Addressing The Burden Of Spine-Related Disorders
Through Integrated Value-Based CareThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Health Affairs Forefront, February 12, 2025 ~ FULL TEXT
OPEN ACCESS Ryan Burdick • Christian Péan Sara • Holleran Inga Morken • Christine Goertz
Faculty of Health Sciences,
Ontario Tech University.
Editor’s Note:
This article is the latest in the Health Affairs Forefront series, Accountable Care for Population Health, featuring analysis and discussion of how to understand, design, support, and measure patient-centered, cost-efficient care under the umbrella of accountable care. Readers are encouraged to review the Call for Submissions for this series. We are grateful to Arnold Ventures for their support of this work.
The unsustainable rise of health care costs in the US, coupled with suboptimal health outcomes, is driving both conversation and real action toward value-based care (VBC) models in this country. There is no more low-hanging fruit for this effort than spine-related disorders. Low back and neck pain cost us more than $134 billion annually and continues to rise at a rate more than twice that of overall health spending despite the fact that it is already at or near the top of all direct health care expenditures.
Despite aggressive and often invasive treatment approaches, low back pain remains the leading cause of physical disability worldwide with neck pain not far behind. This divergence between cost and outcomes is driven largely by the sustained use of expensive and ineffective treatments that can lead to more harm than benefit. Overreliance on prescription opioids began in the early 2000s, based on weak evidence suggesting that these medications were safe and effective treatments. In addition, the US maintains a higher rate of surgical interventions, more frequent specialist consultations for initial diagnoses, and consistently higher use of medically unnecessary advanced imaging when compared to international standards.
Recognizing the profound impact of spine-related disorders, organizations including theAmerican College of Physicians, the
Centers for Disease Control and Prevention, the
Department of Veterans Affairs, and the
World Health Organizationhave all advocated for evidence-based, nonpharmacological treatment strategies for low back pain. These approaches emphasize conservative care as the first line of treatment, with invasive interventions reserved for cases in which patients do not improve with initial measures. However, adherence to guidelines remains poor, reflecting a systemic misalignment of incentives and care priorities in spine care.
A shift from fee-for-service care to value-based models would correct the perverse incentives that currently undermine optimal treatment of spine-related conditions. Such a transition could prioritize outcomes, reduce the overuse of low-value services, and incentivize the integration of multidisciplinary and evidence-based approaches. To date there is limited funding from government agencies for this effort and a lack of industry initiatives to explore what a value-based, population health-focused framework for treating spine-related disorders would entail. However, there are signs of movement in this direction. For example, the Center for Medicare and Medicaid Innovation (Innovation Center) recently rolled out a strategy to support person-centered, value-based specialty care to begin addressing the issues with fee-for-service care. Nevertheless, more work is needed. In this article, we outline the pressing need to build upon this and other existing VBC models for a range of disease conditions to directly target the delivery of evidenced-based spine care within a value setting.
Creating Value-Based Spine Care ProgramsIntegrate New Care Teams Within Primary Care For Spine-Related Disorders
Spine-related disorders are a leading reason why individuals seek medical care in the US, an approach that often begins with a visit to a primary care provider. However, primary care providers face mounting patient and administrative demands, including managing multiple chronic conditions and coping with the pressures of a nationwide primary care provider shortage. These challenges make it difficult to effectively address spine-related disorders. Primary care providers are further constrained by a lack of formal training in pain education and spine-related disorders. It is estimated that most medical schools teach only nine hours of formal coursework on these conditions. In addition, the majority of primary care providers have little or no training on guideline-concordant treatments, such as spinal manipulation, acupuncture, or rehabilitative exercises.
In response, concerted efforts are needed to expand accessible, high-quality care to the tens of millions of Americans with spine-related disorders. One option is to fully embed specialized provider groups, such as chiropractors or physical therapists, within primary care settings. These providers are equipped to deliver first-tier and second-tier treatments for spine-related disorders, enabling primary care providers to focus on other diseases and comorbidities commonly associated with spine pain such as depression and anxiety. Integrating these specialized providers at the primary-care level could reduce referrals to services unlikely to add value and increase access to higher-level interventions when needed. Scalable models exist. Such care pathways are well-established throughout the Department of Veterans Affairs and Department of Defense, and offered at some academic health centers. There are also opportunities to create and pilot programs that assess the financial feasibility of leveraging efforts by the Innovation Center and others, such as Maryland’s Total Cost of Care Model, to reduce statewide hospital spending.
