Acute Low-Back Pain Care Pathway:

A full-size rendering in PDF format is available here: Acute Low-Back Pain Care Pathway

For nearly four months, the Alliance’s Low-Back Pain Implementation Collaborative has worked with 30 participants representing an array of stakeholder groups, from employers, insurance plans, unions and labor trusts to physicians, other health care professionals, government agencies, and patient advocates to establish a clear guideline for treatment —the Acute Low-Back Pain Care Pathway.

The aim of this new standard of care is to limit unnecessary imaging, surgery and prescribing of opioids, which contributes directly to low-value care and represents substantial waste in the health care system. The most recent data shows that an estimated 140,000 low-value services were provided to Washington residents for low-back pain with a cost of about $10 million.

The Acute Low-Back Pain Care Pathway provides options at key decision points to support the delivery of high-value care, including:

  • Evaluating “red flags” for issues that indicate require immediate care,
  • Identifying “yellow flags” for patients who are at risk of long-term disability and work loss,
  • The range of self-management supports such as remaining active, locating chiropractic care, physical therapy, and primary care resources, and
  • Obtaining other high-value evidence-based care, for example, acupuncture, behavioral health, exercise, and medical massage.

Resources: 

As part of its ongoing effort to address the treatment of low-back pain, the Washington Health Alliance’s Low-Back Pain Implementation Collaborative has collected resources from its stakeholders that highlight efforts to address the issue. The materials below include webinars, patient handouts and member newsletters. The collaborative encourages individuals and organizations share these free materials.

Videos:

Articles and Handouts:

Acupuncture

Credential Definitions

License of Acupuncture (L.Ac.) –  Two academic years of science training followed by a minimum of 750 hours of Acupuncture and Eastern Medicine and passage of the national board exams given by the National Certification Commission for Acupuncture and Oriental Medicine.

Washington State’s requirements are here: License of Acupuncture (L.Ac.) and Eastern Medicine Practitioner (EMP) – WA State Department of Health

Medical Acupuncture (DABMA) – An additional certification in acupuncture available to licensed MDs or DOs, who already have had education and training in anatomy, physiology, neurology, and all the other basic and clinical sciences involved in medical diagnosis and treatment.

ACU Provider Directories

National Directory of Licensed Acupuncturists – National Certification Commission for Acupuncture and Oriental Medicine  (there are over 700 in Washington)

National Directory of Medical Acupuncturists – American Academy of Medical Acupuncture  (as of 2022, there are 6 in Washington)

Chiropractic

Chiropractic Provider Directory

Directory of Washington Chiropractors – Washington State Chiropractic Association

Physical Therapy

Physical Therapy Provider Directory

Directory of Washington Physical Therapists – American Physical Therapy Association Washington

Research Supporting the Use of Integrative Care for Low Back Pain

  1. Where to Start? A Two Stage Residual Inclusion Approach to Estimating Influence of the Initial Provider on Health Care Utilization and Costs for Low Back Pain in the US – BMC Health Sciences Research
  2. Active Rehabilitation for Work Related Low Back Conditions – Washington Department of Labor and Industries and Washington State Chiropractic Association
  3. Non Pharmacologic Pain Treatment, Report to the Washington State Legislature – Washington State Health Care Authority

Past Updates:

June 2022

Washington Health Alliance Director of Purchaser Strategies Denise Giambalvo and Director of Data Management and Analyst Mark Pregler co-presented “Driving Market Change through Multi-Stakeholder Collaboration” at the Civitas Networks for Health Member Roundtable Meeting on May 23rd.

They reported on the analysis conducted by the Alliance in the first phase of this work, Aligning to Drive Value, with a report for eight employer/purchasers on the amount of low-value that was delivered to their members and families compared to the state average from January 1, 2016 through June 30, 2019 using the Milliman MedInsight Health Waste Calculator™. The highlights include:

  • approximately 20% of individuals received at least one-low value service;
  • more than $320 million was spent on low-value care by the eight purchasers;
  • there was a higher rate of low-value care delivery, approximately 10% more each year, for the purchasers’ populations compared to the state average; and
  • one of the most common low-value services provided was the prescription of opiates for low-back pain.

Looking statewide on the issue of low-back pain, analysis using the Alliance’s voluntary All-Payer Claims Database, found that in 2020, more than 72,000 individuals in Washington state received low-value care, including more than 140,000 unnecessary services such as X-rays, MRIs and CT scans and the inappropriate prescribing of opioids, at a combined cost of approximately $10 million.

Since the kickoff of the second phase of this project, bringing together 30 stakeholder organizations to work together “to improve the value of care for all patients with low-back pain in Washington state” in February 2022, there have been convenings both large and small, surveys conducted to share progress across all of the stakeholder groups (health insurance plans, physicians, purchasers, and allies), and the development of a care pathway to support higher quality health care delivery across the state.

If you are interested in joining this exciting project, contact Alliance Director of Purchaser Strategies Denise Giambalvo. The Collaborative is supported by the Arnold Ventures’ Provider Payment Incentives Portfolio.

