Excellus Blue Cross Blue Shield has started an innovative program working with providers in New York to develop a community model of spine care for patients suffering from spine-related disorders.
"Right now the patient as a consumer has dozens of choices related to spine care and we see tremendous variation in the manner in which that care is delivered," says Brian Justice, DC, Associate Medical Director, Pathway Development and Spine Care, Excellus Blue Cross Blue Shield in Rochester, N.Y. "It's hard from the payer's perspective to measure quality with all this variation. We are working to find a cadre of practitioners who can agree on common pathways and then measure value-driven data."
Dr. Justice discusses the program and his vision for developing new models for spine care.
Q: What are the goals of your spine program? Do you think you'll be able to meet them with this innovative approach?
Dr. Brian Justice: We are really trying hard to bring the clinical care community together. As with many service lines, we find 'silos of care' with little interaction or discussion between the silos. The basis of our spine pathway came out of work done by a team of my colleagues and was first implemented in Massachusetts. We put together a hospital-based spine care pathway and published the data on our outcomes and ability to reduce costs.
The hospital administrators liked the program so much, and it was so well received in the community, that they suggested we market it around the country. My colleagues formed Spine Care Partners, LLC (www.spinecarepartners.com) and are implementing the program in several different cities.
I brought the program back to Excellus Blue Cross Blue Shield and my hometown in upstate New York. We wanted to see what types of efficiencies we could bring to spine care by focusing on evidence-based, patient active care on the front end, and then implement the program more broadly into an entire community. One of the challenges we have is the variation of care delivered to spine patients. We see significant variation in all spine services, whether it's a PCP, chiropractor, PT, pain interventionist or surgeon.
Additionally, whomever the patient sees first has a significant impact on the direction and extent of subsequent care.
Reducing variation is challenging, but if we can manage it, we can expect higher patient satisfaction, better clinical outcomes and decreased cost.
Q: What have you learned from your efforts so far?
BJ: We are learning that the first practitioner that interacts with the patient is critically important. There is a strong need in spine care for patients to actively engage in their recovery because that highly impacts outcomes. For example, if the language practitioners use is fear evoking, it can prompt the patient to a more aggressive course of care. If the language and clinical choices used by practitioners enhances a sense of patient control of their episode, outcomes are often better.
With a focus on a continuum of care pathway, our goal is to put more clinically appropriate patients in the waiting room of the specialist, as patients have been pre-screened with a consistent and evidence-based approach. We encourage community spine providers to receive training in the spine care pathway so they can consistently treat, triage and manage the vast majority of spine pain patients.
Out spine care pathway is designed to get the right patient to the right provider at the right time. In the current system, we are sometimes getting patients to the surgeons' office too late and other times they don't need to be there at all. This is true with all the spine providers. We are working toward 'right timing and right sizing' care by looking at the person as a whole. Along these lines, we are putting emphasis on biopsychosocial screening and contextualizing these findings into the entire clinical encounter.
Q: The biopsychosocial components of spine and back pain patients are often left out of treatment today. How do you think addressing these issues could make a difference?
BJ: The attitudes and beliefs patients bring into their treatment, along with comorbidities and perpetuating factors, are often the key triggers of what turns an acute episode into a chronic condition. We are looking for these indicators early in the case presentation, shifting resources and addressing some of these early complexities.
By doing this we are better able to treat and triage patients going through the system. We suspect we can impact patients' pain experience after addressing discovered psychosocial barriers and ultimately prevent some cases from becoming chronic.
Q: What benefits do spine surgeons and specialists see from incorporating this model into their community?
BJ: We engage specialists early in our pilot and they have enjoyed a higher yield of patients who clearly need their services. I can appreciate that some spine surgeons want to see the full spectrum of spine pain patients, but it doesn't make sense to have the surgeon triage all patients. Sometimes spine patients can be efficiently treated by showing them self-care measures, following up with a visit and discharging them. Of course, some patients need to hear from a surgeon that they are not surgical candidates and our model takes this into consideration.
Q: Do the specialists and hospitals in the area support your efforts? What do they think about this model for managing patient care?
BJ: We've had a lot of positive comments from providers and hospitals within our community. The hospitals have been very supportive and philosophically, most are on board. Most see the utility of this type of program. As risk sharing and bundling models become more common, the program's acceptance will likely grow. We are planning a community-wide roll out, addressing the impact of spine costs on patients, health systems, government and the community as a whole.
When it comes to a wide spectrum culture change, you have to start at the community level with education. We are also inviting employer groups to discuss the huge burden of indirect costs of spine issues, as well as the importance of patient-active care and avoidance of fear-based language.
We are hoping to get the local community centers, faith institutions, YMCAs and health clubs involved to share the importance of regular exercise, mindfulness and to reinforce that patients can take control of their conditions. We are looking to make self-directed spine care more affordable and accessible.
Spine pain has an almost 100 percent lifetime prevalence rate. What we want to do is educate individuals to self-triage so they know whether they need to go to the emergency room or manage the pain at home or should they see a healthcare provider….and who would be the best first practitioner for them to see?
Q: In your opinion, how is shared risk for back pain evolving? What do you think is important for providers to know?
BJ: We have the advantage of looking at the piloted program in Massachusetts, which is ahead of the curve nationwide with ACOs and patient-centered medical homes for shared risk modeling. Our spine care model is well received there because it unburdens the primary care physician and meets the triple aim of CMS: better care, better outcomes and lower costs.
From a surgical perspective, the surgeons in Massachusetts are engaged in risk-sharing models and actively involved with a program that doesn't solely incentivize surgery. They are looking for the best way to manage patients from a population perspective. I'm excited about that model because they are emphasizing the idea of community and shared decision-making to create an optimal pathway for patients. Providers need to be part of a spine team with low cost, regionally dispersed offices at the conservative end, as well as regional quality-driven centers of excellence for interventions and surgeries. All need to be focused on value. All need to communicate with each other and with patients in a common language.
Sometimes we are not getting patients to the surgeon/specialist quickly enough and other times patients are seeing surgeons and other specialists when they don't need to. We have put a classification system into our pathway to help providers and patients parse which practitioner a patient needs to see. This has a positive impact on outcomes.
Q: Do you think this model could be adapted to other communities around the country?
BJ: This model is a unique approach to care delivery and certainly could be modeled not only in other communities around the country but also in other service lines of healthcare. Our model includes prevention and wellness initiatives, which many communities already have started to some degree.
We are encouraging thought leaders in our community to participate in the evolution of the conservative spine care pathway and to expand into interventional and surgical care as well. We continually ask the question: "Is there a simpler way?" Given equal levels of evidence, we choose the approaches with less inherit complexity, fostering less clinical variation and better outcomes. The relative simplicity of the program enhances its likelihood of being reproduced.
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