Back pain in the US: Numerous causes, uncertain treatment

This much is clear: America has a serious back pain problem.

Back pain presents a growing challenge for the health care system. Back pain (including neck pain) is the cause of more than 10 percent of primary care visits. Roughly $86 billion of health care resources goes toward treating it each year.

The condition puts a significant burden on employers, as well. Lower back pain is the leading cause of job-related disability, according to the NIH. Back pain in general costs at least $20 billion in lost productivity each year.

It’s also clear that risk factors for back pain have become extremely prevalent in our society. Aging, obesity and a sedentary lifestyle make people more likely to develop lower back pain.  

But as the nation struggles to address this mounting problem, what’s not clear is how to treat it. In the meantime, vast amounts of money may be wasted on ineffective treatments.

Spine surgeries rise, with questionable benefits

A recent article in JAMA Internal Medicine noted that “Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care,” with an increase in strategies such as costly CT and MRI imaging and referrals to other providers, likely for “procedures or surgery.”

The authors concluded “With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care.”

Others have noted a growing number of procedures for back problems. The Healthcare Cost and Utilization Project found that spinal fusion surgeries increased by 70 percent from 2001 to 2011, when nearly 490,000 of the procedures were performed.

According to a Washington Post analysis of these surgeries, “some experts say that a portion of them – perhaps as many as half – were performed without good reason.” According to the story, Blue Cross Blue Shield of North Carolina saw its number of lumbar spinal fusions fall by 32 percent in one year after it decided to use research findings and professional guidelines to reduce the number of these surgeries.

In 2010, Cigna began requiring patients to go through a six-month program that included physical and behavioral therapy before it approved surgery, according to Modern Healthcare.  

Patient factors, expert judgement influence decisions

Individual patient factors can influence the outcome of back pain treatments. Research has implicated depression and workers’ compensation in poorer outcomes.

And as the Washington Post observed, back pain experts don’t always see eye to eye. “In some cases you have two physicians providing different opinions, and there is more than one way to treat a patient,” a surgeon who was scrutinized for his particularly busy practice said in a deposition, according to the newspaper.

Independent review organizations (IROs) play an important role in balancing the needs of individuals, employers, insurers and other stakeholders during back pain treatment decisions. An experienced IRO will offer guidance using factors such as evidence-based guidelines, medical literature, standard of care and regulatory requirements. At Advanced Medical Reviews, our credentialed, board-certified specialists also take patient-specific circumstances into account when offering their expert judgment in back pain cases. Dr. Louisine Alpern, MD, AMR’s Vice President of Clinical Services states,  “AMR reviewers help improve patient care by providing their expert unbiased opinions on these rather complex cases.”

The optimal approach for back pain cases isn’t always immediately clear. But the impartial input of an IRO can provide helpful clarity.