The recent increase in costs for spine care has attracted the attention of the media,1 government,2 third-party payors,3 and physicians.4 One recent study found significant variability in the volume of spinal surgery performed across geographic regions in the United States. As previously thought, this variability could not be explained by the local or regional supply of spine surgeons.5,6 This has occurred without a concomitant increase in physician visits for low back pain (LBP).7 There has been an explosion of new technology in spine care that has pulled financial resources away from other areas of health care and may be an unequal “burden” to society. The total cost of this care is rising and, like the total cost of health care, rising faster than the country’s gross domestic product.8 Clearly, there is a need for rational approaches to treating a patient with spinal disease that produces good results in a fiscally responsible way.
The spine patient entering the system faces many challenges. The patient must depend on advice from health care providers, often seeking advice from several providers from different backgrounds.9 This leads to increased costs and, despite well-published guidelines, dissemination of an inconsistent base of knowledge due to poor implementation of treatment suggestions.10–12
An idealized approach to patient-centered spine care should maximize the use of proven treatments and curtail unproven or potentially harmful approaches. This should occur in a timely and efficient manner to minimize the time and money patients forfeit to undergo treatment. Reducing time lost from work and productivity is an important outcome to patients, and with a work-related episode, to industry and its insurers.
The goal of this manuscript is to describe an approach that uses best-available evidence and guidelines to managing the patient with a spinal disorder. It will support the use of outcome-driven treatment methods, and discourage the frequent and often repetitive use of nonsupported treatments. Additionally, institutional benefits of a spine service line will be discussed, as they are notable. The implementation of this approach at the institutional level defines a model “spine line” of care.
Primary Spine Care
There are many ways a patient with spinal disease can enter the health care system (Figure 1). These entry “portals” determine the future episodes of care the patient will receive. Unfortunately, there exists a lack of solid, fundamental knowledge of the pathophysiology of LBP among and between spine care providers. The patient’s clinical progress is further complicated by the variability of language and diagnostic and therapeutic approaches taken by the initial providers. As a result, patients receive conflicting advice and potentially unneeded diagnostic tests by this methodology. This ultimately leads to a less than ideal use of time and resources. However, it may be possible that spine care can be delivered in an efficient and effective manner if we adhere to a systems-based, guideline-driven approach that focuses on health care value.
There is no doubt that the majority of LBP episodes are cared for at home. A first-time episode of acute back pain may, however, prompt a visit depending on the severity or chronicity of the symptoms and any real or perceived neurologic deficits. This interaction may occur with a primary care provider, chiropractor, orthopedic surgeon, or emergency room physician. These providers all approach the history, physical examination, and diagnostic testing for LBP differently, providing equally variable degrees of expertise and advice.
The vocabulary or “language” used in these different settings may unnecessarily confuse and alarm patients. Patients are often given lifting or moving restrictions and fear permanent tissue damage or neurologic catastrophe. The Fourth International Forum on LBP met in Israel in 2000 to discuss the advances in LBP care. The major focus was on de-emphasizing the biologic “injury” model and moving toward a more biopsychosocial model. For example, there are numerous occasions in which patients’ fears of “back injury” are confused for spinal injury. Use of the term “back injury” would wrongly corroborate and support those fears. Additionally, the impulse to treat LBP as a biomechanical entity was also curbed. Their final concern was over the implementation and dissemination of this information.11 What is well known, but not universally accepted, is that the majority (>90%) of back pain episodes will resolve within several weeks with minimal supportive care provided there are no “red flags.”13 There was concern regarding the difficulty in providing this fundamental information to clinicians, and, more importantly, changing their attitudes and behaviors toward LBP.11
The present spine care delivery system can be thought of as a fragmented, often nonstep-wise system. To improve on this model, we suggest a more step-wise, guideline-based paradigm for spine care (Figure 1). This “Spine Service Line” seeks to use current (evidence-based) knowledge about the natural history of LBP, and apply this knowledge to best treat it at both acute and chronic stages. The overall objective is to reduce costs associated with inefficient delivery of care, duplicative diagnostic testing, needless specialist consultation, and questionable surgical intervention.
