David J. BenEliyahu, DC
The health care landscape in the United States is rapidly evolving with a shift to new payment models such as “pay for performance,” and the Merit-based Incentive Payment System (MIPS) instituted by the Center for Medicare Services. Healthcare providers and health delivery systems need to evolve as well to keep up with the changes in the way care is delivered. This article describes some of the contemporary practice principles that are being implemented by hospital systems and physicians nationwide. Chiropractors should become versed in these contemporary practice principles and consider implementing them into their practices.
Back pain continues to be a significant societal problem with 25 percent of all Americans experiencing chronic back pain. It carries a $250 billion price tag in treatment costs and lost productivity.1 The U.S. Bone and Joint Initiative, in its fourth edition of the Burden of Musculoskeletal Disease, reported that musculoskeletal conditions affect 50 percent of the U.S. population, of which 50 percent will have spine-related disorders.2 The World Health Organization lists chronic back pain as the leading cause of global disability.3 With studies showing high recurrence rates for back pain ranging from 25%-33% after one year, and chronic back pain often associated with a higher incidence of medical co-morbidities, a more comprehensive approach in the management of spine related disorders is needed.4,5,6,7
The chiropractic profession has a window of opportunity to take the lead in care coordination and comprehensive management of this specific population of patients. As spine care providers, we are expected to achieve good clinical outcomes for the patient’s spine pain, provide a good patient experience, and enhanced value to our care. Studies published in peer-reviewed journals on low back pain have documented that chiropractic care is cost effective, results in good clinical outcomes, increases health-related quality of life, and reports high patient satisfaction.8,9,10,11,12,13 These general goals of health care have been referred to as the “Triple Aim” by the Institute for Healthcare Improvement.14
Comprehensive clinical management of the spine pain population should include not only diagnosis and treatment, but also focus on these additional principles:
- Interprofessional collaborative care
- Team-based care
- Care coordination
- Risk factor management
- Measuring clinical outcomes
- Engaging patients in their care
- Reducing gaps in care
This more comprehensive approach to care has been referred to as “Population Health Management.”15
Studies in several prestigious medical journals have consistently demonstrated clinical efficacy of spinal manipulation for back pain, and recent Gallup polls have demonstrated positive public opinion for chiropractic.16 Yet, as a profession, we still see less than 9 percent of the U.S. population.17 Implementing the principles of the Triple Aim and Population Health Management into chiropractic practice would likely result in enhanced clinical outcomes. Incorporating these practice principles could increase public utilization of chiropractic, establish a progressive identity for the profession, and enhance the profession’s cultural authority for spine-related disorders. Cultural authority is defined as the accumulation of public trust determined by legitimacy and competency by a professional group.18 Cultural authority must be earned, and is both a local and national phenomenon. The chiropractic profession must routinely collaborate with members of the medical community, as well as social and public health offices. Collaborating when clinically appropriate, and with population health management principles for spine pain patients, can help increase our profession’s cultural authority for patients we mutually serve.19
Since the public and society already identify chiropractic with spine care, spine-related disorders should be our focus for achieving cultural authority.20,21
What is the Triple Aim?
In 2008, Donald Berwick from the Institute for Healthcare Improvement (IHI) published a paper on a framework to improve U.S. health care based on three tenets:
- improving the patient experience of care
- improving the health of populations
- reducing per capita costs.
He labeled this framework the “Triple Aim.”22 Berwick et.al., identified that to improve the health of the population and achieve the Triple Aim, one must specify the population of concern, embrace integration, identify the integrators of care, and have cooperation of all stakeholders in healthcare delivery. Key measurement principles that apply to the Triple Aim include: a defined population, tracking data and outcomes and benchmarking results against other systems or providers.23
Furthermore, it incorporates six key measures for improvement, outlined by the Institute for Medicine: Care that is safe, effective, timely, efficient, equitable and patient-centered.24
In 2014, Bodenheimer et.al. expanded the Triple Aim to the “Quadruple Aim” by adding an additional tenet of improving the provider experience to account for increasing physician “burnout.”25 In 2010, the Affordable Care Act (ACA) was instituted to increase the quality, and decrease the cost, of care Americans receive--incorporating Triple Aim principles. To decrease cost of care, a shift to “pay for performance” models by Medicare/CMS and other health plans is being instituted. In 2017, Forbes reported that 50 percent of all healthcare payments made by UnitedHealth Care, Aetna, and Anthem were from value-based payment models.26 Reimbursement will be based on qualitative measures as opposed to quantitative measures. This year, CMS will add a cost/value element to their Quality Payment Program, with which many chiropractors participate.
