Journal of General Internal Medicine 2019 (Aug); 34 (8): 1381–1382 ~ FULL TEXT
William B. Weeks, MD, PhD, MBA, Jason Pike, PhD, Jeremy Donath, BS, Paul Fiacco, MD, and Brian D. Justice, DC
The Dartmouth Institute for Health Policy and Clinical Practice,
Lebanon, NH, USA.
From the FULL TEXT Article:
In the US, spine pain treatment is expensive and has uncertain
outcomes.  To reduce waste and improve patient outcomes,
organizations like the American College of Physicians  and
Choosing Wisely (in concert with Consumer Reports)  have
published conservative spine care treatment recommendations.
As part of an effort to improve the clinical effectiveness and
value of spine care, on March 1, 2015, Excellus BlueCross
BlueShield (Excellus), headquartered in Rochester, NY, introduced
a spine care pathway that incorporated conservative
spine care recommendations in 1 primary care practice (with
11 primary care physicians (PCPs)) within an Excellus Accountable
Cost and Quality Arrangement (a reimbursement
model similar to an Accountable Care Organization) but not in
another (with 74 PCPs). We sought to analyze the impact of
the pathway’s implementation by comparing expenditures for
spine pain care in those practices.
We obtained data on patients who were attributed to either
primary care practice at any time between 4/1/14–3/31/18.
Using ICD-9 or ICD-10 codes to identify spine pain patients,
we treated any expenditure on spine pain care as an event.
Each year, for each site, we calculated per-member-per-month
(PMPM) spine care costs in 4 categories (all spine care, spine
surgery care, opioid care, and manual care (physical therapy or
chiropractic spinal manipulation)) for each attributed patient.
We calculated PMPM expenditures for each cost category in
each of the 3 years following initiation of the intervention and
used a difference-in-difference approach to calculate the relative change from baseline (the year before intervention) to the
3rd year following intervention.
To generate time-group interaction estimates for each spine care cost category, we used a
longitudinal Poisson model that accounted for repeated measures within each group over time, included 4 annual periods
for each group, and used PMPM expenditure as an incidence
rate; the model controlled for average age, percentage male,
forecasted risk score (generated from prior use patterns), and
deductible benefit design characteristics of the population for
each annual evaluation period.
The study was found to be not human subjects research by
Dartmouth College (CPHS # STUDY00030530).
Over the 4-year period, all spine care costs decreased for both
the intervention and the control group; however, those costs
decreased at about 4 times the rate in the intervention group
than the control group (28.3% vs. 7.2% reductions); most of
the reduction in per-member-per-month (PMPM) cost for spine care in the intervention
group was attributable to reduced PMPM spine surgery costs
(both p < 0.001, Table 1).
In both groups, opioid treatment
PMPM costs and manual care PMPM costs increased from
baseline. However, Poisson longitudinal regression results
indicated that adjusted PMPM care costs in the intervention
group fell, relative to those for the control group, for all
examined categories save manual care, which increased at a
statistically significant rate (Table 2).
In this retrospective, controlled, before-after study, we found
that implementation of a conservative spine pain treatment
pathway was associated with significant reductions in per-member-per-month (PMPM)
healthcare expenditures for spine pain care; most cost savings
were attributable to reduction in spine surgery costs. Our
Poisson model found relatively reduced opioid utilization
and relatively increased manual care costs, both anticipated
by-products of guideline implementation. 
While our findings are preliminary, in an era of increasing
healthcare costs and use of complex and expensive spine
surgery techniques they show promise for meaningful care
cost reduction and value enhancement when providers
conservatively manage spine pain.
Importantly, our analysis
underscores the value of using control groups, formal analytics,
and academic partnerships to understand the impact of
quality improvement and clinical effectiveness projects, measures
that have been recommended to improve the robustness
of quality improvement efforts. 
Conflict of Interest:
Dr. Pike, Mr. Donath, and Dr. Justice are employees
of Excellus BlueCross BlueShield in Rochester, NY. Dr. Fiacco
is an employee of Central New York Family Care, Syracuse, NY. Dr.
Weeks declares that he has no conflict of interest.
Mafi JN, McCarthy EP, Davis RB, Landon BE.
Worsening trends in the management and treatment of back pain.
JAMA Intern Med. 2013;173:1573–81.
Qaseem A, Wilt TJ, McLean RM, Forciea MA;
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530
American Board of Internal Medicine Foundation (ABIM Foundation)
Choosing Wisely: Treating Lower-back Pain 2018.
Weeks WB, Goertz CM.
Ineffective Policies to Address the Opioid Epidemic.
JAMA Psychiatry. 2017;74:974.
Grady D, Redberg RF, O'Malley PG.
Quality Improvement for Quality Improvement Studies.
JAMA Intern Med. 2018; 178(2): 187.