We propose that the primary episode be managed according to accepted treatment guidelines.14,15 These types of guidelines suggest that LBP can and should be cared for on the primary care level. More complicated or chronic treatment is generally not addressed well by these guidelines, but we will address this problem later.
With a portal-type approach, at once a part of the problem because of the inconsistencies of training and experience can be solved if a standardized, guideline-oriented approach is applied. This way, any number of providers of varying specialties can provide initial evaluation and management. In fact, offering choice may be preferable to many patients and provide for a diversified revenue stream. The key to this approach is that each provider, whether it is a primary care provider, orthopedic surgeon, or chiropractor, performs the same evaluation, orders appropriate diagnostic testing, and employs accepted treatment approaches. This is possible in an institutional setting, be it a large hospital-based clinic or a private, spine care practice. This would require a commitment to educate and train all providers, and to ensure compliance on local and regional levels.
There should be a standardized intake process, including a thorough history and physical examination, and collection of all demographic and psychosocial information. Detailed documentation of the mechanism of injury, past history of spine problems, and present level of disability is important to include, particularly in today’s legal environment. Each patient should be “in processed” in the same manner, ideally into an electronic medical record. There should be consistent data collection on all patients. This improves efficiency with which patients can be evaluated and managed. For example, advanced imaging in early treatment for LBP does not change treatment decisions, or outcomes, but increases associated costs.16,17 By establishing system-wide indications for magnetic resonance imaging, the use of these expensive methods can be curbed. Additionally, the available data could be used for research purposes, quality measurement, and assurance efforts. This method of data collection also leads to better compliance with documentation requirements, and, thus, more appropriate evaluation and management coding and billing. The outcome of this is optimization of reimbursement for provider and institution but, more importantly, good, efficient patient care.
This guideline and systems-based approach can improve value to the delivery of this type of care. Porter and Teisburg18 recently defined value in health care as the “quality of health outcome per dollar spent.” Spine disorders are ideally suited to be treated by a system that is managed at the disease level. In fact, Porter and Teisburg18 argue the very economics of health care are driven at the disease level. As in many industries, cost and quality can improve simultaneously with improvements in error prevention, efficiency, and expertise. Even if costs remain stable in this model, this would inherently increase the value of dollars spent to manage spinal disorders. In other areas of orthopedics, mortality and complication rates after primary and revision total hip arthroplasty were clearly shown to be significantly lower in patients who were operated on by high-volume surgeons in high-volume centers. This was found in both Medicare and non-Medicare populations.19,20 In fact, across surgical specialties, including cardiac transplantation, esophageal cancer, and elective aortic aneurysm repair, disease-based care centers have been shown to have better outcomes and lower costs per patient treated regardless of their complexity.
Institutions that adapt this way of thinking and insist on value delivery can also profit from many sources of revenue. Colocating disparate providers and services needed to deal with spine conditions can maximize efficiency and reduce inconvenience for patients. This captures the revenues generated from the various providers (primary care provider, orthopedic surgeon, chiropractor) but also various ancillary services involved with spine care, most notably imaging and physical therapy.
Many patients will see relief of LBP symptoms over several weeks to months, leaving an even smaller group of patients with chronic disabling back pain and/or sciatica. Indeed, the major controversies in spine care focus on the evaluation and treatment of this subgroup. The cost burden created by this subgroup is significant. Duration and frequency of illness are correlated to analgesic use, health care utilization, and cost.21 Moreover, the indirect costs of LBP (mainly time lost from work) accounted for 85% of the total costs of LBP treatment, while direct costs (medications, physician visits, etc.) accounted for 15%. More study needs to be done to determine ways to lessen the impact of indirect costs in LBP, whether this means increasing spending on direct treatment costs has yet to be determined.
