January 2006 | Back to Table of Contents
When the Pain Won't Go Away
By Scott D. Smith
Treatment for chronic low-back pain—often flawed, inconsistent, and costly—is now in the crosshairs of a national quality organization and a local insurer and provider.
Editor’s Note: This is the second of a two-part series on treating back pain. In December, Quality Rounds explored what defines quality care for acute back pain.
Four years ago, Thomas Marr, M.D., had back pain that was out of control. After nine months of ineffective treatments, he could no longer walk to the end of his driveway, and a surgeon told him that if his pain continued unabated he would likely need surgery.
But Marr’s condition turned around after he visited a physiatrist, who saw that Marr’s deconditioned back muscles were causing his pain. The physiatrist prescribed exercise and referred Marr to a physical therapist with expertise in treating back pain. He also offered Marr hope: He said if Marr completed the strengthening program, he could look forward to 30 minutes of pain-free walking within six months.
Today, Marr says he is without back pain and fully functional. If Marr were an average patient, lessons learned during his several-month-long back-pain journey might have just resulted in a good piece of advice to offer friends and family. Namely, find a provider who has expertise in treating back pain.
Instead, as the associate medical director of HealthPartners, Marr’s personal experience influenced his decisions as he led a HealthPartners effort to build a back-pain treatment program designed to achieve better outcomes for patients and lower costs for the payer. The program offers guidance for treating all back pain with special emphasis on identifying chronic back-pain sufferers, referring them to networks of experts and measuring treatment outcomes. HealthPartners is the first health plan in Minnesota to take such a comprehensive, disease-management approach to back pain. HealthPartners, which launched the program in September, expects it will help people heal faster and cut its back-pain treatment costs by $3.5 million a year.
Physicians, even those who specialize in this area, say treating chronic low-back pain—pain that lasts longer than six weeks—can be difficult and confusing. To start with, it’s often difficult to identify the cause of the pain. After that, they must decide which of several treatment options to consider, including physical therapy, chiropractic alignments, spinal injections, and surgery. And often, they must make that decision without clear guidance.
Expert opinion can differ in all of these areas, says William Lohman, M.D., an occupational medicine physician and consultant to the Minnesota Department of Labor. Chiropractors say patients won’t get better without physical manipulation, different physical therapists recommend different exercises (the Institute for Clinical Systems Improvement [ICSI] guideline says there is no conclusive evidence favoring one exercise over another), and some providers recommend steroid injections after two weeks. Some physicians say surgery is the answer for chronic sufferers, while others think exercise is just as effective. In addition, depression or stress can compromise a patient’s ability to manage back pain. “There is a high incidence of depression and other mental health issues [associated] with chronic pain,” Marr says.
If back pain continues for six week or more or if patients have a series of acute episodes and the condition starts to become a chronic problem, there is less certainty about how to treat it.
“The longer out you are from the initial incident,” Lohman says, “the greater the controversy, the more fierce the controversy, about what’s the right thing to do for somebody.”
According to the National Committee for Quality Assurance (NCQA), many of the 31 million people affected by low-back pain each year never receive recommended care. In addition, the organization found that unnecessary surgeries and diagnostic imaging tests are common.
Given the variability in treatment, it’s not surprising that back pain is the sixth most costly condition in the United States, accounting for health care expenditures of more than $12 billion a year, according to Georgetown University’s Center on an Aging Society.
Increasing costs prompted HealthPartners to start its back-pain program, Marr says. Approximately 63,000 HealthPartners members, or about 10 percent of its total membership, experience low-back pain every year, incurring medical expenses of about $15 million. The insurer spends about $1.3 million a year on spinal injections and about $3.25 million on spinal-fusion surgeries.
Finding a Solution, Measuring Outcomes
In designing the program, Marr spoke with primary care physicians, surgeons, and other specialists in Minnesota, who confirmed that back pain was a major issue and told him that better case management could prevent surgeries.
With that in mind, HealthPartners has created networks of preferred chiropractors, physical therapists, pain-management clinics, mental health providers, injection therapy specialists, and surgeons. The goal is to steer patients to these providers, who have expertise in treating low-back pain and have agreed to follow ICSI guidelines and report their outcomes.
As its yardstick for measuring progress, HealthPartners is using the Oswestry low-back pain disability index—a series of questions designed to measure how back pain affects a person’s ability to manage everyday activities such as walking, lifting, and personal care.
The Oswestry index produces a score of zero to 100—zero represents no disability and 100 indicates the patient is incapacitated or bed-bound.
Primary care physicians, who oversee a patient’s care, ultimately make referrals to the other specialists on the team. For instance, they may refer patients to a physical therapist if an acute episode of back pain lasts longer than two weeks. The physical therapist tallies an Oswestry score during the patient’s first visit, then retests every four weeks. Scores are electronically sent to HealthPartners and integrated into its electronic medical records system, which the disease-management arm of HealthPartners and the patient’s physician can use to track a patient’s progress.
