Physicians increasingly ignore clinical guidelines for treating back pain, causing skyrocketing costs with approaches that put patients at risk from unnecessary surgery, overuse of narcotics, and other problems, according to a study in JAMA Internal Medicine.

“Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments. . . .” The study, “Worsening Trends in the Management and Treatment of Back Pain,” adds that “routine back pain will usually improve with such conservative treatments within three months.”

However, researchers at Beth Israel Deaconess Medical Center and Harvard Medical School, examining about 24,000 cases of back problems from 1999 to 2010, found a 51% increase in prescriptions for narcotic painkillers.

The authors suggest that this contributes to a rapid increase in narcotic overdose deaths, an increase that parallels a reported 300% rise of sales of such drugs since the 1990s. “In 2008, overdoses in narcotic analgesics led to an estimated 14,800 deaths — more than cocaine and heroin combined.”

Meanwhile, the use of CT and MRI scans increased by 57%. (Guidelines say that they are to be used only in rare cases.)

You cannot overlook the role primary care physicians play — or don’t play, says the study. There was a 106% increase in referrals from primary care to other physicians.

“When comparing visits with the patient’s self-identified PCP vs. those with another health care professional, we found that non-PCPs were much more likely to order advanced imaging. Presumably, this group includes those who perform procedures such as spinal surgery. Thus, these referrals from PCPs are likely to result in substantial downstream use that is disconcordant with current guidelines.”

A commentary by Donald E. Casey, Jr., MD, MPH, MBA, that accompanies the study says that “more appropriate incentives are needed for patients and physicians, such as higher patient out-of-pocket insurance copayments for expensive imaging and linking of payments for clinicians to improved outcomes for populations of patients with back pain.”

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.