There is a widespread and fast-paced trend in medicine for practice acquisition of both primary care and specialty practices by hospital systems, insurance companies, industry, and even venture capitalist groups. As of 2018, a survey by the Physicians Foundation found that less than one third of medical practices remained independent, with the majority being employed by a hospital or health system.27
The principles of population health management and Triple Aim are incorporated within the health system’s electronic medical record system, with software designed to track patient outcomes. While chiropractic practices are generally not being acquired in the way medical practices are, we as a profession should adopt these principles for management of spine-related disorders. If we do, it is likely to enhance the chiropractic profession’s progressive identity with respect to management of spine conditions.
Population Health vs. Population Health Management
Kindig and Stoddart first introduced the concept of Population Health (PH) in 2003, defining it as the health outcomes of a group of individuals and the distribution of such outcomes within that group.28 Since that time, there has been considerable attention and multiple definitions given to PH.
- Population Health (PH) represents the health outcomes of a group of individuals that includes the distribution of the clinical outcomes in that group. PH focuses on the health in a particular sector for ordinary people in the community, as well as the educational, and socioeconomic disparities that exist in the population. For doctors of chiropractic (DCs), the defined population of patients in the community that we impact are patients with spine-related disorders. I propose we modify this particular population subset to Population Spine Health.
- Population health management (PHM) represents the measurement of improvement in the health outcomes of a particular population, as well an emphasis on identifying risk factors that can affect outcomes. It addresses the health needs of all patients in that community seen along the continuum of care with respect to patient engagement and an integrated care model. Patient-centered collaborative and coordinated processes are built on prevention and disease-management protocols.29,30 I propose we define the subset spine pain population to Population Spine Health Management (PSHM).
While many community-based chiropractors may not be familiar with these principles as an adjunct to their care, both PH and PHM are routinely assessed in hospitals, large health care systems and government health plans. The following PSHM core strategies should be embraced and implemented into chiropractic clinical practice. They can help increase quality of care and achieve measurable clinical improvement for the spine pain patient population.
1. Adopt standardized Spine Care Pathways (SCP) and spine care algorithms into the clinical workflow.31,32,33,34
An SCP identifies the type of case the patient presents with, and the steps needed to treat that patient, taking into account evidenced-based practice, interprofessional collaboration and wellness goals. It helps streamline delivery of care and is associated with reduced healthcare expenditures.35,36 An example of an SCP for mechanical low back pain from the Mather Hospital Back and Neck Pain Center includes the following:
- Description: Back pain dominant, may include leg pain not past the knee. Likely pain generators include one or all of the following: the facet joint, sacroiliac joint and associated muscles. No neurologic signs, no red flags (no cauda equina symptoms, infection, fracture, fever), no yellow flags (psychosocial involvement), no signs of discopathy, or radiculopathy.
- Treatment: Chiropractic care/Physical therapy. Includes spinal manipulative therapy, myofascial therapy, adjunctive modalities, exercise rehabilitation, identification and management of risk factors such as smoking, medical comorbidities, and high BMI.
2. Identify care gaps and reduce disparity of care.
- Track patients who are noncompliant and attempt to engage them in their own care and outcomes. Utilize computer technology to email and text reminders for follow-up appointments.
- Increase access of chiropractic care to a larger percentage of the U.S. population, as utilization still remains at about 8%-9%. Engaging in interprofessional collaboration with local physicians and community hospitals can help individual chiropractors increase utilization of chiropractic services.
- Increase access to disadvantaged populations and reduce disparity in care delivery. Collaborate with local community health centers, and FHQCs that provide care to underserved populations.
3. Identify, stratify and manage risk factors commonly associated with spine disorders.
- Medical co-morbidities can negatively impact clinical outcomes and will often require greater resources and effort. Risk factors that are not managed or modified can often lead to recurrence and chronicity.
- Risk factors such as diabetes, high BMI, smoking, psychosocial issues, fall risk, sleep disorders, substance dependence, osteoporosis and prior spinal surgeries should all be identified, stratified and modified through care coordination and collaborative care.
- Identify Social Determinants of Health and navigate patients to an appropriate social service agency for co-management.
- Determine risk stratification—into low, medium and high-risk categories—by devising a scoring system. Add a check list to office intake forms that identifies risk factors and can be filled out by staff. This can help alert the doctor to what needs additional attention and collaborative care.
- Each risk category can then be assigned a clinical care pathway that outlines treatment, collaborative care referrals, patient engagement tasks, follow-up schedules and any needed community health programs such as smoking cessation, weight management and substance dependence treatment.
- Patients with high risk may require more attention, follow-ups, and enhanced care coordination and collaborative care. Procedures and systems within the office can be put in place to routinely monitor high-risk patients.
