Spine J. 2017 (Oct); 17 (10): 1570–1574 ~ FULL TEXT
Christine M Goertz, William B Weeks, Brian Justice, Scott Haldeman
Palmer Center for Chiropractic Research,
741 Brady St,
Davenport, IA 52803, USA;
The views made stated here are the viewpoints of the authors and not necessarily the institutions with which they are affiliated.
KEYWORDS: back pain; primary spine practitioner; health care workforce; spine care delivery; value
From the FULL TEXT Article:
Back and pain is the leading cause of disability in the world, with global prevalence and burden increasing with age.  In the US, the prevalence and costs of back pain treatment are high and increasing.  In 2010, US citizens who had low back pain lost an estimated 149 million days of work, costing businesses up to $200 billion in lost productivity.  In 2013, musculoskeletal conditions such as back pain were the most common Social Security Disability Insurance (SSD) program qualifying diagnoses, accounting for 30.5% of program participants that year and 40% of the growth in the SSDI enrollment since 1996.  That same year, 27.5 percent of the adult population reported low back pain in the prior three months.  Between 1996 and 2013, low back and neck pain were identified as the third most expensive disease category in the US, with direct costs of treatment estimated at $87.6 billion in 2013. 
The benefits of many widely used treatments for back pain, such as spinal fusions, epidurals, and opioids, are modest while potential harms are clear. [7–10] Further, back pain treatment is highly variable, [11–13] suggesting that systematization of treatment through development and application of guidelines would improve outcomes and reduce care costs. [14, 15]
The high costs, high prevalence, variable treatment, and variable outcomes of spine care create an opportunity to dramatically improve the goals of healthcare reform for the US population by reconfiguring how spine care is delivered. Efforts to improve spine care should focus on the use of effective, conservative, non-surgical options, [14–16] attempt to ameliorate anticipated primary care shortages,  enact effective and efficient evidence-based treatment recommendations (that address the fragmented and misdirected care, inappropriate incentives, and inefficient communication that add complexity to spine care treatment), [18–20] and measure and monitor outcomes. Such efforts also should attend to new reimbursement models  that require providers to engage patients more effectively, manage chronic diseases more efficiently and successfully, and demonstrate that their interventions produce value. [22–24]
We believe that changing how spine care is delivered can help achieve triple-aim goals of improved care, improved outcomes, and reduced costs.  Central to this process is the establishment and empowerment of a Primary Spine Practitioner (PSP) who can manage acute and chronic spine care and function within a patient centered medical home, an Accountable Care Organization, or independently (as a virtual member of such organizations). To demonstrate value, the PSP will need to coordinate care, communicate with other providers, collect critical data elements, and monitor healthcare resource utilization. Below, we outline a new model for spine care delivery that achieves these triple-aim goals, in part by answering the Institute of Medicine’s call to “retool” the existing workforce in anticipation of an aging America. 
The Primary Spine Practitioner Model
The PSP is central to the model (Figure). The PSP will coordinate and manage spine care, following evidence based clinical guidelines [27–30] and implementing shared decision making processes that ensure patient informed choice about treatment decisions. The PSP represents a new role for and a redeployment of existing, professionally trained spine care experts who can provide evidence based spine care processes and who are versed in a variety of conservative spine care treatments. By autonomously managing moderate back pain and coordinating the care of complex back pain patients, PSPs can effectively expand the primary care workforce, provide conservative healthcare techniques that promote better overall health, and improve healthcare value by concurrently improving spinal health outcomes and satisfaction while reducing spine-care related healthcare costs.
Patients with back pain who present to a healthcare system will be initially referred to the PSP. After urgent care needs are identified and triaged, a responsive baseline pain-specific measure (such as the numeric rating scale ), a comprehensive measure of health and functioning (such as the PROMIS 10, which has been recommended for research studies of low back pain ), and vital signs (including BMI) will be obtained. An important aspect of the initial evaluation will include an assessment of the patient’s health habits and beliefs, so that conservative approaches to spine care can be considered. Further, prior year patterns of care will be reviewed, so that new patterns of pain management can be suggested. Using this approach will allow for early prediction of case complexity  that can help identify patients who warrant increased intervention and avoid chronic care dependent states. Finally, costs and other outcomes of care should be captured so that efficient and effective methods of addressing back pain patients can be identified and incorporated into guideline development. 
Successful spine pain care requires a bio-psycho-social approach. [35–40] Therefore, critical team members needed to support the PSP include the primary care provider, specialty providers, dieticians, mental health care providers, and physiotherapists. Possibly, group therapy techniques could be used to gain efficiencies, motivate patients, and encourage self-care and mutual support. The PSP should manage and coordinate such care.
