Article looks at reform concepts put into practice

Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.

Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.

Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to

If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.

“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted  Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.

“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.

“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”

The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.

So what are those health reform themes?

Value-based purchasing – loosely translated – is paying for what works.

Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.

Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.

So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.

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