The goal is not to endorse 1 guideline or system over another but to standardize approaches to LBP care. This is not new in the literature. We propose improving value by decreasing unnecessary and duplicative testing or imaging, reducing overused specialist consultations, and curbing untested or untrue beliefs regarding LBP. The point is not to generate as much revenue as possible but to generate as much care as is appropriate.
Secondary Spine Care
The next level of care starts when the patient fails to improve despite simple measures, and the pain becomes chronic. However, the definition of when LBP transitions from acute to chronic has not been agreed on. Some use the duration of pain, others the burden of pain (number of days in pain), others the impact of pain.22 Thus, when pain persists, despite prompt and appropriate care, a closer look is appropriate. But it is often at this point where expenses can escalate. Diagnostic tests and treatments that have not been rigorously tested or scientifically proven will often be tried. Cummins et al23 reported on the utilization of health care resources by patients before enrolling in the Spine Patient Outcomes Research Trial. Visits to surgeons, medical specialists, therapists, chiropractors, and alternative medical specialists were recorded. Over 80% of patients visited surgeons, over 60% saw physical therapists, 30% to 40% visited chiropractors, and 23% to 26% alternative medicine. Among treatment methods, 90% had passive methods, 66% to 76% physical therapy, 25% to 38% chiropractic care, and 50% or more had injections. More than 90% of patients were taking some form of medication.24 Clearly, this population consumes significant resources.
Short of surgery, any of a number of providers can coordinate secondary care provided a guidelines-based approach is applied. It is somewhat intuitive that some providers are better suited to treat spine problems at some levels but not all. For example, a family medicine physician or chiropractor may want to defer to a physiatrist, neurologist, or orthopedic surgeon for the next level of care. A neurosurgeon or orthopedic spine surgeon might not see acute back pain and would rather consult later in the continuum of care when surgery might be a possibility. This approach optimizes the correct level of care delivered by the correct level of provider.
Advanced diagnostic testing is appropriate at this point as more treatment resources are contemplated. The overuse of magnetic resonance imaging has been mentioned previously. However, there is support for its use in patients who have had LBP for a prolonged period of time.25 The American College of Radiology appropriateness criteria also consider LBP >6 weeks to be a red flag and support advanced imaging in this situation.26 In the setting of true radicular signs and symptoms, electromyography may be used as a diagnostic tool. Therapeutic maneuvers can include injection therapy. The indications for their use in LBP are indeterminate and are not entirely supported by strong evidence. Their short-term use in patients with radicular complaints has been well supported by strong evidence.27
It is in this secondary phase that these multiple revenue streams from imaging, injections, and electrodiagnostic testing can be generated for the provider institution. Physical medicine treatments like physical therapy, alternative approaches such as acupuncture, yoga, Pilates, or manual therapies, can also provide an income stream for the vendors of these services. The scientific legitimacy of these treatments has not been validated; some have been shown not to deliver any long-term benefit in chronic LBP. The demand for these services still exists (mostly patient driven) but when applied appropriately, may be beneficial for some who may have recalcitrant symptoms. These services provide revenue with varying margins. Some are covered by third-party payors, while others are not, but interestingly, patients will pay out of pocket for alternative treatments.
The institutional revenue generated by these methods will depend on contracts and local reimbursement schemes. As noted earlier, this subgroup of patients is significantly smaller in number, but the cost of treatment per patient is significantly higher. Ekman et al28 examined the burden of LBP illness to the Swedish society. They followed 302 patients over 3 months. Those having pain for greater than 50% of the days were included. They calculated that cost per patient with chronic LBP in Sweden was around $19,500. In a country whose health care costs occupy around 10% of their gross domestic product, the analogous calculation for the United States would be much higher.28
Controversy between specialties exists about the timing of surgical intervention, particularly when signs and symptoms of neurologic involvement are present. Even in those cases, we would argue that there is enough scientific evidence to come to an agreement if there were a will to do so. In any case, it is not the point of this article to argue the specific treatment approaches but to offer a framework for providing appropriate and efficient delivery of spine care.
