This article is more than 5 years old. Information may no longer be current.
Standardized levels of care for back pain: New program targets physician behavior
|
The questions being raised include: Are there financial incentives influencing the ordering of some of these studies and procedures? Might some physicians who own scanners, MRIs and procedural facilities overutilize them? In other words, can doctors be trusted to do the right thing?
Insurers and Medicare believe they need to step in to control maximum health benefits for back pain and lower costs at the same time. They want to standardize quality care by limiting choice and reducing individual physician discretion.
New back pain ‘test’
The payers have chosen back pain as a test area to see if financial incentives and public education can modify physician behavior more rapidly than other current means. The new approach will involve paying physicians a bonus if they change their behavior based on guidelines of care for low back pain. The types of back pain programs now being introduced will resemble those used in standardizing care for diabetes and heart disease.
Already, the National Committee for Quality Assurance (NCQA) has a new program to encourage a more standardized level of care for patients with low back pain. To qualify for financial incentives, physicians must document their treatment in detail and collect considerably more data than under traditional requirements. This will include performing a mental health assessment, counseling for smoking cessation, reporting on patient education and discussing treatment options.
Protocols and protection
Additional payments will go to physicians who follow guidelines for exercise, stretching and avoiding bed rest. Proponents contend that having this back pain treatment protocol in place will give physicians a legal basis for treatment decisions while offering a government-approved protocol that makes it easier, when appropriate, to deny drugs, immediate testing and injections. It would help doctors resist pressure to do more studies and procedures sooner.
|
Added reimbursements for participating physicians — the carrot — will often require collecting more data, documenting time spent with patient education, and assessing and documenting mental status and any secondary gain factors. Fees would depend on the percentage of patients who do not receive tests outside of the guidelines (eg, epidural injections in those without radiating leg pain). Given that the goal of this program is to reduce costs, standardize medical care and ensure “the best practice,” supporters say it should reduce the number of epidural steroid injections, significantly reduce the number of X-rays, CT scans and MRIs, and may reduce the overall numbers of surgeries — including those involving fusions and instrumentation.
To participate in the new Back Pain Recognition Program (BPRP), surgeons must submit an application. One added incentive (beyond the modest financial enticements): special recognition for those selected — their name and location is to be listed on the NCQA’s Web site.
For busy orthopedic surgeons, I see this program adding another layer to the burden of increased data collection and reporting, with an associated increase in overhead and impact on office patient flow. Still, everyone must decide individually on the value of the increased reimbursement vs. added costs and whether they want to participate.
Delaying the inevitable
It appears that overall reimbursement from government programs will continue to reduce and these latest financial incentives will simply slow the rate of decrease for a time.
We all support the concept of evidence-based medicine and I should hope we would follow science-based guidelines without coercion. It is interesting that officials are now developing programs of financial incentives to change behavior patterns they feel connect to financial incentives.
I personally feel overwhelmed at times in clinical practice with all the required documentation and authorization requests, the need to respond to denials, the forms to fill out and the data collection already required. We must watch this approach of offering incentives to physicians to help reduce health care costs, change questionable practices patterns and standardize care with guidelines as it develops, just as I have argued that we must monitor the data interpretation of the new studies that will be used to determine treatment and reimbursement options (see Orthopedics Today, October).
The alternative current approach is simply to deny reimbursement for these tests and procedures. It appears payers will use both approaches in the years ahead.
For more information:
- See the National Committee for Quality Assurance (NCQA) Web site: http://web.ncqa.org/tabid/137/Default.aspx