On-site integration is not the only way to improve care coordination between primary care providers and specialists. The Centers for Medicare and Medicaid Services (CMS) has implemented changes that could more meaningfully incorporate specialists in caring for patients across the low back pain spectrum. An example is the addition of chronic pain management and treatment codes (G3002 and G3003) to the current fee-for-service Physician Fee Schedule. These codes describe a monthly bundle that allows primary care providers to provide diagnoses, administration of validated pain rating scale, care plans, medication management, pain and health literacy counseling in addition to care coordination with physical therapy, occupational therapy, community-based care, and other specialists. As a result, primary care providers are incentivized to meet the strengths, goals, clinical needs, and desired outcomes of patients with low back pain, potentially decreasing the need for unnecessary imaging and expensive invasive procedures such as surgery or corticosteroid injections.
The formation of new interdisciplinary care teams as described above is an essential component to developing effective VBC models for spine-related disorders. Current pathways are highly fragmented, leading to poor accountability for quality and cost outcomes. Horizontal integration through the integration of new care teams and improvements in care coordination can address this fragmentation, enabling shared responsibility for clinical and financial outcomes. Potential benefits include expanding the bandwidth of primary care providers, better adherence to evidence-based guidelines, and shared accountability for downside financial risk while benefiting from shared savings.
Moving Beyond The Biomedical Model
One approach to reducing the costs of spine-related disorders aims to capitate payments associated with specific types of spinal surgeries. The Innovation Center has used alternate payment models such as the Transforming Episode Accountability Model (TEAM), where beginning in 2026, TEAM participants will receive a target price to cover all costs associated with surgery and 30 days following discharge for select surgeries, such as spinal fusions. A similar program, the Bundled Payments for Care Improvement Advanced (BPCI-A) Model, seeks to use bundled payments linked to specific quality measures beginning with an inpatient stay or outpatient procedure and 90 days post-discharge. Many spinal surgeries, which are included in either of these models, account for a considerable share of total expenditures for spine-related disorders and are critical to control escalating costs. While this effort takes us in the right direction, its narrow focus on surgical procedures ignores the need for expansion of first-line guideline-concordant care that can often prevent surgery altogether.
Such innovations may sound simple, but they are challenging to implement. For one thing, a definitive biomedical diagnosis for spine-related disorders can be elusive. As a result, the biopsychosocial model, which incorporates psychological and social domains into an overall treatment approach has been proposed as an alternative to the current narrowly focused approaches focused at biomedical diagnosis. Recently, it has been argued that even this more expansive perspective on low back pain does not go far enough. In answer to this dilemma, the Department of Veterans Affairs has developed an approach they call the Whole Health Model. Whole Health shifts the focus from treating specific symptoms to addressing the overall well-being of the patient. This model encourages health care providers to engage with patients holistically, asking not just “What is the matter with you?” but also “What matters to you?” Implementing value-based payment models that focus on what matters to patients is crucial for managing chronic conditions such as spine-related disorders, in which both neurological and psychological factors, lifestyle choices, and personal goals significantly influence treatment outcomes. By aligning care with the patient’s values, the Whole Health approach has demonstrated improved satisfaction and health outcomes, particularly in complex, chronic conditions.
CMS is uniquely positioned to adopt new innovations that prioritize a Whole Health approach for spine-related disorders. TEAM and BPCI-A models could be expanded to incorporate an overall framework of care that begins with the use of low-risk, evidence-based treatments such as spinal manipulation, physical therapy, acupuncture, and cognitive behavioral therapy. The patient care trajectory would only escalate to more intensive interventions, such as prescription medications, injections, or surgery when patients fail to respond to these conservative measures. Such arrangements hold the potential for participating health care systems to transition away from the traditional fee-for-service approach for spine-related disorders treatment, which incentivizes frequent and costly interventions. This change has the potential to yield considerable cost savings by reducing the overuse of high-cost, low-value interventions commonly seen for spine-related disorders, while prioritizing patient values within treatment approaches.
Prioritizing Equity And Parity
Spine-related disorders consistently rank among the top five health care expenses across public insurance, private insurance, and patient out-of-pocket spending in the US. Nearly everyone will experience spine pain at some point in their lives, with one in eight individuals suffering from chronic pain. Given the pervasive nature and substantial costs associated with spine-related disorders, it is essential that all patients, regardless of their insurance coverage, have access to evidence-based care within a value-based framework. Moreover, spine-related disorders disproportionately impact underserved populations, including those with limited access to care, lower socioeconomic status, and greater exposure to adverse social determinants of health (such as those with unstable housing or physically demanding jobs). Black patients report higher pain levels and worse physical health scores preoperatively and postoperatively compared to White patients, while disparities for Black patients have worsened over the past two decades, even as outcomes for Medicaid patients overall have improved. These trends highlight the urgent need for targeted, equity-focused interventions.
