How Low-Value Care for Back Pain Can Cause a Cost Cascade

More than a quarter of adults report experiencing uncomplicated lower back pain. However, the common paths of treatment may not be the most effective strategy to identify the cause of the pain and may ultimately lead to financial strain on patients. Dr. Ishani Ganguli, of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital, and Dr. Mark Friedberg, of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital and Blue Cross Blue Shield of Massachusetts, and their co-authors recently?published a study?that explores these ideas. Drs. Ganguli and Friedberg told us more about the research in this Q&A:?

Q: What is low-value care and why is it such a critical issue in today’s healthcare landscape?

Low-value care refers to medical services that—for a specific type of patient or scenario—have little or no potential for benefit yet have the potential for harm. For example, while there are plenty of good uses for MRI scans, in the specific case of adults with simple low back pain that started recently, the harms have been shown to outweigh the benefits. And yet, these low-value MRIs are common.

These low-value services can harm patients’ health and contribute to overspending on U.S. health care—which is another kind of harm to patients. Even though these low-value services don’t help, patients pay for them – both directly through out-of-pocket spending, and indirectly via their insurance premiums, which are higher for every patient than they would be if unnecessary services were never ordered in the first place.

Q: Why did you investigate low-value imaging for uncomplicated low back pain? What motivated your study?

Low back pain is one of the most common reasons people see their doctor, and too often they get an MRI or X-ray that is unlikely to help. These imaging tests can also pick up all sorts of “incidental findings” (abnormalities that might have nothing to do with back pain) that may lead to expensive and time-consuming follow-ups (what we call cascades) that are similarly unlikely to be helpful in the end. Prior research has confirmed this phenomenon following low back pain imaging, but these cascades had not yet been studied among commercially insured adults. Also, prior studies hadn’t included cascades coming from incidental findings nor measured how much patients paid out-of-pocket.

Q: What were your key findings?

We found that more than one-third of patients who went to the doctor with uncomplicated low-back pain got a low-value MRI or X-ray. These patients were then more likely to experience cascades - that is, follow-up services after the test related to the spine or to incidental findings. These were costly for patients. For example, MRI recipients paid up to $500 out-of-pocket in the following year, and not surprisingly, this number was even higher for those with high-deductible health insurance plans. Of course, these are averages—not every patient is going to experience a cascade, and for some patients, those costs are much higher.

Q: ?What do your findings mean for clinicians and patients? What can be done to help address or prevent the kind of cost/service cascades that you describe?

Our findings make it clear why clinicians shouldn’t order these low-value imaging tests for low back pain in the first place. Studies show that interventions like education, nudges, and financial incentives can help encourage clinicians to avoid ordering these unnecessary tests. The results also remind us that for any medical decision, it’s so important for clinicians to talk with patients about the tradeoffs—weighing potential benefits against potential harms which include physical harms, psychological impact, and financial harms (which, in this case, were substantial).