Tertiary Spine Care
Physician approaches to evaluation and treatment vary most in those patients who fail to recover from their painful episodes. Fragmented and inefficient care results, leading to depreciation of health care dollars. For example, there are patients with chronic LBP who will be subjected to numerous injections despite good evidence that shows they are not helpful.13 Multiple episodes of care will have been delivered (with associated escalation in cost) without a concurrent rise or improvement in health status. Even more confusion and disagreement exist in surgical management. Weinstein et al5 evaluated rates of lumbar surgery across hospital regions within the United States. They found that rates of lumbar discectomy varied by 8-fold and lumbar fusion 20-fold. In contrast, variation in hip fracture surgery was 3.6 and hip replacement 5.6.5 The real issue remains, which rate within those variable regions is correct? In other words, who is getting too much surgery, who is being neglected, or are all rates of surgery too high? There appears to be no way of knowing at this time.
It may be difficult (or impossible) to achieve universal agreement on how to treat this smallest group of patients. What may be more important is to establish a consensus within an institution or practice to treat systematically patients using techniques consistent with specific indications. Without rigorous class I studies, 1 indication cannot be established to be more appropriate than another. A consensus opinion may be the next best step. Surgical trials with a sham group have proven difficult to justify, but there are those who advocate the idea.29 A methodological approach to data collection can facilitate prospective analysis of patients and outcomes using measures that have already been discussed.30 If an EMR exists, it can be formatted for more effective data management and analysis. The overall goal is to limit the variability in lumbar surgery that exists within a practice or institution. Improving consistency of practice will enable surgeons to narrow indications and find those patients who will truly benefit from operative intervention.
The revenues from invasive procedures such as injections, pain procedures, and surgery are tremendous, but the associated costs must be understood and managed closely. These factors include costs of implants and disposable surgical supplies, lengths of stay, and payor contracts. Device manufacturers are an integral part of the “supply chain” and must be considered when managing the overall budget. Negotiating costs of implants can provide relief but may require a commitment of volume or other exclusivity. Surgeons at that hospital could agree to use 1 company’s implants and secure better pricing from the manufacturer. When done correctly, these relationships can lead to good cooperation between institution, vendors, and surgeons, and cost containment.
Hospital inefficiencies such as longer than needed lengths of stay need to be examined. Therapists and case managers should all be educated and made aware of the importance of expedient discharges. Surgeons should also be a part of the process as prolonged recovery is no longer necessary when complications do not arise. Hopefully, minimally invasive surgical techniques will add value by minimizing patient morbidity and decreasing lengths of stay. Other departments like hospital billing services should be evaluated to ensure appropriate and expedient collection. Additionally, operating room inventory should be managed according to volume of implant use.
Hospitals need to understand better their cost structure to negotiate more effectively with payors and obtain appropriate reimbursement for instrumented spinal procedures. Creating exceptions in the contract for implants separate from the diagnosis-related group (DRG) payment, so-called carve-outs, can reduce the burden of implant costs. The hospital and physician are responsible to the payor to practice according to guidelines and best practices. The institutional costs alone can be a significant segment of total costs of care, and should be managed and controlled.
The patient with spinal disorders is a disabled person often in desperate need of care. We are charged with providing efficient, patient-oriented care that manages his/her painful problem from the initial presentation to the point where he/she either requires operative intervention or long-term pain management. Using a systems-based approach that manages the flow of patients can improve economies by reducing redundant processes. The colocalization of the various segments of the service line can enable better control and management of this process as well.
Institutions can benefit from multiple revenue streams from the patient’s initial presentation to the surgical procedure. Careful management of the associated costs can improve profitability. Larger volume centers can profit even more by understanding the trends and processes that erode profits or improve margins. Cooperation with hospital administration, surgeons, and industry is critical but can be done to benefit all those involved.
- The spine service line has the goal of managing patients with spinal disease using systems-based, guideline-driven approaches.
- Minimizing unhealthy concepts about spinal disease and improving the consistency with which spine care is delivered is a key component of the spine line.
- Careful coordination must occur between providers but also between providers and institutions.
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