1. Spine/Low Back Pain Update May 29, 2013 1

2. Goals for Today’s Presentation 1. Provide update on Spine SCOAP proposal 2. Summarize the progress made by the Spine/Low Back Pain workgroup 3. Get feedback about draft goals and recommendations under consideration by the Spine workgroup 2

3. Update on Spine SCOAP Proposal In October 2012, the Bree unanimously voted At the March meeting, the Bree discussed the use of “community standard” in response to concerns from HCA Letter sent to HCA in mid-April clarifying the Bree’s intent and proposing revised language 3

4. Timeline of Spine SCOAP Proposal Action/StatusRecommendation October 2012 (sent to HCA in Jan 2013) Bree approved Spine SCOAP proposal “To approve the Spine SCOAP proposal – that the Collaborative establish participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery” March 2013HCA respondsConcerns with community standard language April 2013Bree discussed HCA response, revised language based on HCA concerns & submits revision to HCA See next slide 4

5. Revised Proposal “To approve the Spine SCOAP proposal – that the Collaborative strongly recommends establish participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery* - with the following conditions: 1) Results are unblinded. 2) Results are available by group. 3) Establish a clear and aggressive timeline. 4) Recognize that more information is needed about options for tying payment to participation.” * Spine SCOAP will begin with hospitals performing spine surgery and will expand to include procedures done at Ambulatory Surgery Centers as well as other non-hospital facilities such as interventional radiology suites. 5

6. Update from HCA Have not received formal response yet Josh Morse from HCA will give a verbal update at today’s meeting 6

7. Spine/Low Back Pain Workgroup Update

8. Populations of Interest Report will target three patient populations: 1. Adult low back pain (LBP) patients that are at a low risk of developing chronic pain and require minimal care 2. Adult LBP patients that are at a medium risk of developing chronic pain and require additional care to overcome physical obstacles to recovery 3. Adult LBP patients with psychosocial obstacles to recovery (“yellow flags”) that are not responding to conservative treatment and are at a high risk of developing chronic pain Excludes patients with LBP associated with major trauma and patients with “red flags” that suggest a serious underlying condition 8

9. Draft Primary Goal Improve return to function for LBP patients while reducing the cost of care by increasing evidence-based evaluation and management of patients in target populations 9

10. Draft Secondary Goals 1. Reduce use of inappropriate interventions that do not support return to function or improve health outcomes 2. Increase early identification and management of patients who are at a higher risk of developing chronic pain 3. Provide tools and support to clinicians for the delivery of evidence-based care 4. Increase adoption of both financial and non-financial incentives to change provider practices and reward value- based care 5. Increase public awareness that low back pain is a chronic condition, and no “magic bullet” treatment exists 10

11. Draft Measures of Success Key challenge: How can the Bree (or any entity) collect this data in the absence of a registry? Thoughts? 11 Outcome MeasurePossible Data Source(s) Improve return to function timeL&I, providers, patient surveys, others? Improve functional status as measured by the Oswestry Low Back Pain Scale Providers/health plans that use Oswestry to collect pre- and post- function scores, employers (include in medical leave paperwork?) Improve patient experienceStill exploring options

12. Draft Measures of Success Any other measures that the workgroup should consider? 12 Process MeasurePossible Data Source(s) Reduce inappropriate use of MRIs for LBP patients in the first 28 days NCQA, Puget Sound Health Alliance (Community Checkup) Reduce overall MRI and lumbar fusion rates for LBP patients L&I, Medicare, Spine SCOAP Increase use of screening tools (e.g. STarT Back or a similar tool) Large health care systems that implement these recommendations, possibly health plans that have billing codes assigned to the use of screening tools

13. Draft Recommendations – Hospitals/Clinics Support or sustain a LBP quality improvement program that includes measuring patients’ functional status over time using the Oswestry Low Back Pain Scale Use a validated screening tool like the STarT Back tool or Functional Recovery Questionnaire (FRQ) no later than the 3 rd visit to identify patients that are not likely to respond to routine care Take steps to integrate evidence-based guidelines, scripts, shared-decision making, and patient education material into clinical practice and workflow (e.g., EMR, a clinical decision support tool such as UpToDate, etc.) 13

14. Draft Recommendations – Hospitals/Clinics (cont’d) Sponsor evidence-based CME for staff on the best practices for the evaluation and management of non-specific LBP patients to prevent progression from acute to chronic pain (in combination with operational changes that support/reinforce best practices) Include information in lumbar spine MRI reports about the frequency of similar findings in the general population Implement “hard stops” that require providers to demonstrate appropriateness of imaging before ordering 14

15. Draft Recommendations – Individual Providers Commit to using evidence-based guidelines and tools recommended by the Bree Collaborative, including the ACP/APS guidelines and Oswestry Use a validated screening tool like the STarT Back tool or Functional Recovery Questionnaire (FRQ) no later than the 3 rd visit to identify patients that are not likely to respond to routine care Incorporate shared decision-making into clinical practices Establish referral relationships with physiatrists 15

16. Draft Recommendations – HCA/Medicaid/DOH/L&I Sponsor an evidence-based education campaign about low back pain (ideally modeled after an Australian campaign with proven effectiveness) Partner with WSHA, WSMA, the Washington Academy of Family Physicians, American Academy of Physical Medicine and Rehabilitation, and other interested parties Provide subsidies/incentives to providers that use shared decision-making with their LBP patients Sponsor a new payment methodology for LBP care 16

17. Draft Recommendations – Employers/Purchasers Encourage providers and delivery systems to track and report return to function rates in a transparent manner Provide recommended patient education materials about LBP to all employees and their families Negotiate tiered networks or other types of benefit design that will encourage patients to go to providers that have demonstrated evidence-based practices 17

18. Draft Recommendations – Health Plans Support new, innovative financial models for LBP care Require providers to demonstrate that they have had patients complete a screening tool (such as STarT Back or FRQ) as part of prior authorization process for imaging, spinal injections, and/or spinal surgery Require patients with non-specific low back pain (and no red flags) be evaluated by a physiatrist before scheduling a visit with a surgeon 18

19. Draft Recommendations – Health Plans Consider establishing the collection of data on functional outcomes as a requirement for payment Identify complex cases (e.g. a patient who is getting opioid prescriptions from multiple doctors) and refer them to a provider or case manager that can oversee their care 19