Managed Care - June 2008 - (Page 48)

certainly are not going to be worse from delaying surgical treatment.3 Spinal fusions have increased dramatically and now disc arthroplasties (disc replacement) are on the rise. This health plan has encountered at least 15 requests for these procedures in the last two months. Independent reviewers are giving mixed opinions about the effectiveness of these procedures. Many health plans continue to consider them investigational, but the health plans find themselves under tremendous pressure to approve them. After all, patients are living with fear that they might become paralyzed if they do not undergo an intervention quickly. Few physicians are willing to spend the time to educate their patients about their conditions and their options. DRUG THERAPY Drug costs for the care of these conditions continue to rise. Naturally, nonsteroidal anti-inflammatories (NSAIDs) are prescribed in high volume and usually ibuprofen is out of the question. Patients complaining of severe pain are often given opioids. If newer narcotics are prescribed, the cost of caring for their condition is escalated even further. Couple this with the fact that 24% of patients receiving narcotics for their back pain will develop drug seeking behavior, which will likely result in additional medical costs for behavioral health and other medical interventions.4 Good alternatives for the management of acute back and neck pain do exist and are very effective. The first step is to assess patients for potential high risk conditions with a proper history and physical examination. Fears and misconceptions are common among patients with neck and back pain, and these must be addressed. The patient needs a confident explanation about his condition, and he must be empowered to resume normal activities.5 Sometimes these interventions occur in the primary care office. Often patients have fear and seek instant relief in the form of procedures and drugs. Primary care physicians find themselves struggling to increase productivity and, as a result, have little time to adequately capture their patient’s confidence, provide thorough explanations about his condition, and contradict what his neighbor told him about the benefits of being exposed to the magnetic field in the MRI machine. Even the National Committee for Quality Assurance (NCQA) has recognized how difficult this task is, so a new HEDIS (Healthcare Effectiveness Data and Information Set) measure to track the incidence of diagnostic imaging during the acute phase of back pain has been implemented. How can a community health plan improve the care of these patients, improve medical costs, and achieve outstanding results on this new HEDIS measure? CHP operates with a very low overhead so tacking on a complex pre-authorization process for diagnostic X-rays and procedures would not be desireable. CHP is a hybrid model HMO and operates a very effective staff model practice that provides primary care for 40% of the plan’s population. Leveraging the staff model practice, CHP pursued a pilot project to test a new approach to the management of patients with back and neck pain. The business need was clearly established because of rising diagnostic, drug, and procedure costs. In fact, CHP estimated total costs for patients with spinal conditions and their associated pain syndromes at $4 million annually. This amount is comparable to the unavoidable heroic expenditures incurred for all solid organ and bone marrow transplants and their associated drug costs. So, how could the cost of back and neck pain be reduced? Many good physicians and consultants in the community readily reported that patients were not receiv- ing rapid access to good conservative treatment with practitioners who could spend adequate time and energy evaluating, educating, and training these patients. The potential care settings, techniques, philosophies, and capacity of many practitioners were evaluated. Capital Health Plan then formed a collaborative project with Orthopedic and Sports Physical Therapy. PILOT PROJECT The project was designed to provide the CHP population with rapid access to this physical therapy practice. This population comprised 40% of CHP’s overall population. These physical therapists agreed to track each patient entering and completing the program by assessing level of pain and functional score. Each patient completing the program received a telephone survey call at three-month intervals. In addition to rapid access, the therapists agreed to do anything in their power to eliminate barriers to access, such as providing occasional early or late appointments and also waiving copayments if this was perceived as a barrier, but this was rare. Orthopedic and Sports Physical Therapy employs the mechanical diagnosis and therapy (MDT) technique. Pain syndromes respond in various patterns to the MDT assessment. Based on this assessment, a treatment that is specific for the resolution of the discomfort produced by the individual’s pain source is designed. The patient must then be extensively educated on the techniques to relieve their symptoms as well as encouraged to employ these techniques with any recurrence. The outcomes of the MDT technique have been extensively studied for lumbarrelated pain syndromes. Ronald Donelson, MD, a 20-year veteran of nonoperative spine care at the State University of New York, reports that the MDT techniques are also highly effective for cervical region pain syndromes. He expects this opinion to be 48 MANAGED CARE / JUNE 2008

Table of Contents Feed for the Digital Edition of Managed Care - June 2008

Managed Care - June 2008 Editor’s Memo Contents Viewpoint Letters News and Commentary Legislation & Regulation Medication Management Compensation Monitor Plans Chart Course in Rough Waters A Conversation With Barbara Starfield, MD Smoke Signals from Payers Slow Going for Clinical Decision Support Back Pain and Physical Therapy Formulary Files PlanWatch Outlook

Managed Care - June 2008

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