If a patient’s score is 60 or higher, meaning that their pain affects all aspects of their life, the therapist refers him or her to a nurse who will determine whether to assign the patient a nurse case manager.
“We’re looking to the physical therapists to be the lynchpin in the whole process,” Marr says.
Since starting the program in September, HealthPartners has already identified a significant number of patients with high Oswestry scores who qualify for case management, Marr says.
The nurse case managers follow up with patients by phone to check whether they are getting the therapies they need. The nurses also check whether patients are following through with treatment recommendations, such as doing their exercises.
The nurse case managers also check whether the patients have other medical issues such as arthritis or mental health problems that need treatment. HealthPartners believes that by keeping these patients involved in their treatment, it can ultimately save money and improve outcomes, and patients will be less likely to need surgery.
However, in cases that can’t be resolved with physical therapy, primary care physicians may refer patients to a preferred injection therapist. These are primarily interventional radiologists who have agreed to follow the ICSI guideline for injections.
The ICSI guideline states that steroid injections should be considered before surgery and that if the injection controls the patient’s pain, 70 percent to 90 percent of those patients will achieve good or excellent results at one year without surgery. That guideline also says that no study has shown a clear advantage of one approach (interlaminar, caudal, or transforaminal injection) over another. However since that guideline was completed, an ICSI technology assessment committee has concluded that transforaminal epidural injections for patients with seven weeks of back pain are more beneficial than the other types of injections, Marr says.
During a transforaminal injection, a practitioner uses fluoroscopic guidance to drive a needle into the epidural space and inject steroids near the irritated nerve.
The providers in HealthPartners’ network have agreed that “whenever possible” they will use the transforaminal approach, Marr says.
Another piece of the low-back pain puzzle is referring patients whose pain has crippled them or stolen their ability to work to select pain-management clinics for several weeks of day-long treatments. HealthPartners has identified three such programs: the Abbott Northwestern Sister Kenney Chronic Pain Rehabilitation Program, Fairview-University Medical Center’s Pain Management Center, and Mayo Clinic’s Pain Rehabilitation Center. “We know that those programs have outcome measures for patients who were appropriately selected that show they can really turn their lives around after many years of functional disability,” Marr says.
HealthPartners has also identified a network of spine surgeons who have developed criteria for when spinal fusion of degenerative discs is necessary. Determining when to operate is still a clinical judgment call because disc herniation on MRI or CT scans doesn’t necessarily indicate surgery. The decision to operate is based on the presence of severe, uncontrolled pain, profound or progressive neurological symptoms, or a failure to respond to conservative therapy, according to the ICSI low-back pain guideline.
The health plan tried to form a network of primary care physicians to participate in this initiative but found these doctors weren’t interested in specializing in treating this group of patients who, Marr says, can be challenging.
Finally, HealthPartners has created training modules for its members, including a five-session telephone course to teach patients about such things as appropriate exercise and good posture.
Pay for Performance?
Right now, providers choose to be part of the preferred networks. In exchange, HealthPartners markets the providers as having expertise in treating back pain. However, Marr says, HealthPartners is in the process of developing pay-for-performance measures for back pain. HealthPartners already has pay-for-performance initiatives for diabetes, depression, and heart disease.
HealthPartners may be ahead of a trend in terms of trying to efficiently and effectively manage back pain. In August, the NCQA announced it was developing a national program to identify physicians who provide high-quality care for chronic back pain. It has formed a 15-member Spine Care Advisory Committee, of which Marr is the only member from Minnesota, that will develop the program and launch it in late 2006.
Physicians such as Joseph Wegner, M.D., M.P.H., an occupational medicine physician with Physicians Neck and Back Clinics in Roseville, agree that chronic back pain is an area of medicine that badly needs some standardization of treatments and measurement of treatment outcomes.
Wegner says there is still a great deal of controversy among physicians about the causes of back pain and the best methods for treating it. He acknowledges that physicians end up using a trial-and-error approach that can leave patients feeling frustrated and disenchanted as the trials and errors pile up and their back pain gets worse.
It is also hard to eliminate some treatments because sometimes they work and sometimes they don’t, “and those are the stories myths are made from,” says Wegner, whose clinics are part of the HealthPartners preferred network.
For Wegner, only concrete outcomes data, which doesn’t exist right now, will clarify the situation, and that is why he thinks the HealthPartners initiative is a good first step. “Ultimately, for this whole thing to change, there are going to be some winners and losers. Right now, it’s a black hole that is full of money, and everybody wants to get a piece of it,” Wegner says. MM
Scott Smith is staff writer for Minnesota Medicine.