Tens of Thousands of Back Pain Patients Overtreated in Six Health Plans

Tens of Thousands of Back Pain Patients Overtreated in Six Health Plans, According to HealthCore Study

INDIANAPOLIS, March 16 /PRNewswire/ -- More than 35,000 people had unnecessary imaging tests and almost 1,000 underwent inappropriate back surgery less than six weeks after diagnosis, according to a study of six WellPoint-affiliated plans over a 12-month period, conducted by HealthCore, WellPoint's outcomes research subsidiary.

Many people with back pain -- a condition experienced by 9 out of 10 Americans at some point in their lives -- undergo imaging tests and surgeries much earlier than recommended by national guidelines on back pain.

"As Americans, we spend roughly as much on back problems as we do for cancer or diabetes with very little change in overall result," said Dr. Sam Nussbaum, WellPoint chief medical officer. "In some cases, invasive measures are necessary, but in most, they are not. Most people will get better without having the risk, pain and expense of surgery."

Most episodes of back pain resolve in six weeks, according to the National Committee on Quality Assurance 2007 Back Recognition Program. Yet, HealthCore's study showed that $23.6 million was spent on back surgery and diagnostic imaging during the first six weeks after members reported an episode of back pain.

"It's been well documented that 30 percent of health care spending goes toward redundant or inappropriate care(1)," said Dr. Joseph Singer, vice president of medical affairs for HealthCore. "Our health care system should use evidence-based decision-making processes, such as the NCQA guidelines, to deliver clinical services that improve the quality of life and productivity of Americans."

Lumbar injuries result in approximately $149 million in lost work days per year.

The annual productivity losses resulting from lost work days are estimated to be $28 billion.(2) Back pain is estimated to make up one-third to one-fourth total workers' compensation costs.(2)

Spine-related expenses increased 65 percent -- more rapidly than overall health expenditures -- from 1997 or 2005; however, there's no evidence to suggest that the outcome of individuals with back pain has improved.(3)

HealthCore's analysis determined that a number of patients with back pain received inappropriate MRIs, X-rays, CT scans, and, in some cases, unnecessary surgeries. While the number of surgeries was small in comparison to the overall number of individuals with back pain, they greatly increased the cost of caring for patients with back pain.

"We also have concerns for our members' safety in exposing them to unnecessary radiation," Nussbaum said. "A lumbar spine CT, for example, exposes a person to as much radiation as he or she would expect to receive from 65 X-rays. When these procedures are unnecessary, they should be avoided."

The HealthCore study analyzed medical and pharmacy claims data for 172,377 members in WellPoint health plans in six states, and found that the majority of patients with lower back pain receive care for less than six weeks, which is consistent with previous studies indicating that most patients with back pain improve after six weeks.(4,5)

    Some key findings from the study include:

    --  52 percent of patients with low back pain were treated by their doctor
        for six weeks or less.
    --  Among those low-risk members treated for six weeks or less, 7 percent
        received an MRI, at an average cost of about $600 per procedure.
    --  About $1.8 million could have been saved by the health care system if
        half of these members who received MRIs during the first six weeks of
        reporting back pain had avoided it.
    --  About $1.3 million could have been saved by the health care system if
        75 percent of those who received a second, and likely unnecessary, MRI
        avoided it.
    --  Although less than 1,000 low-risk back pain patients (or 1 percent)
        had back surgery within the first six weeks of diagnosis, total health
        care costs in this time period exceeded $18 million for these patients
        alone.
    --  Members' overall treatment costs and procedures rose in relation to
        the number of specialists they saw.

In 2005, Americans spent $85.9 billion looking for relief from back and neck pain through surgery, doctor's visits, X-rays, MRI scans and medications, up from $52.1 billion in 1997, according to a study in the Feb. 13 issue of the Journal of the American Medical Association. That increase hasn't reduced the number of people reporting back pain. Fifteen percent of adults reported back problems -- up from 12 percent in 1997.

"This is an area that lends itself to greater scrutiny, clinical study and evidence-based medicine," Nussbaum said. "As a result of the HealthCore study, WellPoint is investigating approaches to support members and physicians to ensure appropriate care can be delivered to all members with back pain."

About the study

The study is based on an analysis of clinical measures as established by the National Committee for Quality Association Back Pain Recognition Program. The study included 172,377 individuals with low back pain in six WellPoint health plans who were diagnosed with low back pain from Jan. 1, 2005 through Dec. 31, 2005.

Members were excluded if they were not with a WellPoint health plan for at least six months before and 18 months after their initial back pain diagnosis. Members were also excluded if they were younger than 18 or older than 64 on Jan. 1, 2005. Members with certain "red flag" conditions, such as cancer, trauma and those with numbness, lack of sensation, loss of reflexes, and symptoms associated with nerve risk damage, were also excluded.

Those studied had a median age of 45 years and lived in California, Ohio, Missouri, Kentucky, Indiana and Georgia.

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