, it is understandable why payers would have concern over the appropriateness of the procedure. To address this concern, payers utilize clinical treatment guidelines in an effort to determine if the recommendation is ‘appropriate’.
In some cases, the guidelines provide clear and convincing support for or against the procedure, but in many others the finding is not so clear cut. The patient may have some but not all of the clinical findings that are ‘necessary’ to support surgery; there may be other medical conditions present that complicate treatment determination; the patient may want one type of treatment for their own reasons.
The result is the payer – and the physician – are functioning in a somewhat grey area.
There are obvious financial factors in play as well. The physician gets paid to do the procedure, the pharma company gets paid if the patient takes their meds, the device company gains revenue for each device sold, the payer saves money if expensive procedures aren’t performed, the patient may want drugs for inappropriate reasons.
The ethical issues are apparent. While we would hope that decisions would be based solely on the evidence, there often isn’t enough of the right type of evidence to arrive at a clear cut decision. When that occurs, what other factors affect the decision? How are disagreements resolved, and what is that resolution? When there’s strong disagreement, what factors, evidence, criteria are ‘used’ to support the parties’ different positions?
If you have experience with situations that speak to this ethical dilemma, I’d appreciate hearing from you.


Texas’ efforts to add science to the art of work comp medicine

As anyone who has studied physician practice patterns is only too aware, there is wide variation in how physicians practice; the kinds of tests they order, whether they admit patients to the hospital or treat on an outpatient basis, the drugs they prescribe and the outcomes they deliver.
If we are to gain control over health care costs and ensure patients receive the right treatment and payers get value for their dollars, we have to force more science into the art of medicine.
Texas’ Division of Workers Comp’s push to publish data [sub req] on work comp physicians’ compliance with clinical guidelines is a step in the right direction. While only in the formative stage, and pretty limited at that, the effort is long overdue but nonetheless a critical step in reforming the dysfunctional mess that is our health care system.
Unlike any other good or service, when employers ‘buy’ health care they have no idea of what that investment returns; they don’t know what they get for their dollars. When an automobile manufacturer buys tires, it makes its decision on which tires it buys based on the performance of those tires, their durability, ability to carry the car’s weight, handling, cost, and value compared to other tires on the market.
That same auto manufacturer has no idea what it gets when it spends millions on health care. What is the return on investment on the premiums paid and the services bought with its dollars? How does it measure the value of the office visit, the return on the MRI, the 30 day supply of medication?
Because employers don’t know and can’t measure the return on their medical spend, they focus on spending as little as possible – they have to provide health and workers comp insurance, but want to spend as few dollars as they can because there’s no way to know what the return is on that investment.
Which is why Texas’ efforts are so important. While one can (and I’m sure some will) argue that they are starting too small, (WorkCompCentral reports that one recommendation is to begin looking “at compliance by doctors with treatment guidelines in ordering MRIs for back and spine injuries”), it is far more beneficial for all concerned to begin the effort, to engage providers, payers, regulators, and claimant advocates than to wait till there’s broad consensus on multiple performance measures.
What’s great about workers’ comp is that unlike group health or medicare or medicaid, the same dataset includes information about return to work, the cost and duration of disability, and the final ‘functional’ outcome (I’ll concede that these data aren’t always accurate or consistent). When we’re evaluating medical care, the ultimate outcome should always be based on the degree to which the patient recovered and returned to functionality.
What does this mean for you?
Do not let the perfect be the enemy of the good – encourage Texas’ DWC to proceed quickly with their initial efforts, engage with them in a positive way, share data, and push for more measures, more results, more openness. Understand that physicians have concerns about outcomes, many of them legitimate, and work with them wherever possible.


How many dollars are wasted on physical therapy?

