1. Changing Patterns of Care: Spine Centers of Excellence Association of Community Health Plans February 25, 2009

2. Spine surgery rates in west Michigan are among the highest in the nation Ratio of total spine surgery rates to US average, 2002-2003

3. priorityhealth.com 3 Muskegon, MI7.9 Petoskey, MI6.4 Kalamazoo, MI5.8 Grand Rapids, MI5.8 Marquette, MI5.8 Flint, MI5.7 Lansing, MI5.5 Saginaw, MI5.4 Royal Oak, MI5.2 Pontiac, MI4.7 Detroit, MI4.6 Dearborn, MI4.3 Traverse City, MI4.3 St. Joseph, MI4.2 Ann Arbor, MI4.1 Youngstown, OH3.9 Wilkes-Barre, PA2.0 Terre Haute, IN1.6 All back surgery discharges per 1000 Medicare Enrollees, 2004 Spine surgery rates for Medicare patients high in west Michigan National Medicare average

4. priorityhealth.com 4 Inter-system treatment variation Pain Specialist 19-33% Pain Specialist 19-33% Neuro- surgery Orthopedic surgery Imaging 55-67% Imaging 55-67% Physical Therapy 51-66% Physical Therapy 51-66% Physiatry 11-56% Physiatry 11-56% Chiropractic 3-8% Chiropractic 3-8% Neurology 5-13% Neurology 5-13% Emergency department 4-8% Emergency department 4-8% ?

5. priorityhealth.com 5 Physiatrist use is inversely related to lower spine surgery rates

6. priorityhealth.com 6 Priority Health Spine Centers of Excellence The evidence RCTs show that for the majority of patients with back pain, conservative care is as effective as surgery Multi-disciplinary spine clinics can reduce surgery rates Fully-informed patients tend to be more conservative than MDs Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001350 Spine. 2007 Jul 15;32(16):1735-47 BMJ. 2008 Jun 14;336(7657):1355-8 J Bone Joint Surg Am. 2008 Sep;90(9):1811-9 Ann Intern Med. 2008 Dec 16;149(12):845-53 Spine. 2005 Apr 15;30(8):927-35 Spine. 2001 May 15;26(10):1179-87 Spine. 2008 Feb 15;33(4):428-35

7. priorityhealth.com 7 The evidence RCTs show that for the majority of patients with back pain, conservative care is as effective as surgery Multi-disciplinary spine clinics can reduce surgery rates Fully-informed patients tend to be more conservative than MDs Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. The implementation of multidisciplinary, nonsurgical spine clinics coincided closely with a 33% reduction in the rate of lumbar disc surgery. The observed reduction seems most likely to be causally associated with educational activities and improved patient care provided by the clinics. Spine. 2005 Nov 1;30(21):2469-73 Priority Health Spine Centers of Excellence

8. priorityhealth.com 8 The evidence RCTs show that for the majority of patients with back pain, conservative care is as effective as surgery Multi-disciplinary spine clinics can reduce surgery rates Fully-informed patients tend to be more conservative than MDs Involving patients in clinical decisions: impact of an interactive video program on use of back surgery. Use of shared decision making videos appears to facilitate decision making and may help to ensure informed consent. For patients with herniated disks, it reduced the surgery rate 22% without diminishing patient outcomes. Med Care. 2000 Sep;38(9):959-69. Priority Health Spine Centers of Excellence

9. priorityhealth.com 9 The system change Effective 11/1/2007 Priority Health required that patients without surgical red flags be seen in a physiatrist-led spine clinic before being evaluated by a spine surgeon After consultation, there are no limits to access to spine surgeons No limits on other specialties such as physical therapy, chiropractic care or neurology Prior preparation Established an advisory board of practicing physicians Recruitment of physiatrists to apply for recognition as an SCOE Meetings with orthopedic spine and neurosurgeons to explain the program Primary care, employer and broker communications Priority Health Spine Centers of Excellence (SCOE)

10. priorityhealth.com 10 Spine Centers of Excellence: Expectations Payer expectations of spine centers –Triage within two days of referral –Access within ten days for acute problems –Discussion of treatment options –Use of shared decision making tools/DVDs –Communication with primary care physicians within four days Spine center expectations of payer –Provide intensive member, provider and employer education –Publish list of approved centers –Provide comparative reports for each center –Provide four spine videos from the Foundation for Medical Informed Decision Making at no cost –Increase reimbursement by $100 for each new patient seen

11. priorityhealth.com 11 Shared decision making “When fully informed and acting as full partners with their physicians in decision making, members tend to choose different, more conservative interventions than their doctor would if acting on the patient’s behalf.”