4. Assess and coordinate management of Social Determinants of Health (SDoH).
According to the National Academy of Medicine, medical care accounts for only 10%-20% of the modifiable contributors to healthy outcomes for a population.37 The other 80%-90% are attributable to SDoH. The WHO defined SDoH as “the conditions in which people are born, live, work and age.38 It is estimated that 68 percent of patients have at least one SDoH. These are comprised of health-related behaviors (i.e., smoking, lack of exercise, poor diet), socioeconomic factors (i.e., income issues), and environmental factors (i.e., housing issues, lack of transportation).39,40 Hospitals, large health systems and government health programs are screening for SDoH. While we as chiropractic clinicians don’t have the resources to address all of these factors, we can try to identify them when we take a patient’s history during the intake process. Since SDoH typically represent barriers to care, addressing them will enhance the quality and comprehensive level of care we provide. Developing a collaborative referral partnership with community social service centers and social workers can help overcome barriers to care such as SDoH and help achieve better health outcomes for our patients. Addressing SDoH with our patients can help position chiropractors as important members of the community’s healthcare team and contribute to a progressive identity.
5. Reduce and prevent chronicity.
Chronic low back pain has been associated with higher incidence of medical co-morbidities and economic burden compared to those without chronic low back pain. Co-morbidities often associated with chronic low back pain include diabetes, coronary artery disease, hypertension, arthritis, hyperlipidemia, depression and opioid medication misuse.41,42,43,44 Other studies have shown that patients with multiple co-morbidities received poorer care for their low back pain.45 Comprehensive care that is patient centered, evidenced based, and rooted in the Triple Aim and PSHM principles would likely help reduce chronic low back pain and possibly positively impact medical comorbidities. General treatment strategies for chronic diseases can benefit people with back problems. For example, lifestyle modifications such as diet, exercise, weight control and smoking cessation have been shown to be beneficial for both.46
6. Establish interprofessional collaborations.
Interprofessional collaborative relationships with primary care and medical specialties helps foster coordination of care for patients in need of medical care, and can enhance referrals of spine pain patients for chiropractic care. A patient-centered, team-based approach to care helps improve clinical outcomes.47 Studies have demonstrated that usual medical care with collaborative chiropractic care results in statistically significant clinical improvement.48
Interprofessional Collaborative Practice may be defined as multiple health workers from different professional disciplines providing comprehensive and high-quality health services for patients in the community.49
Create collaborative relationships with primary care physicians, behavioral medicine providers, neurologists, orthopedists, neurosurgeons, interventional pain management specialists, social workers, registered dieticians, other related medical specialties and community health service offices.
Collaborative relationships can be formed in small-scale settings (micro-collaborative practice) or large settings (macro-collaborative practice):50
- Private practice (practice agreements/referral relationships with other specialties, or consider leasing space in your office to other specialists).
- Group practice (lease space in a specialty practice, work for a multi-specialty practice, partnerships with other disciplines).51
- Hospital settings (community, academic, and VA)
- Federally Qualified Health Centers
- Accountable Care Organizations and Medical Homes
- Large corporation/business entities
- Sports arena (professional, collegiate and Olympic organizations)
7. Engage patients in their own care.
Counsel patients on lifestyle changes (i.e., diet, exercise, posture, weight loss, smoking cessation). Patients need to comprehend that they are our partners in helping them become healthier, achieving their health goals and increasing their quality of life
8. Manage and coordinate the patient’s care.
Triage patients to the most appropriate care for their particular disorder, based on history, examination and imaging findings. Co-manage the patients’ conditions with medical specialists or primary care physicians whenever it is appropriate. Studies have shown that care coordination results in better outcomes, higher patient satisfaction and lower costs.52,53
9. Measure clinical outcomes utilizing standard functional outcome assessment tools.
- Utilize outcome tools such as the Oswestry, Roland Morris, Neck Pain Disability Index, PHQ9, StaArt Back, Promis 29, and Quality of Life (QOL) surveys.
- Consider the use of an EHR to measure outcomes and participate in the Medicare Quality Payment Program.
- Consider using a Spine Registry to help measure your outcomes and benchmark outcomes against other providers.
10. Monitor patient satisfaction.
Measure the patients experience by utilizing patient satisfaction surveys to monitor the practice’s ability to enhance the patient experience. Many hospital systems use the Press-Ganey Survey to monitor patient satisfaction. Chiropractic clinicians can create their own patient satisfaction survey or use commercially available surveys.
