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.

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