Insurers Are Finally Figuring It Out

A preprint of a retrospective cohort study involving 600,000-plus patients has been released by a research team affiliated with UnitedHealth Group and Optum. The study examines the impact health care provider (HCP) type has on episode cost and use of high- and low-value services for low back pain.¹

Low-value services include diagnostic imaging, opioids, spinal injections and surgery. High-value services include non-invasive and non-drug care – including chiropractic. The authors note that "mismanagement of LBP has been estimated to be a source of almost half (46%) of low-value spending in US health care." They also note that "early exposure to non-guideline concordant care increases the risk of LBP transitioning from an acute to a chronic condition," as was demonstrated in a study published last year. Doctors of chiropractic have the highest percentage of clinical-guideline concordance at 70.2 percent.^2-5

The study evaluated the rate and timing of 14 types of services, segmented into first-, second- and third-line categories based on American College of Physicians' LBP clinical practice guidelines. LBP episodes were divided into pooled and nonsurgical samples.

Chiropractic manipulation was the most frequently provided type of first-line care (33.5 percent), followed by active care (19.3 percent) and passive therapy (15.4 percent). Radiographs were the most frequently provided second-line care (25.6 percent), followed by NSAID prescriptions (23.1 percent). Third-line care included opioids (16.2 percent), spinal injections (6.7 percent) and surgery (3.1 percent).

"Non-prescribing HCPs emphasize guideline recommended first-line services, with DCs having the lowest total episode cost of any HCP for both pooled and nonsurgical samples. Specialist HCPs were associated with frequent use of low-value services, and high total episode cost. These findings were consistent for individuals experiencing single or multiple episodes during the study period."

The authors concluded: "Systemic changes across the health care delivery system should be considered to increase the likelihood of individuals seeking and receiving guideline-concordant, high-value care for LBP. In the absence of red flags this may include increasing the proportion of LBP episodes initially contacting a non-prescribing HCP and increasing primary care and specialist referrals for non-pharmacological treatment before introducing second- and third-line services."

This study is yet another demonstration of the importance of starting LPB care with a doctor of chiropractic. Medical care usually doesn't begin with first-line services and rarely includes chiropractic care, which is the lowest-cost first-line service. When medical care does include first-line services, they are in addition to second- and third-line services. Medical providers are again encouraged to consider chiropractic care as the first choice for LBP.

Editor's Note: As of press time, this study is pending peer review; thus, it should not yet be used to guide clinical practice. The paper includes a Care Pathways supplement with extensive tables and graphs, making it great to send to other providers and decision-makers.

References

1. Elton D, Kosloff TM, Zhang M, et al. Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study. medRxiv, 2022.06.17.22276443. Read here
2. "The Road That Leads to Chronic Low Back Pain." Dynamic Chiropractic, April 2021.
3. Werber A, Schiltenwolf M. Treatment of lower back pain - the gap between guideline-based treatment and medical care reality. Healthcare, 2016;4:44.
4. Stevans JM, Delitto A, Khoja SS, et al. Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Netw Open, 2021;4(2):e2037371.
5. Amorin-Woods LG, Beck RW, Parkin-Smith GF, et al. Adherence to clinical practice guidelines among three primary contact professions: a best evidence synthesis of the literature for the management of acute and subacute low back pain. J Can Chiropr Assoc, 2014 Sep;58(3):220-37.