Incorporating care quality and health equity metrics within VBC arrangements through accountability for quality and equity measures within payment models represents not only a moral imperative but also a substantial economic opportunity. The concentration of costs and suboptimal outcomes in underserved populations underscores the potential return on investment when care management efforts prioritize these groups. Integrating social needs screening and addressing social drivers of health within care pathways can reduce disparities, improve outcomes, and lower expenditures. Recent CMS policies mandating social risk adjustment and screening reflect growing recognition of the financial and clinical value of population health strategies for musculoskeletal conditions. Tracking equity-focused metrics—such as outcomes stratified by race, socioeconomic status, and Area Deprivation Index—enables care teams to identify disparities and tailor interventions to patients’ specific needs. By prioritizing equity and adopting population health approaches, VBC models can deliver sustainable improvements in spine health, reduce unnecessary expenditures, and ensure that all patients receive high-quality, evidence-based care.
Achieving equity requires alignment among all payers (similar to that found within the Vermont All-Payer Accountable Care Organization Model), ensuring that hospitals and practice groups are able to participate in value-based models that operate independently of a patient’s insurance type. Such alignment would help reduce the current fragmentation in care delivery and eliminate redundancies, leading to more efficient and equitable treatment. Establishing a value-based model that treats spine-related disorders without discrimination based on insurance will result in significant improvements in health equity and outcomes for all patients suffering from painful spine conditions.
Build Data Infrastructure Capabilities For Supporting Value-Based Care Models
Existing data infrastructure needs improvements in scale to address current limitations to supporting innovations within value-based spine care. One industry leading approach, CMS’s Making Care Primary (MCP) Model, provides data to help primary care providers better identify high-performing specialists, improve care coordination, and hold specialists accountable for quality and costs. While CMS has begun making progress toward better supporting the integration of primary care providers and interventional specialists, there are still significant opportunities for improvements at supporting providers of non-invasive treatments prior to surgery to engage with patients on conservative approaches. The MCP Model, and its use of assessing patients’ health over time, could provide primary care providers with information on providers that deliver higher-quality care and create further opportunities for using high-value services and eventually, shared savings.
Registries are a critically important tool in the quest to advance VBC models for spine-related disorders because they provide a structured approach to collecting and analyzing patient data over time. Robust registries are able to identify effective strategies and best practices by capturing detailed information on patient demographics, treatment interventions, cost of care, and long-term results. The CMS Quality Payment Program has led the way on this issue, with other organizations following suit. For example, the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons have partnered to create the American Spine Registry, with the goal of enhancing care quality through continuous monitoring and feedback. At the more local level, Duke University Health System uses a low back pain registry to track use, outcomes, and cost of the more than 40,000 patients with low back pain they see each year. Implementing longitudinal quality metrics allows us to evaluate and compare the cost-effectiveness of multiple treatments over time, fostering accountability and evidence-based decision making for stakeholders developing VBC models.
Looking Ahead
The staggering combination of financial burden and poor patient outcomes associated with spine-related disorders underscore a critical need for systemic change in the US health care landscape. Current practices, heavily reliant on invasive procedures and opioid prescriptions, fail to deliver lasting relief and perpetuate a cycle of high costs and ineffective care. Transitioning to VBC models (such as BPCI-A, MCP, or TEAM) characterized by integrated intradisciplinary care teams and rethinking the biomedical model in lieu of a Whole Health approach holds the promise of reducing expenses and enhancing patient well-being. These strategies have the potential to reduce unnecessary expenditures, improve patient outcomes, and address disparities in care delivery.
Implementing these strategies will require a concerted effort among health care providers, payers, and policy makers to prioritize equitable access to evidence-based treatments. This is difficult but not impossible. Such a shift could pave the way for a more effective and compassionate approach to managing spine-related disorders, prioritizing patient preferences and overall health. By aligning incentives and fostering interdisciplinary collaboration, we can begin to close the gap between spending and outcomes, ultimately transforming the treatment landscape for tens of millions of people. The time for innovation is now; the health of our population depends on it.
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