To see the presentation, click here.

 

May 2022

The Washington Health Alliance’s Low-Back Pain Implementation Collaborative (Collaborative) is continuing to make progress on its mission to “advance the market to improve the value of care for all patients with low-back pain in Washington state.” The Alliance appreciates the commitment of the Collaborative’s 30 participants across all stakeholder groups who are working together to make significant progress on this important initiative:

Aetna Proliance Surgeons
American Physical Therapy Association Regence BlueShield
Aon SEIU 775 Health Benefits Group
Association of Washington Cities Seattle Metropolitan Chamber of Commerce/Business Health Trust
Bloodworks Northwest Teamsters
City of Seattle The Boeing Company
Confluence Health UFCW 21
Davis Wright Tremaine UW Medicine
Dr. Robert Bree Collaborative Virginia Mason Franciscan Health
Kaiser Permanente Washington Washington Acupuncture and Eastern Medicine Association
King County Washington Health Benefit Exchange
MultiCare Health System Washington Optum Care
Point B Washington State Chiropractic Association
Port of Seattle Washington State Health Care Authority
Premera Blue Cross Washington State Department of Labor and Industries

 

In a recent survey, participants reported on the actions they are taking to reduce low-value and increase high-value care for patients with low-back pain.

Health plans reported:

  • Setting up telemedicine visits as a first stop for triage
  • Directing members to a 24-hour nurse line
  • Providing education to members on how to self-manage pain
  • Improving an on-line member portal
  • Providing more non-surgical care options
  • Implementing prior authorizations for advanced imaging and surgery

Health care providers reported:

  • Educating primary care providers about care center options
  • Instituting baselines to understand the prevalence of low-value care
  • Tracking calls to primary care clinics to find out how many result in an Emergency Department or Urgent Care visit
  • Referring patients to care options sooner
  • Reviewing, updating, and developing patient education materials
  • Considering how equity is reflected in care for those with low-back pain

Health care purchasers (employers and union trusts) reported:

  • Informing members on the difference between acute and emergent low-back pain
  • Considering bundled payment models to allow for more integrated services
  • Incentivizing the first point of contact to be with a primary care provider, rather than the Emergency Department
  • Promoting health coaching program options to members
  • Informing members with a history of chronic low-back pain of free treatment options
  • Tailoring benefit design to evidence-based treatment recommendations

Health care allies reported:

  • Building awareness of the problem of inconsistent treatment for low-back pain
  • Creating purchasing and payment standards that use consistent care quality metrics
  • Supporting the use of shared decision making including pain education, self-care, and effective triage
  • Working towards producing information videos and investing in educational tools for all stakeholders; health care consumers/patient, providers, purchasers, and plans

During its most recent meeting on April 26th, the group considered various opportunities and recommendations to improve the care delivered to people with low-back pain with the Collaborative’s advisors:

  • Dan Cherkin, PhD, Affiliate Professor in Family Medicine, University of Washington; Director of Research, Osher Center for Integrative Medicine; Emeritus Senior Scientific Investigator, KP Washington Health Research Institute;
  • Mark Fendrick, MD, Director, Center for Value-Based Insurance Design; Professor, Internal Medicine, School of Medicine and Professor, Health Management and Policy, School of Public Health, University of Michigan, is also a project advisor;
  • Andrew Friedman, MD, Section Head of Physician Medicine & Rehabilitation, Virginia Mason Medical Center; Chief of Physiatry, Virginia Mason Franciscan Health; Clinical Assistant Professor, Department of Rehabilitation, University of Washington; and Chair, Industrial Insurance Medical Advisory Committee, Department of Labor; and
  • Joshua Liao, MD, MSc, FACP, Associate Professor Medicine; Associate Chair for Health Systems, Department of Medicine; Adjunct Associate Professor, Health Systems and Population Health.

The Collaborative is supported by the Arnold Ventures’ Provider Payment Incentives Portfolio. Contact Alliance Director of Purchaser Strategies Denise Giambalvo for more information on the Collaborative.

 

April 2022

Progress on Working Together to Improve Low-Back Pain

As we continue with the Washington Health Alliance’s Low-Back Pain Implementation Collaborative, all of the stakeholders, purchasers, health plans, and health care professionals are identifying ways they can work together to improve the value of health care provided to all of those with low-back pain in Washington state.

As we have learned from our expert advisors, catching low-back pain within the first three months is critical to both alleviate unnecessary doctor visits and improve the likelihood that the patient’s symptoms can be appropriately treated.

Another important foundation to improve low-back care is education, both for providers and patients. Providers are more likely to get the best outcomes when they have the right tools to triage the patient and direct them down the right pathway. Patients also benefit from education because they can learn about care options and ways they can help themselves. In the case of low-back pain, long periods of bed rest can prevent recovery and there is truth to the saying, “motion is lotion.”

