Before the 400-plus employees at a General Dynamics Corp. plant in northern Florida start their shift each day, they perform five minutes of targeted movements — sometimes in groups and sometimes individually — specifically designed to protect the joints that are so crucial on and off the job.
The employees also are asked to pause momentarily throughout the day to repeat some of those movements, especially stretching out the lower back, said Judy Harris, an occupational health nurse practitioner at the chemical manufacturing plant. “I want them to transfer this to their full lives,” she said, “and not just think that injuries occur on the job.”
Companies like General Dynamics are building on medical evidence that shows relatively low-cost and low-tech measures can help ease back pain, which, according to one report, affects nearly 1 in 4 U.S. workers. Whether it’s promoting better body mechanics or physical therapy requirements before an imaging test, employers are striving to press the pause button on a rush to back surgery.
“Once you’ve cut, you can’t go back — there’s no reset,” said Olivia Ross, associate director of the Pacific Business Group on Health. “In a situation where you’re not sure surgery will help, we really want them [employees] to exhaust all other conservative measures before we start the snowball.”
As wellness programs have become common in the workplace over the past decade, employers are more attuned to the cost of back pain not just in workers’ compensation claims but also on the health claims side of the ledger as strains accumulate, said Chuck Smithers, interim CEO of the National Business Coalition on Health. “You step off the ladder the wrong way over the weekend and then you get into the office, and all of a sudden the chairs aren’t very ergonomic and so it ends up exacerbating the problem.”
The goal of these various back initiatives, proponents say, is to short-circuit what some describe as a cascading effect, in which employees get pricey imaging tests that highlight a back issue that might or might not be causing their pain and thus are referred to surgery.
Last April, the Pacific Business Group on Health added a spine initiative to its Centers of Excellence program, in which participating employers pay for both workers’ travel and medical costs to encourage them to pursue a multifaceted spine evaluation at a designated facility.
“One of the things that has been most interesting for me, from talking to our surgeons, is how many cases they see where someone is coming in for the second or third procedure because the first one never should have been done,” said Ross, who oversees the Centers of Excellence program.
Fostering better joint mobility at the General Dynamics plant, which officials implemented after contracting with Tallahassee, Florida-based Integrated Mechanical Care Inc. in 2011, has already paid off on the workers’ compensation side, according to data Harris provided. The plant, which spent $6,555 on lumbar claims in 2013 and an additional $5,814 in 2014, paid out just $370 during the first six months of 2015.
Evidence vs. Practice
An analysis by the San Francisco-based Integrated Benefits Institute revealed that almost 25 percent of workers report experiencing lower back pain, a problem that ends up costing employers $51,400 annually per 100 employees in lost productivity and medical treatments. Yet data show that despite clinical guidelines stressing the importance of less-aggressive interventions such as physical therapy, it hasn’t made a significant dent in practice.
From 1999 through 2010, the percentage of patients sent for physical therapy remained unchanged at 20 percent while referrals to other physicians increased from just under 7 percent to 14 percent, according to a 2013 study in the journal Spine. The use of narcotics also increased. They were prescribed for 19 percent of back pain cases in 1999 vs. 29 percent in 2010. The costly images like CT scans and MRIs also increased. They were ordered in 7 percent of cases in 1999 vs. 11 percent a dozen years later.
Some surgeries, such as repairing a herniated disc in an active worker, can potentially offer relief, said Dr. Richard Deyo, a lower-back-pain researcher based at Oregon Health & Science University in Portland. But other surgeries, most notably spinal fusions for back pain alone (without any nerve pain down the leg, called sciatica), continue to increase.
Those fusions are “the most controversial because we have clinical trials suggesting that the surgery may not result in much better results than rehabilitation alone,” Deyo said. A 2012 study in the journal Spinefound that the number of spinal fusions had more than doubled, increasing 137 percent from 1998 to 2008.
Back operations are driven in part by vivid imaging tests like MRIs, Deyo said. By the age of 50, nearly everyone will have some evidence of a bulging or degenerated disc or other sort of spinal abnormality, he said. “The problem there is once you see these things, both the doctor and the patient may be alarmed and feel like they have to do something, even though that may not be the cause of the pain,” he said.
Preventing the Cascade
The Pacific Business Group on Health’s addition of the spinal initiative is an attempt to head off that procedural snowball effect, joining the Centers of Excellence’s programs targeting cost-effective care for hip and knee replacements.
JetBlue Airways Corp., Lowe’s Companies Inc. and Wal-Mart Stores Inc. were the first employers to sign up, and Ross anticipates that as many as a half-dozen employers will join the spine program by 2017. They are working with several designated hospitals to refer employees and dependents — typically those who have already been recommended for back surgery — to travel to the facility for a full work-up and discussion of related options with a physical therapist, a surgeon and other clinicians, Ross said.
It’s a voluntary program, but there are some built-in incentives, said Bob Ihrie, Lowe’s senior vice president of compensation and benefits. Participants don’t have a copay or deductible for the medical consults at the facility and related treatment, including surgery if recommended, as well as the travel costs for themselves and a companion, he said.
