By Mary O’Donoghue, Chief Clinical and Product Officer, MedRisk
Low back pain sends more patients to the doctor than most other ailments and is the leading cause of workplace disability. It accounts for $100 billion annually in health care costs, with approximately two-thirds of the costs coming from lost wages and lost productivity. Plus, both the incidence and severity of the low back pain cases appear to be on the rise.
Key cost drivers include early magnetic resonance imaging (MRI). A Liberty of Mutual Research Institute for Safety study published in Spine examined 3,000 workers’ compensation claims and found that when MRIs were performed either within the first 30 days of the onset of pain or when no specific medical condition justified the MRI, the claims had significantly higher medical costs. These costs were $12,000 higher, according to an earlier Liberty Mutual study of a smaller sample of the same claims. These claims were 17 to nearly 55 times more likely to have electromyography, nerve conduction testing, injections, additional advanced imaging, and/or surgery. In addition, these injured employees were three times more likely to remain on disability than those who didn’t receive an MRI.
MRIs can trigger catastrophizing and other psychosocial issues, making patients feel they must really be in bad shape if the doctor ordered an MRI. Except for cases of severe trauma, infection or cancer, evidence-based guidelines for low back pain treatment suggest a month trial of conservative treatment before considering the MRI.
The MRI’s link to surgery is particularly concerning, because spinal surgery is notoriously unreliable. More than half of the workers who received lumbar fusion through the state of Washington’s work comp program felt that neither their pain nor functional recovery had improved after lumbar fusion. Some said they were worse off.
The Ohio Bureau of Workers Compensation recently published a rule requiring that injured workers first receive 60 days of conservative care before surgery will be considered. The rule was based on several studies of BWC data that found that fusion patients had much worse outcomes than non-fusion patients. Opioid dependence, increased disability and high rates of failed back syndrome as well as additional surgeries and new psychiatric problems were among the negative outcomes.
So, what is conservative care? Physical therapy, chiropractic care, and lifestyle changes such as weight loss and exercises to strengthen the core and back muscles and increase mobilization of the spine fall under this category. Passive therapies such as ice packs, heat packs and ultrasounds can also reduce pain temporarily.
Physical therapy may be especially promising. A Military Health System study showed that low back pain patients who received early and guideline-adherent physical therapy were less likely to receive advanced imaging, spinal injections or lumbar spine surgery. Early was defined as within 14 days of diagnosis. Treatment costs for patients receiving appropriate physical therapy were 60 percent lower than for patients not receiving early physical therapy.
More importantly, early physical therapy appears to promote a more rapid return to function and it reduces disability following an episode of low back pain, according to the results of a 2015 clinical trial published in the Journal of the American Medical Association.
Current research shows that patient education plays a strong role in achieving positive outcomes and reducing treatment costs for low back pain. A 2014 study published in the Journal of Bone and Joint Surgery found that just one or two physical therapy sessions prior to surgery resulted in an estimated 29 percent reduction in postoperative care. Researchers attributed the reduction to the instruction patients received on what to expect from the procedure and recovery process, rather than physical benefits of the therapy since those would require multiple, intensive sessions.
Not only does patient education improve surgical outcomes, but it can also increase the patient’s sense of well-being, according to a Gallup analysis. Researchers asked patients to rate their levels of agreement with the following statements: “I knew what to expect after surgery,” “I was prepared for my experience post-surgery,” and “I followed post-surgery instructions, such as rehabilitation or medication.” When patients agreed with just one of these statements, 46 percent were extremely satisfied with the results; when they agreed with all three, 71 percent were extremely satisfied with their results. This group also had fewer readmissions, indicating faster, smoother recoveries and potentially a lower overall cost-per-patient.
Patient education an easy, inexpensive way to impact physical and financial outcomes on low back pain cases. Education can take the form of fact sheets and other written materials, videos and one-on-one conversations. Telerehabilitation technology even makes it possible to demonstrate, monitor, and correct physical therapy exercises in real time to ensure patients perform them correctly.
Payers and their partners that reach out to express empathy and help schedule appointments convey that someone cares and will help them navigate the complicated workers’ compensation system to receive the best care. Providing complete and accurate information about injuries, treatment and recovery helps instill confidence and allay fears.
Now that we know psychosocial factors can cause low back pain to become chronic, education becomes especially important. For example, providers can avoid triggering fear avoidance and disability beliefs by framing conversations in terms of progress, e.g., “What can you do now that you couldn’t do last time we talked?” They can also stop asking patients to rate their pain on a 1-10 scale, which is highly subjective and can trigger fear of pain, a prognostic factor in chronic pain, according to the Australian Spinal Research Foundation. When reviewing MRIs, for example, providers can avoid terms like “bulging discs” or “bone on bone,” which can prompt catastrophizing. Instead, they can explain that MRIs often detect age-related changes that do not necessarily indicate a need for treatment.
Instead of stressing return to work, focus on what the injured person is likely worrying about and what they would like to accomplish. For example, providers can explain how a set of exercises will enable person to do something they really want to do, whether it’s gardening, playing with their children, jogging, or shopping.
According to the Integrated Benefits Institute, employees with positive expectations about their recovery from acute back pain have shorter work absences than workers with negative expectations. Conservative care, combined with communication and thorough patient education, go a long way toward setting those positive expectations.
About Mary O’Donoghue
Mary O’Donoghue is responsible for MedRisk’s new product and business line development as well as strategic leadership of all clinical programs and research. A dynamic industry expert, Ms. O’Donoghue joined MedRisk with over 30 years of experience in the managed care, group health, disability and workers’ compensation industries having held senior leadership positions in strategic planning, operations management and product development with top carriers, third party administrators and managed care organizations. A Registered Nurse by trade, Mary O’Donoghue brings a strong clinical background and extensive industry experience to the MedRisk team.
Based in King of Prussia, Pa., MedRisk is the leader in physical rehabilitation solutions for the workers’ compensation industry. The company’s programs deliver savings and operational efficiencies that are significantly greater than traditional programs. MedRisk, which has successfully completed a SSAE 16 Type II examination, ensures high quality care and delivers outstanding customer service. To that end, all customer service professionals, healthcare advocates and physical therapists are based in the U.S. Customers include insurance carriers, self-insured employers, third-party administrators, state funds, and case management companies. For more information, visit www.medrisknet.com or call