PSHM is a comprehensive approach to spine care. It addresses our patient population’s needs along the continuum of care, through enhanced patient engagement, coordinated and collaborative care, and our specific therapeutic intervention of chiropractic/spinal manipulative therapy. By incorporating Triple Aim and PSHM strategies and principles into chiropractic practice, providers would most likely enhance clinical outcomes, the quality of care rendered, the patient experience, and the value of care. Value is traditionally referred to as per capita or episodic cost. However, value should also include how well a provider employs PHSM principles to mitigate risk factors, SDoH and the prevention of recurrent episodes and chronicity. Interprofessional collaboration and regular interaction with social agencies, when appropriate, may help contribute to the progressive identity of the chiropractic profession. Over time, this can enhance the profession’s cultural authority for the conservative management of spine pain. These contemporary principles of practice can help the patient, the community, and the chiropractic profession.
Dr. BenEliyahu is administrative director of the Back and Neck Pain Center at Mather Hospital/Northwell Health in Port Jefferson, N.Y., and also director of Mather/Northwell's Chiropractic Collaboration Program. He also serves as clinic director at Coram-Selden Chiropractic Office, Selden, N.Y.
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- Goertz et. Al., Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on P, https://www.acatoday.org/Patients/Why-Choose-Chiropractic/What-Research-Shows on pain and Disability Among US Service Members with Low back Pain JAMA Network Open, May 2018
- Hertzman-Miller et. al., Comparing satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA study, Am J Public Health 2002
- Hurwitz et. al., JMPT 2016
- Lillidahl et.al., JMPT 2010
- Hays R et.al., Group and Individual Change on Health-Related Quality of Life in Chiropractic Patients with Chronic Low back and Neck pain, Spine Vol 44(9), May 2019
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- Kindig et.al., Am J Public Health 93(3) 2003
- Palmer College of Chiropractic Gallup Report, 2018
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- Schneider M, et.al., Spine care as Framework for the Chiropractic Identity, J of Chiro Human 23(1) Dec 2016
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- Berwick DM Nolan TW Nolan, J Whittington, Health Affairs, Vol.27 No.3 2008
- A Guide to measuring the Triple Aim, IHI, 2012
- The Six Domains of Health Care Quality, AHRQ, Institute of Medicine 2015
- Bodenheimer et.al., Annals of Internal Medicine. Vol. 12, No. 6 2014
- Forbes, Feb 2017
- The Physicians Foundation Survey, 2018
- Kindig et.al., Am J Public Health 93(3) 2003
- Swarthout et.al., Am J Health Systems 74(18) 2017
- Matthews et.al, Pop Health Manag, Jan 2017
- Globe et. Al., Clinical Practice Guidelines: Chiropractic Care for Low Back Pain, JMPT 39(1) 2016
- Baker et.al., Algorithms for the Chiropractic Management of Acute and Chronic Spine Related Pain, Topics in Integrative Health Care, Dec 2012
- Haldeman et.al., Global Spine Care Initiative: Care Pathways for people with spine related concerns. Eur Spine Journal August 2018
- Lisi et.al., Chiropractic Integrated Pathway for Low Back Pain in Veterans, JMPT 20189 41:137
- Weeks et al., Journal of Gen Int Med , March 2019
- Paskowski et.al., A hospital based standardized Care pathway, JMPT Feb 2011
- Magnan S, National Academy of Medicine, Social Determinants of Health 101, 2017
- About Social Determinants of Health, World Health Organization, April 2018
- Kaiser Family Foundation, May 2018
- Healthy People 2020, Social Determinants of Health, Office of disease Prevention, April 2018
- Garcia et.al., J Pain Research 2018
- Fernandez et.al., Plos One 2016
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- Gore et.al., The Burden of Chronic Low back pain: Clinical Comorbidities, Spine 37(11) May 2012
- Ramanathnan et.al., What is the association between comorbidities and the appropriateness of care for low back pain. BMC Musculo Dis, 19(391) 2018
- Back Problem Snapshot, Australian Institute of Health, July 2018
- Creating Patient Centered Team Based Approach to Care, AHRQ , US Dept HHS, March 2016
- Goertz et. Al., Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on P, https://www.acatoday.org/Patients/Why-Choose-Chiropractic/What-Research-Shows pain and Disability Among US Service Members with Low back Pain JAMA Network Open, May 2018
- Interprofessional Education and Collaborative Practice The WHO, 2010
- BenEliyahu, Interprofessional Collaboration Presentation, NCLC 2019
- When considering leasing space, refer to your state laws and regulations, and/or consult a healthcare attorney.
- Pollack et.al., Patient Sharing and Costs of Care, J Gen Int Med, 28(3) March 2018
- Pollack et.al., Patient Sharing and Quality Care, Med Care 53(4) April 2015