The treatment of musculoskeletal pain is a ten billion dollar problem in the United States; one that all but cries out for a shift to value-based reimbursement.
Low back pain (LBP) is one of the most common care complaints in the world, affecting an estimated 60 to 80 percent of the global population. Instances of chronic back pain can have a pervasive and profound impact on a patient’s life. In 2010, researchers for the Global Burden of Disease Study found that out of nearly 300 studied conditions, back pain ranked the highest in terms of years lost to disability.
Given the prevalence of LBP, high rates of treatment seem intuitive and logical. However, the steep increase in the cost and volume of surgical interventions far outstrips reasonable expectations.
According to one study published in the Annals of Rheumatic Disease, those who report spine problems face a medical cost burden nearly twice that of those without back or neck complaints. Moreover, costs have sharply increased over the last decade. Aggregate hospital costs have risen by 177 percent between 2003 and 2015. By the last year of the reviewed period, annual expenses topped $10 billion by 2015 and posed an average bill of $50,000 per admission. Most troublingly, the researchers note that “these costs continue to increase despite a lack of information to indicate that these increased costs are associated with improved outcomes.”
The sharp increase in the volume of LBP-related surgeries is also worth noting. One literature review published in the March 2019 issue of Spine found that the number of elective lumbar fusions in the United States increased 62.3 percent between 2004 and 2015, rising from 122,679 at the beginning of the studied period to 199,140 by its end. Researchers noted that certain conditions contributed more to the rise than others, writing that “although the largest increases were for spondylolisthesis and scoliosis, disc degeneration, herniation, and stenosis combined to accounted for 42.3% of total elective lumbar fusions in 2015.”
The sharp uptick in surgical intervention is particularly notable when compared to rates in other countries. The volume of back surgeries in the US is at least 40 percent higher than those in any other country and stands five times higher than those reported in England and Scotland. The Department of Health Services study that noted these differences also found that back surgery rates increased “almost linearly” with the per-capita supply of orthopedic surgeons — a trend that implies demand for surgery is driven at least in part by the availability of providers.
This implication is troubling, because research has demonstrated that repeat or avoidable spine surgeries can pose long-term harm to patients. In a 2018 issue of the Asian Spine Journal, researchers described repeated spinal surgery as “a treatment option with diminishing returns.” They shared that while 50 percent of initial spinal surgeries are considered successful, only 30 percent, 15 percent, and 5 percent of patients report successful outcomes after their second, third, and fourth surgeries, respectively. Moreover, those who have failed back surgery syndrome (FBSS) tend to experience a poorer quality of life and physical function, as well as higher levels of pain than patients with rheumatoid arthritis, fibromyalgia, and osteoarthritis.
It is clear that merely increasing the number of back surgeries performed has not resolved the issue of chronic LBP — in fact, it arguably may have made outcomes for some patients worse. There is room, however, for a value-based solution. With value-based care, providers could focus on giving patients multidisciplinary, non-invasive support for their chronic pain, and lessen their reliance on opiates and surgery-dominated treatment plans.
This isn’t to say that surgery isn’t an important — even necessary — course of treatment for patients. Research has affirmed the value that these interventions hold. Two recent, randomized studies conducted by the Dartmouth Institute found that surgical decompression does, on average, improve patient-reported measures of disability, pain, and quality of life when compared to non-operative treatments. Researchers further indicated that surgical patients suffering from spinal stenosis tended to have better pain relief and functional recovery outcomes than non-surgical participants.
However, the Dartmouth Institute does note that the benefits of surgical interventions lessened with time and leaves some patients with significant concerns. The study found that after four years, roughly 17 percent of patients had undergone a repeat operation, and 30 percent reported experiencing severe pain.
A value-based approach to back and spinal care could facilitate treatment plans that could meld the benefits of surgery with a multidisciplinary, biopsychosocial framework for care.
Unlike the current fee-for-service system, which naturally focuses on the immediate provision of expensive care over a patient’s long-term outcomes, a value-based approach would incentivize providers to collaborate on a patient’s behalf. Rather than recommending a patient with LBP solely to surgery, a care team could direct patients to physiotherapists, behavioral healthcare providers, musculoskeletal physiotherapists, chiropractors, and osteopaths.
For example, providers might recommend LBP patients who may not need surgery or post-surgical patients who want to avoid further invasive procedures to physical therapy and behavioral health support. Consider the efficacy of behavioral health in treating chronic pain as an example. One study published in a 2018 issue of Translational Behavior Medicine found that chronic pain participants who enrolled in a 6-week cognitive-behavioral therapy (CBT) pain group experienced similar pain relief results to those who relied on opioid painkillers.
Thus, an approach that included behavioral health support could be just as effective in treating back pain as prescribing opiates or recommending further surgery — and potentially avoid the complications that, as noted above, can arise with FBBS. Applying a value-based strategy will reduce surgical overutilization and diminish unnecessary care, all the while providing better pain management care, physical therapy, and psychological support. All totaled, these benefits may provide a significant boost to patient outcomes and experiences.
The shift to value-centric care could also provide significant cost savings by discouraging unnecessary testing or procedures, encouraging efficiency, and prioritizing early assessment with the goal of resolving health concerns before they become pressing or complex. These savings could be significant; estimations from one report in a 2008 issue of JAMA suggests that value-based care may provide “as much as a 20% saving on current expenditure for low back pain care within the mainstream health care sector.”
Some studies have already explored the potential that value-based care strategies pose for spine care. Last year, early trials for the Bundled Payment for Care Improvement Initiative (BCPI), studied the effect of value-based care on patient outcomes and cost savings across 20 hospitals. The research period accounted for approximately 1,000 episodes of care across two years and found both an increase in Medicare payments and a decrease in patient mortality.
All this said, there is room for improvement. The researchers noted that 76 percent of the Medicare payments went towards hospital care, while 14 percent were allocated to doctors. The writers suggest that more should be done to direct funds towards doctors in the future, noting that doing so would improve both patient outcomes and profits.
“Physicians are often the ones most involved in developing successful strategies to decrease length of stay, reduce complications, and prevent readmissions,” they write. “Therefore, as the ‘heavy lifters,’ appropriate incentives for physicians in this regard would likely lead to further improvements in cost.”
The shift towards value-based care isn’t just advisable; it’s necessary. Ample research demonstrates that merely increasing the number of surgical procedures in the treatment of LBP is not a real solution to the problem at hand — not when it increases costs and only partially supports patient needs. In switching towards a value-based system, providers will be better able to create a multidisciplinary, supportive, and cost-effective framework for patients with chronic back pain. To continue as we have is an untenable and ineffective solution — for patients and care organizations alike.