A new prescription for back pain

Published August 20, 2020

Excellus BCBS is using an evidence-based approach to treat back pain. Instead of sending patients to the ER for imaging and surgery, they are sending them to chiropractors and physical therapists. The result: better outcomes and dramatically lower costs.

As an experienced chiropractor, Dr. Lindsay Rae is trained to heal pain using manual therapy. But when a new patient came to her reporting chronic and debilitating low back pain several years ago, she spent their first session talking and listening, without laying her hands on him at all.

For years, this patient had avoided most movement and all exercise following a spinal surgery. “He was told he shouldn’t do any physical activity post-surgery,” says Rae. “More than likely, the surgeon meant ‘No activity while you recover,’ but that’s not what he heard.” What followed was weakened muscles and very little spinal movement. He was now bound to a wheelchair and lived in extreme pain.

Though manual therapy wouldn’t necessarily have been the wrong approach, notes Rae, she knew what this patient needed was help managing his condition long-term. So she engaged him in his own recovery. This meant listening compassionately, using the right words to explain his condition and making a personal connection—all of which would have a longer impact than manual therapies alone. She talked to her patient about the importance of exercise, addressed his fear of movement and taught him self-management strategies.

Rae credits her effectiveness in managing these types of cases to training she received from Excellus BlueCross Blue Shield (Excellus BCBS).

The supermarket approach to back pain

Experts estimate that up to 80% of Americans will experience back pain at some point in their lives.* But where do you go for care when back pain hits?

You might choose your primary care provider (PCP), the chiropractor or physical therapist. If the pain was very bad, you might go to the ER. “It’s really the supermarket approach to back pain,” says Rae. “There are too many options, which can be very confusing to the patient looking for guidance on how to manage their condition.”

The problem with all these options? The care you receive might be more dependent on where you go than what you truly need. Your PCP might prescribe you pain medicine; the chiropractor might manipulate your spine to relieve the pain; the physical therapist might teach you how to stretch and strengthen your back muscles; the ER doctor might perform an MRI and recommend surgery.

“Although all of these options are appropriate for the right patient,” notes Excellus BCBS Medical Director and chiropractor, Dr. Brian Justice, “the challenge is in decreasing variation in care delivery among various providers and helping patients find the right care.”

Fewer surgeries, better outcomes

To solve for the “supermarket approach,” Excellus BCBS is training its network of chiropractors, physical therapists and PCPs to follow an evidence-based clinical pathway, or standard operating procedure, developed by Justice and Spine Care Partners, LLC, after years of research.

In a 2011 study published in the Journal of Manipulative and Physiological Therapeutics, Justice and his coauthors laid out a spine care pathway that categorized and triaged spine-related pain supported by the current best evidence and focused on the patient. The pathway is a conservative approach to spine condition management, focused on the right treatment for the right patient at the right time. Ultimately, it reduces unnecessary MRIs, surgeries and opioids. The result is better outcomes, higher patient satisfaction and much lower costs.

A four-year study published this year in the Journal of General Internal Medicine, co-authored by Justice, corroborated these findings: “Conservative spine care…is associated with reduced healthcare expenditures…[and] reduced opioid utilization.”

In addition to teaching providers this conservative approach to care, Excellus BCBS guides trainees on how to speak to patients with back pain—especially if it’s their first time getting care. Making sure patients aren’t scared of or overly focused on their pain is one of the most impactful ways to improve their outcomes. X-ray and MRI reports that read “degenerative,” “spondylosis,” or “disease” can be scary to patients. Justice says results like this are often part of the normal aging process, though, “like grey hair of the spine.” Misunderstanding these terms can set patients up to think their pain is causing further damage and they may avoid the very movement needed to speed healing as a result.

To date, roughly one thousand PCPs, chiropractors and physical therapists have taken Excellus BCBS’ spine care training. Their patients are now receiving significantly fewer surgeries, imaging services and other, sometimes unnecessary, downstream services as other patients. Their average cost of care is about 40% less.

Rae, one of the first practitioners to pilot this training, attests: “This pathway taught me that just changing the way I said something could make more of an impact on a patient’s health than trying to heal the pain myself.”

Gamifying back pain

Excellus BCBS now has online training available for primary care physicians, chiropractors and physical therapists. Urgent care and emergency room physician training will be rolled out in the fourth quarter of this year. It will also be beta testing a gamified patient app in September that helps members make educated decisions at each step of their care journey.

“As members of the healthcare industry, we’re all under-spending on prevention and education,” says Justice. “The good news is that those things are very low cost, and we can do a lot to change the behavior of our patients and members.”

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*Rubin Dl. Epidemiology and Risk Factors for Spine Pain. Neurol Clin. 2007; May;25(2):353-71.

Excellus BlueCross BlueShield, an independent licensee of the Blue Cross Blue Shield Association, is a nonprofit health plan with 1.5 million upstate New York members. The company's mission is to help people live healthier and more secure lives through access to high-quality, affordable health care. Its products and services include cost-saving prescription drug discounts, wellness tracking tools and access to telemedicine. With more than 3,500 employees, the company is committed to attracting and retaining a diverse workforce to foster innovation and better serve its members. It also encourages employees to engage in their communities by providing paid volunteer time off as one of many benefits. To learn more, visit ExcellusBCBS.com.