Continuing Medical Education Program Helps Physicians Communicate with Patients about Care Appropriateness and Variation in Cost

The Maryland Health Care Commission (MHCC), the independent regulatory agency nationally-recognized for its work to advance cost transparency, had a solution to address high spending on MRIs for low back pain. Trouble was, it was a solution for the wrong problem.

MHCC proposed generating cost comparison data on MRIs facility fees, but physicians quickly pointed out another problem. MRIs didn’t just cost too much, most patients with low back pain never needed one in the first place. Offering a referral to imaging was just a quick and easy way to appease suffering patients. Physicians said they didn’t need a list of better priced facilities. Instead, they wanted strategies to have more effective conversations with patients about unnecessary care.

With this in mind, MHCC has collaborated with physicians and the St. Louis Area Business Health Coalition to develop an online, on-demand, no cost continuing medical education program to share best practices in patient-physician dialogue.

While the hour-long session focuses on reducing use of Imaging for Low Back Pain, a frequently overused service, its broader goal is to better support physicians in helping patients understand more care is not better care and dramatic variations in prices occur depending on where care is received.

“We have a limited amount of time for each visit. Sometimes the easy solution is just to agree to whatever the patient suggests,” said Bryan Burns, a St. Louis internist featured in the educational video. “This CME gives helpful, practice tips to make the most of those short encounters and help patients understand why you are making the recommendation.”

In addition to refreshers on why imaging for low back is typically not needed, the one-hour video features practicing physicians talking to trained medical actors to show how subtle conversational differences translate to dramatic changes in patients’ attitudes and understanding. The video also shows actual cost comparisons of various types of imaging by site of service so physicians can better understand and share with patients the impact of their referral recommendations.

“In talking with physicians, it was clear they knew the clinical reasoning and the cost implications,” said Linda Bartnyska, Director, Center for Analysis & Information Systems, Maryland Health Care Commission. “Still, it wasn’t always easy to communicate these points with patients.”

Despite a long-standing recommendation not refer for imaging for low back pain within the first six weeks, unless red flags are present, many patients are still receiving this costly service. Nearly two million Medicare beneficiaries received unnecessary imaging for low back pain, some of which included exposure to radiation, a 2015 study based on Choosing Wisely recommendations and published in the Journal of General Internal Medicine found.

The BHC, which like MHCC has access to a large claims dataset, finds about one in four patients received a potentially unnecessary image for low back pain.

The measure is included as a metric in many primary care medical home and pay for performance programs including the Centers for Medicare and Medicaid Merit-based Incentive Payment System (MIPS).

“We know health care costs too much,” said Louise Probst, Executive Director of the St. Louis Area Business Health Coalition. “Supporting physicians and patients in limiting unnecessary, low-value care is an important first step to making health care more affordable.”