Jan 27th 2016

Intelligent Healthcare: Managing Low Back Pain at EviCore

One Word: Inspired.

I was watching a TEDMED talk the other day…you know, the short video presentations where the speaker tells a story? This particular talk was about cleaning water that was polluted, as told by Peter Janicki. During the video, pictures of shanty towns littered with trash were situated near the water sources. What does cleaning water have to do with helping our clients and their members, or patients, or your husband or mother, get better treatment for their lower back pain? Sit tight. I will get to that.

For more than seven years, EviCore has been managing high-cost musculoskeletal procedures in the form of hi-tech imaging, pain procedures, and spinal surgeries related to chronic and sometimes debilitating low back pain. We do this well and it is a good thing that we do. About 20% of a given commercial health plan’s member population have a musculoskeletal procedure annually. The cost of those members participating in musculoskeletal procedures is approximately 20% of the commercial health plan’s total healthcare costs. Moreover, one member in eight will miss work due to painful musculoskeletal issues, resulting in decreased productivity.

Back to the water…

Peter was stumped. Although a brilliant engineer, he couldn’t figure out how to get this polluted water clean so that people in the local environment could use it. Then the light bulb turned on: he realized that until he redefined his question and made it—and thus the solution—bigger, he wasn’t going to be successful. He saw that for a sustained solution to cleaning the water, his view of the problem (and ultimately his solution) had to include dealing with the trash problem, which was a major contributor to polluting the water. As a result, his successful solution addressed both problems, resulting in clean water and trash control. While this solution sounds deceptively simple, it has profound implications. In an environment suck as healthcare, sometimes we need to make the problem bigger to successfully solve it.

EviCore’s teams of data scientists, epidemiologists, economists, and clinicians are changing the way we deliver our evidence-based guideline support. We view certain hi-tech procedures that we used to routinely manage individually (e.g., an MRI) now as a component of a longer process, or path of care.

For example, an episode of low back pain, the initial steps may help postpone or ultimately avoid high-cost and often low-value procedures such as spinal fusions. Spine surgeries are not only expensive, they are also often unsuccessful. A study published in 2011 found that patients undergoing surgery for spinal problems faced a failure rate of 74%. Although troubling, these numbers represent a huge opportunity for our healthcare system—to improve the quality of care in the management of back pain while simultaneously reducing costs.

At EviCore, we don’t manage the procedure alone, we look at the needs of the patient and collaborate with the clinician to assist with the often difficult interpretation of evidence-based guidelines. Our in-depth study in this area showed that back-pain patients starting treatment with physical therapy or a chiropractic service—as opposed to a hi-tech imaging procedure—were much less likely to elect surgery of the spine down the road. We saw that using this knowledge in formulating an end-to-end path of care could have a substantial impact on future costs.

Engaging early in the plan of care for a patient (while knowing which path of care is more likely to lead to a potential unsuccessful surgery) is one of the ways that EviCore is changing medical benefits management. We realized, in interpreting the data, that we needed to start managing the patient with back pain from the very beginning—from the standpoint of the entire care cycle—to help avoid the high-cost and potentially wasteful surgical procedures. This end-to-end management is critical. And while it is good for the health plan, it is even better for the patients—many of whom won’t undergo a surgery that may not work.

Sometimes you need to make the problem bigger to find a solution, and we have done that at EviCore with our proactive care management, end-to-end solution for musculoskeletal management.

You can get the details of our study and download the white paper here