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The American Journal of Managed Care October 2018
Putting the Pieces Together: EHR Communication and Diabetes Patient Outcomes
Marlon P. Mundt, PhD, and Larissa I. Zakletskaia, MA
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Medicare Savings From Conservative Management of Low Back Pain
Alan M. Garber, MD, PhD; Tej D. Azad, BA; Anjali Dixit, MD; Monica Farid, BS; Edward Sung, BS, BSE; Daniel Vail, BA; and Jay Bhattacharya, MD, PhD
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Nicholas Ballester, PhD; Pratik J. Parikh, PhD; Michael Donlin, MSN, ACNP-BC, FHM; Elizabeth K. May, MS; and Steven R. Simon, MD, MPH
Gatekeeping and Patterns of Outpatient Care Post Healthcare Reform
Michael L. Barnett, MD, MS; Zirui Song, MD, PhD; Asaf Bitton, MD, MPH; Sherri Rose, PhD; and Bruce E. Landon, MD, MBA, MSc

Medicare Savings From Conservative Management of Low Back Pain

Alan M. Garber, MD, PhD; Tej D. Azad, BA; Anjali Dixit, MD; Monica Farid, BS; Edward Sung, BS, BSE; Daniel Vail, BA; and Jay Bhattacharya, MD, PhD
This instrumental variables analysis estimates that Medicare would realize $362 million in annual savings if all patients with newly diagnosed low back pain were managed conservatively.

Our analysis confirms that imaging studies are overused in the initial management of low-risk patients with LBP32-34 and suggests that substantial Medicare savings could be realized from guideline-compliant care in this setting. We found that 24% of Medicare patients with uncomplicated acute LBP diagnosed from 2006 to 2010 received advanced imaging within 6 weeks of diagnosis. The proportion of patients receiving advanced imaging (MRI or CT) remained constant throughout this period, although clinical guidelines published in 2007 recommended an initial conservative diagnostic strategy (ie, no imaging within the first 6 weeks following diagnosis).15 Diagnostic strategies that included advanced imaging were associated with greater long-term costs than a conservative diagnostic strategy and were not associated with improved outcomes; patients receiving CT accrued the highest costs in the year following diagnosis. We find that $362 million could be saved annually within the Medicare context by treating patients with newly diagnosed LBP with a conservative initial diagnostic strategy, per clinical guidelines.13-15

A fundamental premise of our IV approach is that physician practice patterns vary. One physician may adopt a practice style that favors less intervention while another may adopt a more aggressive attitude toward patient management. Early imaging may be a component of a broader management approach that some physicians take with patients with LBP. Furthermore, physician practice patterns change surprisingly little in response to new evidence and clinical guidelines.35 A key lesson that accompanied the Dartmouth Atlas’s observation of marked variation in physician practice was that these variations are driven more by a physician’s own impressions and experience than by the publication of new guidelines and research.36


Among the limitations of this study is the absence of data on Medicare Part D costs, which prevented us from assessing the use of opioids and other medications to control LBP. Although our IV directly addresses the problem of confounding by indication, there may be residual confounding that the instrument has failed to account for. For example, we did not measure practice type or the physician’s financial incentives to order advanced imaging, both of which have been shown to influence the choice of LBP diagnostic techniques.19 We minimized such biases by using the IV method and by adjusting for a variety of patient demographic and health characteristics. We further limited the influence of high-cost outliers by using log-transformed 2-stage least squares regressions. Additionally, as with all analyses of a random 5% Medicare sample, our conclusions are drawn from a subset of the Medicare population rather than the entire population.

Finally, our research only addresses potential savings from adoption of a conservative diagnostic strategy for LBP. Clinical societies have been recommending conservative strategies for many years, with seemingly little success. Chou et al have hypothesized that financial incentives, including incentives linked to patient satisfaction and self-referral, along with defensive medicine considerations, promote overuse of advanced imaging techniques in this setting.10 Other studies have shown that patients at baseline may feel more satisfied if they receive advanced imaging for LBP; however, those who instead receive a 5-minute educational intervention on the risks associated with lumbar spine imaging and its minimal clinical usefulness feel equally satisfied with their care.19,37


Insofar as payment moves from a per service basis to models closer to capitation, the culture of clinical practice will change: Physicians may be incentivized to adhere to more cost-effective and conservative diagnostic strategies through payment structures incorporating quality measurement, such as LBP-specific measures sponsored by the Agency for Healthcare Research and Quality National Quality Measures Clearinghouse.38 These shifts in physician preferences must come hand-in-hand with shared decision making, in which patients receive trustworthy information on the clinical usefulness of early imaging for LBP.39 Results from this study demonstrate that such shifts in clinical practice toward adoption of conservative diagnostic strategies for LBP, as supported by comparative effectiveness research, could lead to large health expenditure savings. 


This research was supported by the National Institutes of Health (NIH)/National Institute of Aging under grant R37 AG036791. The NIH had no role in the study design, conduct, or reporting of this study and the authors take full responsibility for the content of this research. The authors thank Tom MaCurdy and participants at the Stanford Medical School Research in Progress seminar for helpful feedback. This study was exempted from the Institutional Review Board of Stanford University School of Medicine.

Author Affiliations: Harvard University (AMG, MF), Boston, MA; National Bureau of Economic Research, Inc (AMG, MF, JB), Boston, MA; Stanford University School of Medicine (TDA, DV), Stanford, CA; Department of Anesthesia, University of California San Francisco (AD), San Francisco, CA; Acumen, LLC (ES), Burlingame, CA; Stanford Centers for Health Policy/Primary Care and Outcomes Research (JB), Stanford, CA.

Source of Funding: This research was supported by the National Institutes of Health/National Institute of Aging under grant R37 AG036791.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AMG, TDA, AD, MF, ES, DV, JB); acquisition of data (AMG, JB); analysis and interpretation of data (AMG, DV, JB); drafting of the manuscript (AMG, TDA, AD, MF, ES, DV, JB); critical revision of the manuscript for important intellectual content (AMG, TDA, AD, MF, ES, DV, JB); and statistical analysis (AMG, DV, JB).

Address Correspondence to: Daniel Vail, BA, Stanford University School of Medicine, 291 Campus Dr, Stanford, CA 94305. Email:

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