The Low Back Pain Paradox: Part III

In Parts I and II of this series, we took a little journey into the world of low back pain. As you look at the signs along the road, you come to realize that the low back pain paradox is reflective of the greater woes of the health care system as a whole. As I mentioned in Part I - as goes low back pain, so goes health care.

Solutions, however, oftentimes look more like a quilt of short-term patches more so than real systemic and cultural change. A little of this, a little of that, but no guiding foundational principles.

With that in mind, let's begin with one of the most important principles: the patient must be at the center of the equation. Solutions lie in the phrase "patient-centered care", not in political agendas or turf wars. If we then use science-based clinical guidelines as a framework for the low back pain paradox, then we stand to create a culture of patient-centered solutions. So what does this framework look like?

Here are 9 key elements that need to be a part of the solution to the low back pain paradox:

1. The Right To Choose: If there was ever an example of a reason to broaden patient access to care, it is low back pain. We need to promote a patient's right to choose their provider. Here's a novel thought: allow patients to make the decision regarding who they choose to see for evaluation and treatment of their low back pain. Our legislative system has the capacity to remove arbitrary laws that limit patient access to care. That would, in effect, make legislation evidence-based - a good start to an effective long-term solution.

2. Competition: Once patients have the right to choose freely amongst a variety of providers, we will see a degree of self-regulation within the health care system. Patients will seek those clinicians that can help them attain an outcome. Those clinicians who provide value to a patient will be successful, and those that don't, won't. Is competition a bad thing? Rarely. The marketplace will regulate itself much like other industries and professions.

3. Clinical Reality Check: Most cases of low back pain are non-specific in nature and have no specific patho-anatomical diagnosis, and this is the context in which low back pain needs to be viewed. Keep in mind that 97% of patients will present with mechanical low back pain. Utilize low-cost history and physical examination strategies to make clinical decisions regarding the low back pain patient's clinical pathways. Many clinicians are currently qualified to do so - so let's educate patients and let them choose.

4. Clinician Accountability: Clinicians must be accountable for the assessment strategies and treatment interventions they use. Patients are seeking an outcome, and clinicians should be more accountable to patients on this level. Non-evidence-based clinical practice is not only a cost issue, it is an ethics issue as well.

5. Reimbursement For Evidence-Based Care: Clinical guidelines could (and should) be used as a guide to reimbursement. Clinicians should not be reimbursed "just because they did something to the patient". If you don't reimburse for non-evidence-based assessment and treatment interventions, then you will find a dramatic decrease in utilization. You still want to utilize non-evidence-based strategies? That's fine - just don't expect the insurance company to pay for it.

6. Transparency: Don't keep cost data in a shroud of secrecy. Transparency at all levels will create an open, patient-centered playing field. Again, this will promote competition and the best value (and outcome) for the patient - true "patient-centered care".

7. Competent Self Care: Clinicians need to promote patient independence via effective teaching strategies - not just using a "do as I say" approach. With the right patient-centered approach, clinicians can foster patient self-responsibility for monitoring a) signs, symptoms, and function, b) precautions, and c) appropriate and inappropriate responses to mechanical loading. With pain recurrences being such a big part of the problem, competent self care needs to be a focal point.

8. Exercise And Education: Most clinical guidelines advocate for exercise- and education-based strategies along with self care. That's great. So tell me this - just who exactly is going to provide the patient with "self care strategies" or "exercise"? Do physicians, physician's assistants, chiropractors, massage therapists, or any other clinician spend much time in their training on exercise prescription? No. This is a physical therapist's realm.

9. Appropriate Utilization: One way to cut costs is to decrease over-utilization. How can we do so when a provider refers a patient to their own imaging facility? Another way to cut costs is to choose cost-effective approaches to care as a first line of treatment. That would include early access to physical therapy intervention, which would save money - and a lot of it.

The future is now: What is required to provide true patient-centered care for low back pain? None of these elements require a degree in rocket science to implement. All of the solutions are already right at our fingertips. But they do demand consumer advocacy - and a large dose of both professional and legislative accountability. If not now, then when? And how long can we afford to wait?

Photo credits: Davide Restive