Spine Health Program Overview

A compelling argument could be made that the most inefficient and ineffective area of health care is spine pain management. Nationally, direct costs of spine care have gone up six to eight times over the last 20 years accompanied by an even more dramatic increase in indirect costs (lost work days, decreased productivity). The bottom line: we are putting significantly more money into spine care, with worse outcomes.

The Spine Care Program offered by Lifetime Health Medical Group and Excellus BlueCross BlueShield is designed to address this issue. The program is based on a spine care pathway created by Spine Care Partners© and currently being implemented in hospital systems, ACOs and PCMHs as well as privately operated PCP and specialty groups.

The core of the program is an evidence-based, patient centered spine pathway based on a biopsychosocial model of care. Strong emphasis is put on patient choice, education and motivation in self-care. Educational websites, applications and specific self-care tools are being developed to support these patient directed efforts. Care is co-ordinated by a Primary Spine Practitioner (PSP), a licensed health care provider (i.e. physician, physical therapist, chiropractor, nurse practitioner). The PSP is trained in the pathway and necessary diagnostic, treatment and communication skill sets to effectively manage most cases by treating 85+% of spine patients and triage the rest to appropriate care.

PSPs are the hub of the diagnostic, management and treatment wheel. Relational care concepts create the infrastructure of the PSP/patient interactions, using validated psychosocial questionnaires and motivational interviewing techniques to more accurately access the ‘whole person’ impact of the spine condition and modify treatment and language used to motivate patients to fully participate in their own recovery and future management.

Another unique element of the program is the use of a multidisciplinary team of spine care providers to provide fast, effective quality patient care. The team seamlessly interacts to deliver a virtual value add, process driven model of spine care. Team members are identified through data, experience and peer recommendation. As “fast track” providers, they ensure pre-screened patients access to services within one-two business days, allowing quicker access to second level providers than can be acquired through a typical PCP/specialist interaction. This, in turn, allows ‘teachable moments’ between PSPs and PCPs, outline alternative and evidence based options to early or non-evidence based use of surgeons, injections, imaging and opioids. Evidence-supported shared decision making tools are discussed with patients with each pathway provider encountered. These concepts are supported by employer and community based public spine health initiatives, when possible.

Our spine program quality goals are aimed at better value through optimizing patient provider match, invoking process to the full spectrum of spine care (adding efficiencies via pathway adherence), and identifying psychosocial issues or early signs of perpetuating factors. We then align patient specific resources to address these early indicators of possible chronicity. We are early in our program, but our 'fast track' neurosurgeons enjoy the higher quality surgical patients they are seeing. We feel the timing of surgical intervention is often sub-optimal (too early, too late...) and these front end efficiencies help to right size the timing and the care.

Using data collection tools to examine episodes of care will allow us to monitor cost shifting and overall spine care costs. Strict outcome and patient satisfaction data will allow us to derive value measures to the individual practitioner or provider group level. Quality of life data and spinal registries are on the horizon.

We are evolving the program to a community-wide Spine Care Program to improve clinical outcomes (function, quality of life), the patient experience (patient satisfaction, patient directed outcome measures), and guide appropriate utilization of healthcare resources related to spine care (high value care).

For questions, research articles, or additional information, please contact: Brian Justice brian.justice@excellus.com

Primary Spine Practitioner

The Primary Spine Practitioner (PSP) is, in my humble opinion, the evolution of the chiropractic profession. Over the last 100+ years every field of medicine has striven to make itself better in order to provide individuals seeking treatment the most evidence based care possible within their specialty. The days of the vertebral subluxation complex are over, the chiropractic profession needs to move beyond its 1895 mindset and embrace the concepts developed by the pioneers at Spine Care Partners.

My sincere thanks to Dr. Donald Murphy for his tireless effort in the advancement of our profession via his research and presentation of the facts to those who find chiropractic medicine harmful to the public. Also to doctors, Brian Justice and John Ventura for their community based diligence promoting our profession’s evolutionary change.

I would encourage every chiropractor to embrace this change and move beyond his or her own professional idiosyncrasies because you are in business for only one reason, your patients, and that is what being a PSP is all about!

Good News Regarding Back Pain

Eugene Carragee, MD (et al), Chief of the Surgical Division at Stanford Hospital and Professor of Orthopedic Surgery at Stanford University Medical Center published the findings of a five year observational study in the Nov-Dec 2006 edition of The Spine Journal. The study involved 200 subjects who had no lifetime history of Low Back Pain (LBP) but were at high risk for new LBP episodes. At the outset of the study each subject was given a physical exam and underwent both x-ray and MRI studies. Subjects were assessed every six months for five years via a detailed phone interview and those experiencing any new severe LBP underwent new MRI studies within 6-12 weeks of the onset of their symptoms. All subsequent MRIs were then compared to those taken at the outset of the study. Carragee, et al made the following conclusions:

• Individuals who experience minor trauma (motor vehicle collision, minor fall, lifting injury, etc.) are at NO increased risk for long term problems as long as the injury is rehabbed properly

• Degenerative changes exhibited on MRI DOES NOT increase the risk for long term problems

• Individuals with a “heavy job” are likely to experience persistent, minor LBP but they ARE NOT at increased risk for significant LBP or disability, especially if they do not have high fear beliefs regarding their job duties.

• The vast majority of patients experiencing low back injury exhibit NO CHANGE on MRI

- Essential Messages

• We want to overcome pain not “get rid of it”

• DON’T avoid activity; activity IS GOOD

• LBP although inconvenient and at times very painful can be OVERCOME

• Return to work IS therapy

            ~ You don’t get better in order to go back to work. You go back to work in order to get better!

            ~ Some pain upon returning to activity IS NORMAL