We are excited to be working on this important project, supported by Arnold Ventures’ Provider Payment Incentives portfolio, and look forward to sharing more news of our progress.

 

March 2022

It is estimated that 80% of Americans will have some form of back pain in their lifetime, but not all of them will receive high quality health care to address it. As early as 1985, studies showed the benefits of motion in the healing process and speculation that “help will come in the next decade from a collaborative effort from politicians, industrial leaders and engineers, physicians, psychologists, and biomechanicians.”

Several decades later, that still has not happened. “[B]arriers to optimal evidence-based management include widespread misconceptions of the general public and health professionals about the causes and prognosis of low-back pain and the effectiveness of different treatments, fragmented and outdated models of care, and the widespread use of ineffective and harmful care.”

According to Washington Health Alliance data, approximately 72,000 people with low-back pain received more than 140,000 low-value services an at estimated cost of nearly $10 million in 2020. In addition, a recent review of social determinants of health across 17 countries showed important associations between gender, race, ethnicity, education, occupation and socioeconomic status and low-back pain.

The Alliance’s Low-Back Pain Implementation Collaborative (Collaborative) is working to change that, with the official launch held last month. There are 29 participant organizations representing all stakeholders working together with the mission of “advancing the care for all patients with low-back pain in Washington state.”

A post-launch survey indicated that all participants in the Collaborative felt the orientation with advisors and breakout sessions was relevant to the needs of their organization and several indicated that they are looking forward to developing a plan in which each stakeholder understands their role in reducing medical waste and to supporting equity and reducing health disparities in the treatment of low-back pain.

The Collaborative is supported by the Arnold Ventures’ Provider Payment Incentives Portfolio. For more information on the Collaborative, please contact Alliance Director of Purchaser Strategies Denise Giambalvo.

 

February 2022

Low-Back Pain Implementation Collaborative (Low-Back PIC) Launches!

Working to improve the delivery of evidence-based care for low -back pain by all stakeholder groups, the second phase of the Washington Health Alliance’s Driving Value Project, the Low-Back Pain Implementation Collaborative (Collaborative), met as an all-stakeholder group for the first time on February 3rd. Committed to this project are 29 participants, with the majority from purchaser organizations, but also including commercial insurance plans, large provider groups, and several other important organizations, such as the Bree Collaborative, the Washington State Department of Labor and Industries, and the American Physical Therapy Association.

Alliance Executive Director Nancy Giunto said, “We are so appreciative of our partners on this project. It’s an exciting opportunity for us to not only make a significant difference to thousands of people across Washington state but potentially serve as a model for the nation and help millions.” As part of the Collaborative, there will be individual stakeholder meetings to address the unique issues facing health plans, providers, and purchasers. Priorities include:

  • benefit design changes to best support employee and members returning to function with optimal health outcomes for purchasers;
  • changes to contracts with provider groups to support the use of evidence-based care and patient awareness for plans; and
  • identifying evidence-based practices and supporting changes to workflows that support delivery of high-value care for providers.

During the kickoff meeting, the Alliance heard from:

  • Andrew Friedman, MD, Section Head of Physician Medicine & Rehabilitation, Virginia Mason Medical Center; Chief of Physiatry, Virginia Mason Franciscan Health; Clinical Assistant Professor, Department of Rehabilitation, University of Washington; and Chair, Industrial Insurance Medical Advisory Committee, Department of Labor.
  • Joshua Liao, MD, MSc, FACP, Associate Professor Medicine; Associate Chair for Health Systems, Department of Medicine; Adjunct Associate Professor, Health Systems and Population Health.
  • Mark Fendrick, MD, Director, Center for Value-Based Insurance Design; Professor, Internal Medicine, School of Medicine and Professor, Health Management and Policy, School of Public Health, University of Michigan, is also a project advisor.

If you are interested in making a difference in the quality of health care relating to low-back pain across Washington state, contact Alliance Director of Purchaser Strategies Denise Giambalvo.

This project is supported by Arnold Ventures’ Provider Payment Incentives portfolio.

 

October 2021

Join the Alliance’s Low-Back Pain Implementation Collaborative (Low-Back PIC)

The Washington Health Alliance is continuing its groundbreaking work to translate its data into actionable health care improvements and invites you to join the effort!

As you may recall, the Driving Value Project, made possible by initial support from Arnold Ventures, leveraged select measures from the Alliance’s reporting on high-value care in the Community Checkup and low-value care in First, Do No Harm to work with purchaser members to improve the value of care received by their 550,000 plan participants. You can download the whitepaper here.

Now, with additional support from Arnold Ventures’ Provider Payment Incentives portfolio, the Alliance is taking those lessons learned and expanding the work to include purchasers, plans, providers, and other health care stakeholders. Over the next year, we will work together to make measurable improvements by implementing patient and provider focused strategies that are underpinned by clinical evidence and aligned incentives.

If you are interested in participating or have questions about the Low-Back PIC, please contact Medical Director, Performance Measurement and Practice Transformation Sharon Eloranta.