Tuesday, March 28, 2017

US System Lags in Back Pain Treatment

The US healthcare system is, in a word, dysfunctional.  We know this.  Many of us have experienced it first hand.  We spend a lot and have relatively little show for it:

There are many reasons for this that will require a plethora of future blog posts (political reasons, economic reasons, cultural reasons, etc.)  But today, we'll take a quick look at what happens in a country that adopts evidence-based guidelines in a rigorous, widespread, methodical way and tracks the results of those changes over time.

The Netherlands is a relatively small country northwest of Germany, making up the southern border of the North Sea.  Known for the laissez-faire reputation of its largest city, Amsterdam, the country's healthcare system has a few notable features that are anything but: health insurance is mandatory, the country has a well-established and well-organized network of 160 primary care centers, and both insurers and hospitals are mostly for-profit and compete for business among consumers.

Back in 2011, the Netherlands decided to address the rising cost and complications associated with low back pain.  They did so by essentially mandating adherence to evidence-based guidelines (through highly differential reimbursement - pay for the things that work, pay little/nothing for things that don't) and simultaneously incentivizing return-to-work within the social security and disability programs available to citizens.  Because of its relatively small size and well-organized primary care system, the country was able to gain real traction around evidence-based guidelines within the clinical community.  They reduced spend by 20% over 5 years (this included both direct spend - like clinical services - and indirect spend - like social insurance and disability payments).   

The closing paragraphs of a recent story addressing this study found in the pages of one of my favorite public health newsletters, The Back Letter, summarizes the potential obstacles and opportunities that the US healthcare system presents:
When these reforms were enacted, some providers and patients worried that they would negatively impact outcomes—by limiting their treatment options. But there has been no evidence that these changes have had a negative impact on the health and well-being of the general public. 
However, some of these policies might be difficult to enact in the US. Any suggestion of limiting treatment options in the US sparks protests about “rationing” and “denial of care.” And wholesale limitations on ineffective treatments for back and neck would draw huge opposition from drug and device companies, healthcare systems that employ ineffective treatments profitably, and professional societies whose members routinely offer ineffective or unproven care. 
How does one get a society with an entitlement mentality, with mistrust of any form of regulation, to accept evidence-based limitations on care? Perhaps the recent saga with opioids provides some insights – as the consumer tide has clearly turned against the excessive and deadly prescription of opioids for back and other chronic pain problems.
The key elements in bringing about this transformation in attitudes were vocal public advocates, compelling stories of bad outcomes, easily-understood information, and credible scientists taking strong public stands. These same elements might be brought to bear to reduce inappropriate levels of surgery, injections, pain interventions, and ineffective non-invasive treatments. 
However, the opioid debacle is an extreme situation, given its heavy death toll and destructive impact in every US state. Will healthcare providers, patients, policy makers, and payers be willing to make similar cutbacks to all forms of excessive back care? There is certainly a growing consensus that spine care has to be a primary target in efforts to dramatically reduce spending. However, how that process will play out remains to be seen.
 Who knew healthcare was this complicated?

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