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.1 In the US, the prevalence and costs of back pain treatment are high and increasing.2 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.3 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 1996.4 That same year, 27.5 percent of the adult population reported low back pain in the prior three months5. 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 2013.6
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,17 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 models21 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.25 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.26
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 guidelines27-30 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 scale31), a comprehensive measure of health and functioning (such as the PROMIS 10, which has been recommended for research studies of low back pain32), 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 complexity33 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.34
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.41 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.42 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,45 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 role46 and those who currently treat back pain 47 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 professions51 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 internationally52 and in the US,53-56 training programs must incorporate inter-professional education into their curricula to maximize the effectiveness of the PSP role.57 Patient educational materials, similar to those that have been found to be effective at mitigating overuse of care in back pain58-60 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.
Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases
and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
Martin BI. Deyo R. Mirza SK, et al.
Expenditures and Health Status Among Adults With Back and Neck Problems
JAMA 2008 (Feb 13); 299 (6): 656–664
Global Burden of Disease Study (2010).
Mortality Results 1970-2010.
US Social Security Administration.
Annual Statistical Report on the Social Security Disability Insurance Program, 2013. Tables 6 and 21.
2014. 13 (Accessed February 2, 2015,
Health, United States 2013.
Dieleman JL, Baral R, Birger M, Bui AL, Bulchis A, Chapin A, Hamavid H, Horst C, Johnson EK, Joseph J.
US Spending on Personal Health Care and Public Health, 1996-2013.
Deyo RA, Mirza SK, Turner JA, Martin BI.
Overtreating Chronic Back Pain: Time to Back Off?
J Am Board Fam Med. 2009 (Jan); 22 (1): 62–68
Fineberg SJ, Nandyala SV, Kurd MF, Marquez-Lara A, Noureldin M, Sankaranarayanan S.
Incidence and risk factors for postoperative ileus following anterior, posterior, and circumferential lumbar fusion.
Spine J 2014;14:1680-5.
Marquez-Lara A, Nandyala SV, Fineberg SJ, Singh K.
Cerebral vascular accidents after lumbar spine fusion.
Spine (Phila Pa 1976) 2014;39:673-7.
Martin BI, Mirza SK, Franklin GM, Lurie JD, MacKenzie TA, Deyo RA.
Hospital and surgeon variation in complications and repeat surgery following incident lumbar fusion
for common degenerative diagnoses.
Health Serv Res 2013;48:1-25.
Manchikanti L, Pampati V, Boswell MV, Smith HS, Hirsch JA.
Analysis of the growth of epidural injections and costs in the Medicare population:
a comparative evaluation of 1997, 2002, and 2006 data.
Pain Physician 2010;13:199-212.
Regional data on low back pain point to improvement potential.
Data Strategies & Benchmarks 1998;2:89-90.
Ivanova JI, Birnbaum HG, Schiller M, Kantor E, Johnstone BM, Swindle RW.
Real-world practice patterns, health-care utilization, and costs in patients with low back pain:
the long road to guideline-concordant care.
The Spine Journal 2011;11:622-32.
Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr., Shekelle P, Owens DK:
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491
Chou R, Qaseem A, Owens DK, Shekelle P,
Clinical Guidelines Committee of the American College of P.
Diagnostic imaging for low back pain: advice for high-value health care from the American College
[Erratum appears in Ann Intern Med. 2012 Jan 3;156(1 Pt 1):71],
[Summary for patients in Ann Intern Med. 2011 Feb 1;154(3):I36; PMID: 21282691].
Annals of Internal Medicine 2011;154:181-9.
Weiner DK, Kim YS, Bonino P, Wang T.
Low back pain in older adults: are we utilizing healthcare resources wisely?
Pain Medicine 2006;7:143-50.
Petterson SM, Liaw WR, Phillips RL, Jr., Rabin DL, Meyers DS, Bazemore AW.
Projecting US primary care physician workforce needs: 2010-2025.
Ann Fam Med 2012;10:503-9.
Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al.
Manipulation or Mobilisation For Neck Pain: A Cochrane Review
Manual Therapy 2010 (Aug); 15 (4): 315–333
Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW.
Spinal manipulative therapy for chronic low-back pain.
Cochrane Database Syst Rev 2011;2:CD008112.
Walker BF, French SD, Grant W, Green S.
Combined chiropractic interventions for low-back pain.
Cochrane Database Syst Rev 2011;14:CD005427.
Song Z, Lee TH.
The era of delivery system reform begins.
Wennberg JE, Fisher ES, Skinner JS, Bronner KK.
Extending the P4P agenda, part 2: how Medicare can reduce waste and improve the care of the chronically ill.
Health Affairs 2007;26:1575-85.
Wennberg JE, O'Connor AM, Collins ED, Weinstein JN.
Extending the P4P agenda, part 1: how Medicare can improve patient decision making and reduce unnecessary care.
Health Affairs 2007;26:1564-74.
Achieving health care cost containment through provider payment reform that engages patients and providers.
Health Affairs 2013;32:929-34.
Berwick DM, Nolan TW, Whittington J.
The triple aim: care, health, and cost.
Health Aff (Millwood) 2008;27:759-69.
Retooling for an Aging America: Building the Helath Care Workforce.
The Institute of Medicine. Washington, DC:
National Academies Press; 2008.
Qaseem, A, Wilt, TJ, McLean, RM, and 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
Globe, G, Farabaugh, RJ, Hawk, C et al.
Clinical Practice Guideline: Chiropractic Care for Low Back Pain
J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 1–22
DeLitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ.
Low Back Pain: Clinical practice guidelines linked to the International Classification of Functioning,
Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.
J Orthop Sports Phys Ther 2012;42:A1-A57.
American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment
(OMT) for Patients With Low Back Pain.
J Am Osteopath Assoc 2016;116:536-49.
Childs JD, Piva SR, Fritz JM.
Responsiveness of the numeric pain rating scale in patients with low back pain.
Spine (Phila Pa 1976) 2005;30:1331-4.
R.A. Deyo, S.F. Dworkin, D. Amtmann, G. Andersson, et al.,
Report of the NIH Task Force on Research Standards for Chronic Low Back Pain
Journal of Pain 2014 (Jun); 15 (6): 569–585
Barons MJ, Griffiths FE, Parsons N, Alba A, Thorogood M, Medley GF, Lamb SE.
Matching patients to an intervention for back pain: classifying patients using a latent class approach.
J Eval Clin Pract 2014;20:544-50.
Allen, H, Wright, M, Craig, T et al.
Tracking Low Back Problems in a Major Self-Insured Workforce:
Toward Improvement in the Patient's Journey
J Occup Environ Med. 2014 (Jun); 56 (6): 604-620
Boonstra AM, Reneman MF, Stewart RE, Post MW, Schiphorst Preuper HR.
Life satisfaction in patients with chronic musculoskeletal pain and its predictors.
Quality of Life Research 2013;22:93-101.
Brown CA, Jones AK.
Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a
mindfulness-based pain management program.
Clinical Journal of Pain 2013;29:233-44.
Dersh J, Polatin PB, Gatchel RJ.
Chronic pain and psychopathology: research findings and theoretical considerations.
Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J.
Influence of context effects on health outcomes: a systematic review
Psychological disorders and chronic pain: cause and effect relationships.
In: Gatchel RJ, Turk DC, eds. Psychological approaches to pain management: a practioner's handbook.
New York: Guilford Publications; 1996:pp 33-54.
Penny KI, Purves AM, Smith BH, Chambers WA, Smith WC.
Relationship between the chronic pain grade and measures of physical, social and psychological well-being.
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.
Weeks WB, Goertz CM, Meeker WC, Marchiori DM.
Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination
of Variation According o Respondents' Likelihood to Use Chiropractic, Experience With
Chiropractic, and Chiropractic Supply in Local Health Care Markets
J Manipulative Physiol Ther. 2015 (Oct); 38 (8): 533–544
Whedon JM, Song Y.
