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Efficient Spine Care in the United States

Back and/or neck pain are a prevalent issue in society today and it is estimated that 149 million work days are lost every year in the United States at a cost of $100-200 billion [i.e. lost wages and decreased productivity] due to low back pain alone.[1]^{,[2], [3]} The World Health Organization reports that currently the primary treatment for low back pain is analgesic medication and that the causes for its provocation are rarely addressed.[4] This ineffectual treatment protocol isn't necessarily the fault of the rendering primary care physician due to their “inadequate preparation for practice in the real world” with regards to musculoskeletal medicine.[5] In November 2014, DiGiovann, et al reported that North American medical schools have limited time devoted to musculoskeletal education and cite that only 30% to 40% of schools have required instruction in the musculoskeletal system.[6]^,[7],[8] This is unfathomable when the average total health expenditure per person with back and/or neck pain in the United States is 73% greater than for individuals in other countries.[9]^,[10] The time has come for a truly unbiased and integrative approach to the treatment of low back and neck pain a fact that has been evident within the medical community since 1999.[11]

In July 2011, Murphy et al published a commentary expressing the need for the implementation of a primary spine practitioner (PSP) to effectively triage patients experiencing spine related disorders (SRDs), conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. They state that the PSP “would function as the first contact for patients with SRDs, i.e. the first practitioner that a patient consults when he or she develops a spine problem and could also function as a resource for traditional PCPs (family practice physicians, general internal medicine physicians, pediatric, obstetrical/ gynecological physicians, primary care nurse practitioners or physician’s assistants) to refer patients who present with SRDs”. This implementation exhibits potential benefits to SRD patients (i.e. faster recovery, cost savings, iatrogenic[12] disability avoidance, increased productivity, decreased likelihood of becoming a chronic pain sufferer, high patient satisfaction, focus on prevention), our society ( i.e. knowledgeable care coordinator, SRDs as a public health initiative, improved worker productivity, less long term disability), and the overall healthcare system (i.e. controlling costs, unburdening traditional PCPs, more strategic specialist referrals, disruptive innovation, standardization of care, new evidence and technologies). [13]

Candidates for the role of PSP within our current system would be currently licensed healthcare providers (i.e. chiropractor, physician, physical therapist, nurse practitioner) who would receive additional training based on a spine care pathway which has already been implemented in hospital systems, accountable care organizations, patient centered medical homes,  and privately operated PCP and specialty groups.

The effectiveness of integrative care for SRDs has not only been clinically demonstrated but has been mandated by a renowned medical center’s health plan:

- A 2013 study of Washington state workers who had recently filed worker’s compensation claims due to back injury found a 41.2 percent decrease in lumbar spine surgeries when the claimant consulted a chiropractor first.[14]

- Priority Health a major health plan in Western Michigan found that when they required spine patients who were heading for a non-urgent surgical consultation to first consult a physiatrist, surgical referrals decreased 48 percent, spine surgeries decreased 25 percent, and surgical costs dropped 25.1 percent.[15]

- University of Pittsburgh Medical Center Health Plan requires that patients with chronic back pain undergo a minimum of three months of chiropractic and/or physical therapy before any spine surgery is approved.[16]

So why am I so adamant about this subject? In September 2013, Spine Care Partners in conjunction with Lifetime Health Medical Group and Excellus BlueCross BlueShield commenced the inaugural spine care pathway training which was conducted at Excellus’ corporate headquarters in Rochester, NY. Dr. Fralick and I had the honor of being part of that inaugural class and have experienced first-hand the benefits this evidence based and patient centered program exhibits. Everything the Murphy et al commentary envisioned, at least in regard to SRD patient benefits, has become a reality for the patients who have sought care in our office.

The desire for this integration on a community level became evident to us upon receiving a letter from Excellus Blue Cross/Blue Shield of Rochester dated 29 December 2014. In this letter they outlined a “Waived Copayment Pilot Program” whose purpose is to “help drive care to spine pathway trained practitioners so that the program’s value can be measured and compared to other modalities of treatment for back and neck pain”. This program will extend until 31 December 2015 and only include Excellus employees and their covered family members but underlines the fact that a major health insurer believes PSPs are credible portal of entry providers for patients who present with musculoskeletal conditions.

So I urge all of you who are reading this to share this information with your healthcare providers and encourage them to seek out these practitioners in your community and integrate them into their treatment plans for spine related disorders.   

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[1] Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health, 1999, 89(7):1029-1035.

[2] Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am, 2006, 88(suppl 2):21-24.

[3] Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin, 2007, 25(2):353-371

[4] Duthey, Beatrice, PhD. "Background Paper 6.24 - Low Back Pain." Priority Medicines for Europe and the World 2013 Update. Background Paper 6 - Priority Diseases and Reasons for Inclusion. BP 6.13 to 6.24 (part 2). World Health Organization, 15 Mar. 2013. Web. 11 Mar. 2015. <http://www.who.int/medicines/areas/priority_medicines/BP6_24LBP.pdf>.

[5] Association of American Medical Colleges. Medical School Objectives Project. Contemporary issues in medicine: musculoskeletal medicine education. Report VII. 2005.

[6] DiGiovann, Benedict F., , MD, Richard D. Southgate, , MD, Christopher J. Mooney, , MA, MPH, Jennifer Y. Chu, , MD, David R. Lambert, , MD, and Regis J. O’Keefe, , MD, PhD. "Factors Impacting Musculoskeletal Knowledge and Clinical Confidence in Graduating Medical Students."The Journal of Bone and Joint Surgery E185 96.21 (2014): n. pag. The Journal of Bone and Joint Surgery, Inc. The Journal of Bone and Joint Surgery, Inc.; STRIATUS Orthopaedic Communications, 05 Nov. 2014. Web. 17 Jan. 2015. <http://jbjs.org/content/96/21/e185>.

[7] DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003 Mar;85(3):565-7.FREE Full Text

[8] Pinney SJ, Regan WD. Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am. 2001 Sep;83(9):1317-20. Abstract/FREE Full Text

[9] Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and

health status among adults with back and neck problems. JAMA, 2008;299(6):656-664.

[10] Rosner, Anthony. "Going About Spine Care the Wrong Way - Spine Care "bass-ackwards."" Dynamic

Chiropractic - News, Articles, Research & Information for Chiropractors. MPA Media, 01 Jan. 2014. Web.

10 June 2014. <http://www.lifeinmotionchiro.com/Educational%20Brochures/Going-About-Spine-Care-the-Wrong-Way.pdf>. Vol. 32, Issue 01

[11] Andersson GB, et al. A comparison of osteopathic spinal manipulation with standard carefor patients with low back pain. N Engl J Med 1999;341: 1426-1431

[12] of or relating to illness caused by medical examination or treatment.

[13] Murphy et al. The establishment of a primary spine care practitioner and its benefits to health care reform

in the United States. Chiropractic & Manual Therapies 2011, 19:17 http://chiromt.com/content/19/1/17

[14] Keeney B, Fulton-Kehoe D, Turner J. Wickizer TM, Chan KC, Franklin GM. Early predictors of spine

surgery after occupational back injury: results from a prospective study of workers in Washington

State. Spine, 2013;38(11):953-964.

[15] Fox J, Haig AJ, Todey B, Challa S.. The effect of required physiatrist consultation on surgery rates for back

pain. Spine, 2013;38(3):e178-e184.

[16] "DC Receives Federal Grant to Study Nonsurgical Alternatives to Surgery for Spinal Stenosis: Interview

With Michael Schneider, DC, PhD." Health Insights Today, March 2013.