“Many employees who maybe couldn’t afford the surgery under our regular medical plan might choose to go to the Center of Excellence and they have minimal or no costs,” said Ihrie, who said any costs would be confined to follow-up such as post-surgery rehabilitation closer to home.
Based on Lowe’s first year of joint replacement data from 2014, the evaluation does reduce the likelihood of surgery, according to data Ihrie provided. Of the 231 cases referred to a Centers of Excellence facility, 15 percent were not deemed a surgical candidate. Of those, 92 percent still hadn’t gone through with the surgery six months later, said Ihrie, who anticipates that the back nonsurgery rates will be similar if not higher given research data on overuse.
“People want to say it’s a cost play,” Ihrie said. “For us it’s more of a quality play, really, a quality of life for our employees.”
It’s too early to detail any results for the Pacific Business Group’s spine initiative, but in the first seven months through Oct. 31, 2015, nearly 300 employees or dependents called the Centers of Excellence program for more information, Ross said. Of those, roughly half were referred to one of the designated facilities, which by late 2015 included Seattle’s Virginia Mason Medical Center, Mercy Hospital in Springfield, Missouri, and Geisinger Health System in Danville, Pennsylvania.
By Oct. 31, 78 individuals had visited one of the hospitals for a surgical evaluation. (Some may plan to go but are still scheduling the trip, Ross added.) Of those, 28 underwent surgery, several had another procedure on-site such as an injection, and the remaining 46 were told that they wouldn’t benefit from an operation. “Every single one of those people was told in their home market that they needed to have surgery,” Ross said.
Back surgery is expensive, with a spinal fusion of the lower back most typically costing $70,000 to $90,000, Ross said. “You can imagine if an employer even is paying for five or 10 of these [surgeries] a year that they shouldn’t be, it’s an enormous expense,” Ross said. And that’s before factoring in recovery time off the job and perhaps additional surgeries down the line, she said.
The technique used by physical therapists and chiropractors at Integrated Mechanical Care builds upon a physical therapy approach called the McKenzie Method, which uses assessment and not imaging tests to determine whetherpain can be eased through a series of movements to counter daily and often repetitive joint stressors.
Today’s workplaces, for example, can inflict undue strain on the back, whether someone is working at a computer or on an assembly line, said Chad Gray, a physical therapist and the company’s president. “They are bent forward all day long, but never bend back in the opposite direction as far as they can go,” he said. “What’s going to happen over time is that they are going to gradually lose movement and become stiff.”
One of the priorities of the company, which is working with nearly a dozen employers including General Dynamics and Michelin North America, is tracking employee outcomes. Integrated Mechanical Care’s data show that 9 out of 10 people with lower back pain can be treated, according to Gray. (The remaining 10 percent might have a psychological cause or another component that’s more difficult to resolve, he said.)
Of those, 95 percent have some kind of mechanical cause, such as pressure on the nerve in the spine, that can be counteracted with recommended movements, he said. The remaining 5 percent of patients either suffer from an inflammatory cause and might require an injection or likely needs surgery, he said.
At Michelin North America, the company has brought Integrated Mechanical Care clinicians on-site to evaluate and assist employees with lower back pain or other musculoskeletal complaints at the company’s several on-site health centers and a few other worksites, said Jeni Marconi, worksite health and wellness manager for the Greenville, South Carolina, company. Along with diagnosing and preparing treatment plans, the clinicians also have assisted with on-site ergonomics, such as looking at ways that employees can interact with the equipment to better protect their joints, she said.
The employees at General Dynamics continue to be diligent about performing their daily start-of-shift movements, with participation exceeding 95 percent, Harris said. In 2014 the plant did a reboot, bringing the employees back for an additional session of roughly half an hour “to explain the anatomy and physiology of why” the movements are helpful, Harris said.
“The goal there was that, if you understood, then you would understand why we wanted you to do it more than once or twice a day,” she said, such as when an employee is lifting a fishing boat out of the water some Sunday.
The Integrated Mechanical Care lumbar treatment approach has proven to be nearly 40 percent cheaper compared with traditional care, according to data from one company’s health claims presented last fall at the International Conference in Mechanical Diagnosis and Therapy. The average 12-month cost was $1,749 for the 165 employees with back pain who were treated by an Integrated Mechanical Care clinician — costs that included any follow-up surgery or procedures if needed — compared with $2,905 for the slightly more than 4,400 who got traditional care, according to Dr. Ron Donelson, a spine specialist and study co-author.
The analysis incorporates health insurance claims only and doesn’t reflect related costs, such as workers’ compensation or disability, said Donelson, a proponent of nonsurgical care including the McKenzie approach. Those additional figures once collected, he said, hold the potential to “greatly increase the savings.”
Mobility benefits that companies like General Dynamics and Lowe’s hope will pay off for employees on and off the job.