Low Value Care Spending on Low Back Pain Is Decreasing

The healthcare industry is making strides in diminishing low value care spending for commercially-insured patients with chronic low back pain (LBP), according to a research letter published in JAMA Network Open.

“Many treatments for LBP are ineffective and potentially harmful,” the researchers explained. “Despite published guidelines, practice patterns have been slow to change.”

Reducing low-value care is key when pursuing a value-based care strategy. But conditions such as low back pain can produce damaging patterns of utilization of and spending on low value care. 

The researchers noted four areas of low value care in chronic low back pain treatment: spinal injections, surgery, opioids, and diagnostic imaging.

The research letter leveraged the HealthCore Integrated Research Environment data, pulling claims from 2011 to 2019.

Participants were deemed eligible for the study if they were commercially insured and had multiple claims related to lower back pain eight weeks apart or longer. Over 2.19 million patients were considered eligible for this research. 

The research letter analyzed the outcome utilization and cost of chronic lower back pain treatment. The researchers observed the patients—who were split into nine cohorts—for an entire year after the second date from when the individual qualified for chronic lower back pain.

Utilization in the four areas of low value care dropped over time after the second claim for chronic lower back pain, the researchers found.

“Trends in the use of potentially low-value services for LBP among commercially insured patients with LBP appear to be moving in a desirable direction,” the researchers shared.

Inpatient services declined from 12.4 percent utilization to 9.3 percent. This was the most significant drop among the low-value care services that the research letter analyzed. 

Still, the other decreases were notable. Surgery use declined from 4.5 percent to 3.3 percent. Opioid use dropped from 24.9 percent to 19.4 percent. 

Finally, imaging decreased from 73.6 percent to 59.9 percent. Since low-back pain imaging within six weeks of the initial pain is considered one of the top five most common low-value care services in the US, this decrease is a positive signal that the industry may be moving in the right direction.

Total per patient per month cost also trended downward over time. Overall, the per patient per month cost dropped from $1,216 to $1,101 and the cost of imaging per patient per month dropped by over $180, from $610 to $428. 

Other services dropped approximately $100 per patient per month or less. Inpatient costs decreased from $454 to $355. Spending on opioids fell from $12 per patient per month and surgery costs declined by $40, from $166 to $126 per patient per month.

Meanwhile, other services that the researchers studied saw increases in spending. 

Acupuncture saw the biggest change in spending, with patients spending 24.3 percent more on acupuncture per patient per month over the course of the research period. That being said, the amount of spending on this service remained low. 

Payers have lagged on covering acupuncture as a treatment, even though expanded coverage has been tied to expanded use. Acupuncture’s efficacy has been debated, but CMS gave the treatment a vote of confidence as a form of low back pain treatment by finalizing Medicare coverage for acupuncture in 2020 as an alternative to opioids.

Physical therapy was the other service that saw an overall increase in spending from 2011 through 2019. Spending increased by $6.22 per patient per month over the course of the research period, which amounted to a relative change of nearly nine percent.

The researchers noted a couple of potential limitations in the design of their work. For example, services could have been miscoded. Additionally, patients’ actual level of back pain is uncertain.

Nevertheless, they concluded that the evidence pointed to gradual progress in diminishing low value care spending among patients with chronic low back pain.