Probably a lot. Perhaps most. And certainly a big chunk of the bucks your insurer/TPA is paying.
Unlike surgery, imaging, drugs, and other types of medical treatment, PT has long been a bit of a black art.
The clinical guidelines for PT that do exist (with one exception I’ll get to in a minute) usually say something like ‘two visits a week for four weeks’, without describing what is to be done during those visits, who’s supposed to do what gets done, and equally important, what shouldn’t be done.
That’s the primary reason physical medicine (PT and chiro) accounts for about one out of every five dollars spent on medical care in work comp, and would account for big bucks in group if it weren’t for tightly written benefit limits (x visits at a 50% copay).
Before the PTs out there start flaming me, know that I’m a believer in the ability of appropriate PT and have seen lots of data that support the use of PT in helping injured folks return to functionality. But I’ve also audited many work comp claims where the claimant had been to PT hundreds of times. I recall one where the claimant had over five hundred (500) visits over a three year period, with each PT note looking identical to the previous one. The payer couldn’t cut off the treatment because the treating physician had ordered it, and the clinical guidelines weren’t robust enough to force the issue in court.
Last month the NYTimes had an excellent article by Gina Kolata on just this issue. Here’s an excerpt:
“My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion [that much of PT is waste]. “Very often, I think the hot packs, cold packs, ultrasound and electrostimulation are unnecessary,” he said, adding, “For sure, in many cases these modalities are a waste of time.”
So has physical therapy been tested for garden-variety sports injuries like tendinosis? Or is it just accepted without much question by people who urgently want to get better?
It depends, says James J. Irrgang, a researcher in the department of orthopedic surgery at the University of Pittsburgh and president of the orthopedic section of the American Physical Therapy Association.
“There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”
(not in Ms Kolata’s article, but helpful for perspective…)
Sometimes, manual stretching by a physical therapist can actually eliminate a sports injury, he said…They are the exceptions. More common are the “voodoo” treatments, he said. And what might those be? None other than ice and heat and ultrasound, Dr. Irrgang said.
Ice and heat, Dr. Irrgang said, “can control pain a little bit” but “are not going to take care of the problem.” The underlying injury remains.”
But the lack of credible evidence-based clinical guidelines can make it difficult for payers to contest unnecessary treatment, especially in those states where regulations make it tough for payers to stop paying for unnecessary treatments.
There are credible, thoroughly researched clinical guidelines specific to PT, with the best focused not only on how many visits over how many weeks, but what should be done during those visits. I’ve reviewed all of the guidelines used in work comp for PT, and the most thorough are published by Expert Clinical Benchmarks, a subsidiary of MedRisk. (MedRisk is an HSA client)
Guidelines can’t be developed in six months; rather they must be carefully researched, assessed by acknowledged experts in the field, tested against claims and medical billing data, and reviewed periodically. There are far too many companies touting their ‘utilization review’ programs which are based on little more than the ‘same old same old’ guidelines that have never worked in the past, or quickly-assembled amalgamations of journal articles, neither of which will be of any help in front of a work comp judge.
What does this mean for you?
If you’re serious about managing PT, start with science.

I received an email from a good friend and colleague in the PT business who felt my post was an insult.

Let me reiterate – there are good PTs, and bad PTs.
There is good PT management, and bad PT management.

Some PT is quite useful, appropriate, and necessary, and some is not. When payers don’t use solid clinical guidelines it makes it very difficult for adjusters, case managers, peer reviewers, and hearing judges to differentiate between appropriate and inappropriate PT. And there’s lots of inappropriate PT in work comp.
In the course of my consulting practice, I’ve seen dozens of cases where claimants received more than a hundred PT visits over a year, and many where the total number was well over two hundred. This type of utilization is simply indefensible, and unfortunately often results in adoption of regulatory control mechanisms.
Some states have chosen to use caps on visits as proxies for utilization management, with 24 appearing to be the most common limit. This is at best a blunt instrument, but nonetheless it appears to have resulted in lower costs for physical medicine in the jurisdictions that have adopted the ’24 visit rule’.