Anticipated impact of the model
We anticipate that the model will impact health systems that adopt it in two major ways.
First, value provided to spine pain patients will increase. Value is traditionally defined as quality (which includes patient satisfaction and health outcomes) divided by costs; the PSP model will increase the numerator and decrease the denominator. Patient outcomes and satisfaction will improve because these often challenging patients will obtain more focused, directed, and attentive care. By addressing the bio-psycho-social aspects of spine pain, application of the model should help stem the self-reinforcing interactions of stress, pain, and injury. Further, we anticipate overall per-capita costs will decline, largely through substitution of less expensive care that emphasizes patient activation and conservative care that offers alternatives to addictive medications, and is delivered by highly trained healthcare professionals whose personnel costs are more modest than those of primary and specialty care physicians.
Second, adoption of the PSP model will effectively expand the primary care provider workforce. Spine pain patients can be time consuming and challenging, particularly to primary care providers whose minimal training in spine care can produce discordant care.  The PSP model could relieve primary care providers of the need to dedicate excessive time to spine pain patients, thereby helping to establish a patient mix that is more consistent with primary care physicians’ training. Thus, adoption of the PSP model will effectuate improved efficiency of primary care providers, increase their ability to see other patients, and, potentially, increase primary care job satisfaction.
What is needed to enact the model
While new reimbursement models and concerns about unrestrained healthcare cost growth are colluding to drive efficient healthcare models, the success of the PSP model requires ensuring that the PSP workforce is prepared to do this work, identifying and testing spine care pathways, and continuously improving those care pathways.
Doctors of chiropractic, doctoral level physical therapists, doctors of osteopathy, and physiatrists are logical choices for the PSP role because they both have appropriate training in the differential diagnosis and treatment of musculoskeletal conditions and have the ability to rely upon conservative treatments. A recent national Gallup survey found that the large majority of US adults thought chiropractic care was safe and effective for back and neck pain.  However, given variation in the way spine care is delivered, [12, 13, 43, 44] steps to increase the consistency, uniformity, and quality of care provided by these practitioners are needed. Therefore, licensed providers who have adequate training to fill the PSP role should demonstrate that they are versed and successful in using conservative treatment strategies for back pain management by having graduated from a program that stresses such conservative management, potentially completing additional certification processes that demonstrate such expertise, or participating in ongoing evaluation of and feedback on back pain care management processes, as might be effected by use of a clinical data registry.
Such an EHR-linked registry could drive model development, implementation, and improvement in three ways. First, given the poor agreement about the specifics of best spine care pathways, a registry has the potential to define both the scope of patient care and the appropriate role of the PSP in the healthcare system, providing clarity for PSPs, patients, and other healthcare providers on their respective roles. Second, PSPs could use the registry to obtain feedback on their performance and, by benchmarking against peers, focus their quality improvement efforts and decreasing variation. Finally, payers, medical homes, and Accountable Care Organizations could use longitudinal measures of care, health, and costs that are collected through the registry to identify PSP’s who deliver high value spine care and to build narrow networks of them to provide spine care to their service populations.
Barriers to model adoption
Despite increasing federal pressures to contain healthcare costs and reimburse healthcare based on value creation,  three barriers to model adoption should be anticipated.
First, inconsistencies in treatment approach and quality of care exist among current practitioners. Registry based verification programs that we described should serve to mitigate this concern.
Second, both professionals who might serve in the PSP role  and those who currently treat back pain  may offer resistance. Indeed, while similar models have been proposed before, [48–50] lack of convergence around professional roles may have prevented their widespread adoption. Consensus building within professions  and collaboration across professions focused on determining methods to most effectively and efficiently provide spine care to patients may overcome such resistance.
Finally, although integration of complementary healthcare and conventional medicine has been explored internationally  and in the US, [53–56] training programs must incorporate inter-professional education into their curricula to maximize the effectiveness of the PSP role. 
Patient educational materials, similar to those that have been found to be effective at mitigating overuse of care in back pain [58–60] should be developed to help patients understand how best to access healthcare for back pain, and from whom to obtain it.
Spine care is an increasingly important aspect of worldwide healthcare delivery. The PSP model has the potential to dramatically improve the currently disorganized and costly process of spine care delivery, address concerns about accelerating growth of spine problems, and more efficiently use existing, highly-trained personnel in a way that indirectly expands the primary care workforce. While the model is no panacea, it holds the potential to address a tremendous need, increase efficiencies, and improve healthcare quality and outcomes of an important and expanding patient population.
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