Aetna U.S. Healthcare^® Low Back Pain Program

Charles M. Tomlinson, M.D., M.B.A.
Charles M. Tomlinson, M.D. is a Family Physician and practiced in Fernandina Beach from 1985 to 1997,
and is a past President of the Nassau County Medical Society.
Currently he is Medical Director for Aetna U.S. Healthcare in Jacksonville

Disease management programs are commonly promoted by managed care insurance companies. These programs are designed to target patient populations with significant healthcare needs that might be better met through active case management. Case management intervention can have a significant impact on the quality of care received, the quality of service perceived, and medical costs incurred by the patient. The quality of life is also enhanced. Disease management programs commonly address diabetes, asthma, and congestive heart failure. Aetna U.S. Healthcare has developed a disease management program for low back pain patients as well.

Low back pain is a major health problem in the United States suffered by 80% of adults at some time during their lifetime. This problem leads to lost time at work and school as well as interference with daily activities. Ultimately, many patients will also suffer chronic depression. Low back pain is the second most common reason for a visit to a primary care physician.

Program Description

The Aetna U.S. Healthcare Healthy Outlook Program®, Caring for Low Back Pain, is designed to identify patients with low back pain from administrative claims data or upon referral to the program by physicians, member services, or the patient management (utilization review) department. Claims data in conjunction with pharmacy data is analyzed to stratify each low back patient into one of five risk categories. Levels one through three are considered low risk, and levels four and five are considered high risk. Participation in the program is voluntary.

All patients identified in risk categories one through five receive an introductory brochure. This brochure contains a postcard for patients to request additional educational materials. The introductory brochure discusses the frequency of low back problems in the population and provides simple tips to prevent or control low back pain. All patients in these risk categories receive an annual mailing in October to discuss winter season back injury prevention and a similar mailing in April to discuss spring and summer back injury prevention. Additional random mailings promote additional educational materials available upon request.

Those patients in the highest risk categories, four and five, receive an initial mailing containing a quality of life survey. A case manager reviews the quality of life survey and additional educational materials based on the patient's needs as identified in the survey are then mailed. Additional quality of life surveys are conducted at six and twelve month intervals into the program. The case managers can send educational materials based on these surveys.

Final mailings are sent to individuals at twelve months from the start of the program if no additional needs are identified on the quality of life survey and all goals of the program have been met. This final mailing contains a program graduation letter and a program satisfaction survey. The case managers, based on their review of the initial quality of life survey may choose to send additional member education materials available from the Aetna U.S. Healthcare Caring for Low Back Pain Healthy Outlooks Program. These case managers are experienced nurses often with considerable prior clinical experience with musculoskeletal illnesses. Some of these nurses have even had considerable operating room experience assisting with back surgery. Case management may identify patients who might benefit from second opinions at leading spinal surgery institutions. Once patients have been identified as requiring surgery, the case managers will assist in preparing the patient for a good postoperative outcome. Many times a patient can benefit from smoking cessation, weight loss, or pre-operative physical therapy in order to best prepare for the post operative period. Patients will be identified who might benefit from following the clinical guideline algorithms recommended by the Agency for Health Care Policy and Research (see algorithms).

Algorithm 1 demonstrates a decision tree for the initial evaluation of acute low back problems. This algorithm emphasizes the need to consider potential red flags such as spine fracture, cancer, cauda equina or rapidly progressing neurological deficits. This algorithm refers to Table 1 which can be found in the AHCPR clinical practice guideline number 14. Algorithm 2 describes treatments to be considered at the initial evaluation and at follow up visits. Algorithm 3 provides a decision tree for patients that are slow to recover with symptoms lasting longer than 4 weeks. Algorithm 4 deals with patients that have persistent sciatica, and Algorithm 5 provides guidelines for long term and post-operative follow up.

Results

The Aetna U.S. Healthcare Healthy Outlook Program Caring for Low Back has been in effect in the Southeast region since September of 1998. Member satisfaction through this program has been outstanding to date. The patients have expressed tremendous appreciation for the information provided. They truly feel that being well informed has equipped them to make prudent decisions and to make the commitment required for appropriate rehabilitation and recovery. Aetna U.S. Healthcare has enrolled approximately 30 to 60 patients per month in the Southeast region since the program's inception. Second opinions at leading spinal institutions have been arranged for approximately 50 patients. Ten surgeries have been avoided. Some of the most helpful interventions identified to date include smoking cessation, preoperative physical therapy assessments, and in home physical therapy assessments. The in home physical therapy evaluations identify habits and inappropriate furniture that impede progress.

Although the results to date are all anecdotal, patient satisfaction, improved decision making, and early postoperative recovery appear as emerging benefits of the program.