Problem Addressed

• A common condition: An estimated 60 to 70 percent of adults experience low back pain at some point in their lives. While most back pain will disappear in a few weeks, sometimes it can be chronic and disabling.¹
• Expensive, often ineffective treatments: Treatment for chronic low back pain can vary widely, and there is limited evidence regarding the effectiveness of invasive procedures such as surgery.^2,3 Most ineffective treatments are costly, and many patients who receive them end up back in the emergency department.
• Failure to use low-cost, effective therapies first: There is a tendency to skip low-cost, first-line treatments such as physical therapy or chiropractic care in favor of more expensive interventions such as back surgery, despite evidence suggesting that such first-line interventions can often be effective. At MVP Health Care, utilization managers were seeing an increase in requests for approval of invasive back procedures in patients who had not yet received lower-cost, first-line treatments.⁴

Description of the Innovative Activity

• Identification of eligible members: MVP analyzes claims data each quarter to identify patients who have filed a claim for treatment for chronic low back pain. Members can also self-refer to the program or can be referred by a practitioner or MVP staff member.
• Introductory packet: An introductory packet describing the program is mailed to eligible members. The packet also includes a phone number for the "health coach" (see below for more details), a health risk assessment, pain-sensation scale, newsletter, and self-care handbook. All components of the program are offered free of charge to members.
• Risk stratification: Members who enroll in the program and complete the health risk assessment are separated into two groups: low risk and high risk. Members may move from low to high-risk groups. Low-risk members receive population-based interventions (e.g., newsletters and other educational resources). High-risk members receive a more comprehensive set of individualized education, coaching, and rehabilitation. In addition to using the health risk assessment to identify high-risk members, MVP Health Care relies on referrals from providers of high-risk members who need more specialized care. Information provided in October 2011 indicates that, of the 14,038 individuals who participated in the program in 2010, 37.5 percent were identified as being high risk.
• Population-based interventions for all participants: The program provides comprehensive educational and self-care support for all participants, including the following:
  • Educational resources: MVP provides a variety of educational resources for members with low back pain. Twice a year, a newsletter, The Spine Column, addresses various topics related to back care, including body mechanics, smoking, the benefits of exercise and stretching, weight loss, and common medications for pain. Patients can earn a gift by completing an annual quiz that tests their knowledge about back care. The newsletters are supplemented with targeted mailings on potential areas of improvement in the back-pain population; topics (e.g., emotional well-being) are chosen based on a review of health risk assessments, and the mailings typically include a list of available resources for members. In addition, the MVP Web site provides information on the program and other educational resources for members with back pain.
• Customized interventions for high-risk members: Members identified as being at high risk are provided with a set of personalized interventions designed to help them better manage their back pain.
  • Health coaching: High-risk members receive telephone-based "health coaching" from a registered nurse who specializes in back pain. The health coach uses patient-centered techniques to discuss the goals of the program and to walk members through the stages-of-change model to help modify undesirable behaviors such as smoking, poor diet, or lack of exercise. Guided by the results of the member's health risk assessment, the coach works with members to ensure that they understand back anatomy and to create a plan of modified, joint-sparing activities and techniques at home and work, including stretching and strengthening exercises, relaxation exercises, diet and weight management, smoking cessation, and medication management. Health coaches communicate with patients as needed; coaches also communicate with a patient's primary care physician (PCP) by fax to discuss treatment plans and goals. Health coaches also screen patients for depression, making referrals to the PCP as appropriate. The health coach can also refer patients to a social worker who is part of the MVP Depression Care Program and/or hold joint telephone calls with social workers and the member to help with all aspects of chronic low back pain.
  • Aggressive rehabilitation: High-risk members are offered a rehabilitation program, such as the Med-X-Program (which uses a machine to isolate the back muscles and build strength) or the Wellness Program (a structured exercise program).
• Practitioner tools: MVP provides support tools for practitioners caring for back-pain patients, including a quality improvement manual that provides clinical guidelines for low back pain, various types of pain management, information for the patients, and recent issues of The Spine Column.

References/Related Articles

Results

• Less back pain: Information provided in October 2011 indicates that over a 3-year period, an average of 61 percent of participants reported a decrease in back pain. The Verbal Analog Pain Score is a numerical scale of 1 to 10 in which patients identify their pain in relation to the numbers. Information provided in October 2011 indicates that results from verbal surveys at engagement and a second administration of the health risk assessment conducted after completion of the program demonstrated an average reduction of 2.77 in the Verbal Analog Pain Score.
• High levels of satisfaction: Information provided in October 2011 indicates that this reduction in pain levels led to high levels of satisfaction with the program—almost 98 percent of members indicated that they were satisfied with the program after participating in it for 1 year.
• Behavioral change: Information provided in October 2011 indicates that over a 3-year analysis period, 70 percent of participants reported performing exercises at least three times per week; 25 percent showed at least a 1-point decline in body mass index, while 52 percent of smoking participants were able to quit.
• Reduced absenteeism and associated cost savings: The program led to a more than 50-percent reduction in the average number of missed days from work among program participants, to a level below the national average for individuals with back pain. Applying the average daily wage rate among U.S. workers this reduction in absenteeism saves employers $1,899 per participant each year.
• High return on investment: Information provided in October 2011 indicates that the Back Care Program has generated an average of 20 percent reduction in cost of treatment for low back pain. This outcome is determined based on changes in participant risk scores as a result of program participation over a 2-year period.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Establishment of advisory group: A team of psychiatrists, chiropractors, rehabilitation specialists, orthopedists, neurologists, and others involved in back care identified and developed strategies for overcoming common barriers to use of first-line therapies.
• Review of guidelines: The team examined and updated current clinical guidelines around back pain, including guidelines related to treatment and to behaviors such as exercise and smoking.
• Development of model: Internal analysis of claims data convinced team members that MVP had a sufficient volume of members with chronic low back pain to justify a two-pronged approach: population-based interventions for low-risk members and a more customized approach for high-risk ones. The program was modeled after other MVP health management programs for chronic diseases.

Resources Used and Skills Needed

• Staffing: While MVP staffs the program with internal resources, it sought the expertise of an outside company to obtain certification in health coaching for these staff. MVP uses between one and two certified wellness coaches to care for the approximately 200 high-risk members in the program.
• Costs: As of 2011, total costs for the program, including salaries and supplies, are approximately $200,000 each year.

Funding Sources

Getting Started with This Innovation

• Hire experienced health coaches, or invest in training for them: The health coaches are the pillar of the program, and they need to have the appropriate skills and/or be adequately trained for the position, including in how to work with patients and how to communicate directly with primary care physicians and specialists. MVP Health Care uses nursing staff to serve as health coaches. The nurses initially adopted health coaching strategies through informal methods of learning. Later they underwent formal training and becoming certified in the discipline.

Sustaining This Innovation

• Seek provider approval and support: Providers are critical to the program's ongoing success, both as a source of ongoing referrals and in the provision of followup care and support during and after program completion.
• Market the program aggressively: Because many patients believe that there is no hope for improving low back pain, the program must be marketed aggressively to members.

Additional Considerations and Lessons

• MVP leaders feel that this program is unique and innovative due to its focus on using health coaches for members with low back pain. This is in contrast to other programs that use health coaches for other chronic conditions and other pain programs that do not focus exclusively on low back pain.
• The program has proven popular with employers that appreciate the cost savings associated with reduced absenteeism.