12. priorityhealth.com 12 http://www.healthdialog.com/hd/Core/CollaborativeCare/videolibrary.htm

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15. priorityhealth.com 15 Results

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20. priorityhealth.com 20 Financial impact

21. priorityhealth.com 21 Patient satisfaction data Methods: 740 patients surveyed by phone 1/28-31/2009 Criteria: Seen in a spine center between July-November 2009 Response rate: 48% (356 members) QuestionPercent Seen in a spine center within 10 days of call83% MD reviewed treatment options87% Educational information provided75% Watched a shared decision making video22% Satisfied or very satisfied with physiatrist74% Prior history of spine surgery19% Saw surgeon after a physiatry consultation34% Had surgery after a physiatry consultation27%

22. priorityhealth.com 22 Intend to see or did see a surgeon afterwards Prior history of surgery? YesNo Odds Ratios CI Yes 2420 2.9 No57136 Intend to have or had surgery afterwards Prior history of surgery? YesNo Odds Ratios CI Yes3014 10.2 No33157

23. priorityhealth.com 23 Prior authorization data

24. priorityhealth.com 24 Lessons learned Use an evidence-based approach Use an advisory group of clinicians to develop strategy Meet early, often and face-to-face with all stakeholders Create incentives for provider participation Over-communicate especially with employers and brokers Reach out to individual members to explain the program Provide regular reports to stakeholders and comparative reports to physicians

25. priorityhealth.com 25 Surgical referrals for physiatrists with and without surgical partners Surgery YesNoTotal Physiatrists with Surgical Partner 17 229 246 7%93% Physiatrists without Surgical Partner 13179 192 7%93% 30408 438 7%93% Are patients seen by physiatrists with surgical partners more likely to have surgery?

26. priorityhealth.com 26 10 Months Ending September 2007 10 Months Ending September 2008 Hospital System Total Events% of total Total Events% of total % change market share % change volume SPECTRUM HOSPITAL39143%25343%0%-35% METROPOLITAN HOSPITAL13915%11419%4%-18% SAINT MARYS HEALTH SERVICES13315%7813%-1%-41% MERCY HOSPITAL MUSKEGON-SMHC859%458%-2%-47% HOLLAND COMMUNITY HOSPITAL789%508%0%-36% MUNSON MEDICAL CENTER485%407%1%-17% HACKLEY HOSPITAL233%31%-2%-87% NORTHERN MICHIGAN HOSP131%4 -1%-69% UNITED MEMORIAL HOSPITAL51%7 40% Changes in surgical market share and volume

27. priorityhealth.com 27 10 Months Ending September 2007 10 Months Ending September 2008 Practice GroupTotal Events% of totalTotal Events% of total % change market share % change in volume GLNS Total28742.3%15434.4%-7.9%-46.3% IND Total13319.6%8017.9%-1.7%-39.8% MET Total426.2%4510.0%3.9%7.1% OAM Total12718.7%11425.4%6.7%-10.2% STM Total9013.3%5512.3%-1.0%-38.9% Grand Total679100.0%448100.0%0.0%-34.0% Changes in surgical market share and volume

28. priorityhealth.com 28 Questions?

29. priorityhealth.com 29 For more information contact: John Fox, MD John.fox@priorityhealth.com 616.464.8454 Priority Health 1231 E Beltline NE Grand Rapids, MI 49525 Jim Byrne, MD Jim.byrne@priorityhealth.com 616.464.8326 Priority Health 1231 E Beltline NE Grand Rapids, MI 49525