Geographic variations in availability and use of chiropractic under Medicare.
J Manipulative Physiol Ther 2012;35:101-9.
Hoy D, Brooks P, Blyth F, Buchbinder R.
The Epidemiology of low back pain.
Best Practice & Research in Clinical Rheumatology 2010;24:769-81.
Setting value-based payment goals - HHS efforts to improve US health care.
Triano JJ, Goertz C, Weeks J, Murphy DR, Kranz KC, McClelland GC, Kopansky-Giles D.
Chiropractic in North America: toward a strategic plan for professional renewal--
outcomes from the 2006 Chiropractic Strategic Planning Conference.
J Manipulative Physiol Ther 2010;33:395-405.
Murphy, D., Schneider, M., Seaman, D., Perle, S., & Nelson, C. (2008).
How Can Chiropractic Become a Respected Mainstream Profession? The Example of Podiatry
Chiropractic & Osteopathy 2008 (Aug 29); 16: 10
Snow GJ, Torda P.
Back Pain Recognition Program: an opportunity to improve quality assurance; integrate best practices;
and deliver high-quality, patient-centered care.
J Manipulative Physiol Ther 2009;32:173-6.
Kwon B, Tromanhauser SG, Banco RJ.
The spine service line: optimizing patient-centered spine care.
Spine (Phila Pa 1976) 2007;32:S44-8.
Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ.
The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform
in the United States
Chiropractic & Manual Therapies 2011 (Jul 21); 19 (1): 17
Nelson, C., Lawrence, D., Triano, J., Bronfort, G., Perle, S., Metz, R. D., et al. (2005).
Chiropractic As Spine Care: A Model For The Profession
Chiropractic & Osteopathy 2005 (Jul 6); 13: 9
Haldeman S, Nordin M, Outerbridge G, Hurwitz EL, Hondras M, Brady O, Kopansky-Giles D.
Creating a sustainable model of spine care in underserved communities: the World Spine Care (WSC) charity.
Spine J 2015.
Cohen E, Cambron J, Shiel R.
Measuring the development of integrative care communication patterns and cross-disciplinary knowledge
at a university clinic: a baseline cross-sectional study.
J Manipulative Physiol Ther 2009;32:758-64.
Dunn AS, Green BN, Gilford S.
An Analysis of the Integration of Chiropractic Services Within the United States Military
and Veterans' Health Care Systems
J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 749–757
Lewis D, Paterson M, Beckerman S, Sandilands C.
Attitudes toward integration of complementary and alternative medicine with hospital-based care.
J Altern Complement Med 2001;7:681-8.
Pasternak DP, Lehman JJ, Smith HL, Piland NF.
Can medicine and chiropractic practice side-by-side? Implications for healthcare delivery.
Hosp Top 1999;77:8-17.
Ebrall P, Draper B, Repka A.
Towards a 21 century paradigm of chiropractic: stage 1, redesigning clinical learning.
J Chiropr Educ 2008;22:152-60.
Little P, Roberts L, Blowers H, Garwood J, Cantrell T, Langridge J, Chapman J.
Should we give detailed advice and information booklets to patients with back pain?
A randomized controlled factorial trial of a self-management booklet and doctor advice
to take exercise for back pain.
Spine (Phila Pa 1976) 2001;26:2065-72.
Burton AK, Waddell G, Tillotson KM, Summerton N.
Information and advice to patients with back pain can have a positive effect. A randomized controlled trial
of a novel educational booklet in primary care.
Spine (Phila Pa 1976) 1999;24:2484-91.
Cherkin DC, Deyo RA, Battie M, Street J, Barlow W.
A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet
for the Treatment of Patients with Low Back Pain
New England Journal of Medicine 1998 (Oct8); 339(15): 1021-1029.
Return to the CHIROPRACTIC IDENTITY Page
Return to the SPINAL HEALTH CARE EXPERTS Page