Insurer Sees Improved Treatment for Low Back Pain

Efforts to rein in procedures unlikely to benefit patients with low back pain may be paying off at last, according to a study by Anthem, Inc., the multistate Blue Cross Blue Shield affiliate.

Expenditures for procedures designated as “potentially low value,” such as extensive imaging and surgery, declined significantly among some 2.2 million patients with diagnoses of low back pain from 2011 to 2019, reported Timothy Pham, PhD, of Anthem’s research unit in Wilmington, Delaware, and colleagues in a JAMA Network Open research letter.

Overall costs per patient per month (PPPM) for back pain patients in Anthem’s HealthCore Integrated Research Environment database fell from $1,216 in 2011 to $1,101 in 2019 after adjustment for inflation (P<0.001).

Costs associated with inpatient procedures declined similarly, from $454 to $355 PPPM (P<0.001).

Most of the decrease in dollar terms was driven by reductions in “liberal” use of imaging. At the beginning of the study period, costs PPPM for this category stood at $610 in constant (2018) dollars, accounting for half of all medical expenditures in these patients. By 2019, the figure had fallen by 30%, to $428 PPPM. (Pham and colleagues did not say how they defined “liberal,” but the average monthly per-patient spending does suggest that imaging was performed commonly and extensively.)

In percentage terms, by far the biggest drop was for opioid scripts, costs for which fell by nearly 90% during the study period, reflecting broader trends and attitudes toward opioids across all of medicine.

But total spending on opioids was a drop in the bucket compared with other types of treatment, with PPPM expenses of just $12 in 2011 and $2 in 2019. In contrast, costs for epidural injections averaged about $40 (changing little over the study period) and mean expenses for surgery ranged from $126 to $166.

One category of procedure gained popularity over time. Expenses for physical therapy increased from $70 to $76 PPPM during the study period.

Looking at the bigger picture, Pham and colleagues characterized their findings as demonstrating “a clinical meaningful decrease in use of potentially low value services” for low back pain — which, they noted, is (along with neck pain) the third most expensive condition in the U.S., after diabetes and heart disease. Back pain was also among the first conditions cited in the so-called Choosing Wisely campaign, which debuted 10 years ago, as rife with overtreatment. Pham and colleagues observed that the campaign didn’t have an immediate impact, citing a 2015 study indicating that practice patterns in management of back pain had changed little.

Now, it appears, Choosing Wisely may be paying off.

But not necessarily. The study came with a number of obvious limitations, including that the cost data were for allowed claims, over which Anthem kept ultimate control, and thus the observed trends may have reflected its own policies as much as (if not more than) prescriber behavior. It’s unclear whether the trends can be generalized to other insurers or patient populations. Also, the extent to which utilization was genuinely necessary, and therefore not a “low value service,” could not be determined. And as with any study relying on administrative data, miscoding and other defects remain possible.

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    John Gever was Managing Editor from 2014 to 2021; he is now a regular contributor.

Disclosures

The study was funded by health insurer Anthem and all authors were its employees.