The University of Pittsburgh Medical Center (UPMC) Health Plan, a health maintenance organization affiliated with the university's School of Medicine, has adopted landmark guidelines for the management of chronic low back pain. As of Jan. 1, 2012, candidates for spine surgery must receive "prior authorization to determine medical necessity," which includes verification that the patient has "tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication." Surgery candidates also must be graduates of the plan's LBP health coaching program. The program features a Web-based decision-making tool designed to help plan members "understand the pros and cons of surgery and high-tech radiology." It is the first reported implementation of such a policy by a health care plan.
Putting a Clamp on the Soaring Rates of Spine Surgery
According to the December 2011 issue of the UPMC Health Plan Physician Partner Update, which informed participating providers of the new guidelines and the rationale for their implementation, "We feel strongly that this clinical initiative will improve the quality of care for members who are considering low back surgery, and that it will facilitate their involvement in the decision-making process." The update also noted, "Surgical procedures for low back surgery performed without prior authorization will not be reimbursed at either the specialist or the hospital level."
|A Conservative Strategy for Managing Chronic LBP
• PCP discussion related to self-care consisting of rest, ice, compression and elevation (RICE)
• Screening for psychosocial factors or "yellow flags" and incorporate behavioral interventions as appropriate with other treatment interventions
• Education on self-management techniques – functional ability assessment and education on return to work / usual activity and function
• Enrollment and graduation from UPMC Health Plan Health Coach's Low Back Pain Program (mandatory) which may also include participation in other programs such as weight loss, physical activity, tobacco cessation, depression and/or stress
• Early referral to chiropractor or physical therapist, but before advanced imaging, for manipulation/mobilization; stabilization exercises; directional preference strategies – member and/or provider movements that abolish or cause centralization of pain (McKenzie self-treatment repeated movements that centralize pain)
• Detailed documentation of extent and response to conservative treatment including chiropractor/physical therapy documentation
SOURCE: UPMC Health Plan Policy and Procedure Manual, October 2011: Surgical Management of Low Back Pain
(partial list of considerations prior to spine surgery to determine medical necessity). Complete policy available at www.upmchealthplan.com/pdf/PandP/MP.043.pdf.
"The UPMC should be congratulated for its leadership is establishing policies to assure that the least invasive and most likely to be successful care strategies, including chiropractic care, are applied for a meaningful period of time before surgical considerations are made. This decision is both an important recognition of the value of chiropractic care in the acute low back pain environment as well as a recognition of the clinical and economic downsides to spinal surgery in this situation."
Headquartered in Pittsburgh, the UPMC Health Plan covers insureds in 15 counties in western Pennsylvania. The plan integrates 20 hospitals, 400 doctors' offices and outpatient sites.
Chiropractic Services: What the UPMC Health Plan Covers
"It is the policy of UPMC Health Plan to recognize chiropractic services and adjunctive procedures as appropriate and consistent with good medical practice and will provide coverage when the services are medically necessary and covered by the member's benefit plan for the specific indications detailed in this policy. Coverage is limited to medically necessary services provided by a licensed doctor of chiropractic, within the scope of his/her license."
"Covered chiropractic services include evaluation and management, manipulation, spinal X-rays, therapeutic exercise, and adjunctive procedures that are appropriate and medically necessary for neuromusculoskeletal conditions. ... Indications for Chiropractic Services: Indicated for primary, neuro-musculoskeletal symptoms involving the spine, para-spinal soft tissues, and extremities. Indications for Manipulation: Manipulation is appropriate to restore function that has been reduced or lost by illness or injury. Indications for Adjunctive Procedures: Adjunctive procedures are appropriate to restore function and prevent disability following injury. Indications for Therapeutic Exercise: Indicated for improvement or to restore functional status by building strength, endurance and flexibility of the affected region."