The NCQA Back Care Recognition Program may be a good idea—but do we need another reporting activity?

One of the most common ailments that orthopaedists see—and often feel overwhelmed by—is low back pain. Most of us believe that we do a good job of making appropriate treatment decisions for patients with low back pain. But we often make these decisions based on our years of experience or what we were taught in medical school.

The advent of evidence-based medicine, however, is challenging many of these “tried-and-true” methods. Those of us who support an evidence-based clinical approach do so with the hope that the latest scientific evidence will help us provide more appropriate care for our patients, with better resultsand improved clinical/economic value.

A commendable effort
The National Committee for Quality Assurance (NCQA)—and its new Back Care Recognition Program (BCRP)—should be congratulated on its efforts to create an appropriate, evidence-based treatment plan for low back pain. The participation by several AAOS members on the program’s development committee adds further credibility to this plan.

The NCQA Web site states that the BCRP program will recognize physicians who deliver superior care to patients with low back pain. It also says that following the recommendations will help the patient avoid unnecessary treatment, tests, and expenses.

Under the program, an individual physician would submit 35 patient evaluations as a data sample. Larger practice groups may submit 25 patient evaluations per participant, with a maximum of 200 evaluations per practice group. The required package and application fee to participate in the BCRP program for a single physician is $530, and the fee increases with the number of physicians at that practice site.

Based on that sample, a physician must score at least 40 points on NCQA’s 100-point scale. The tangible reward for doing so is inclusion on NCQA’s published report card list of “recognized” physicians, which is widely distributed. Other possible benefits could include addition to insurers’ preferred physicians lists and/or a favorable score on a performance measure for pay-for-performance programs.

On the other hand
BCRP is still early in its real-world application. The only comparable programs to date are the NCQA’s recognition programs for diabetes and heart/stroke. When I reviewed the physician report card for Tennessee doctors participating in these programs, I found only nine physicians in three Tennessee practices. In California, on the other hand, 2,027 physicians were recognized by these programs; Florida had 132 participating physicians, and New York had 594 recognized

participants. Guam had none and Alabama had two. It appears that physician participation and recognition in NCQA programs varies widely in different regions of the country.

The AAOS Washington office and the Board of Councilors have both worked for many years to defer implementation of a “Centers of Excellence” concept (steering reimbursements toward only those high-volume practice centers that meet arbitrarily high standards at the expense of smaller practices). Even though AAOS fellows participated in developing the NCQA back pain recognition program, the result may be very similar to the Centers of Excellence concept put forward by the Centers for Medicare and Medicaid Services.

Another parallel may be made with the development of certificates of added qualifications for physicians, which the AAOS has opposed. Although the American Board of Orthopaedic Surgery now sanctions these certificates, the NCQA’s recognition program could be seen as providing a similar distinction.

An additional burden?
Although I support the BCRP for the reasons I noted, I am concerned for smaller group practices that choose not to participate because they are already overwhelmed with patients and overextended. They don’t need the added burden of yet another data-reporting activity. The question then becomes, do smaller practices that follow evidence-based guidelines not deliver superior care simply because they do not report their activities to the BCRP? Is one more overhead expense worth the potential reward? Is one more administrative task worth the overhead cost? Is there really a financial benefit to the practice?

The AAOS Guidelines Oversight Committee will soon be developing evidence-based clinical guidelines and performance measures for low back pain. I recommend that AAOS members follow these new developments closely and embrace the evidence-based information that the new guidelines incorporate. Implementing these new guidelines and performance measures once they are developed is crucial and requires widespread support and cooperation from the fellowship.

Whether or not an orthopaedic practice chooses to participate in the BCRP should be based on a careful review of all factors. The bottom line is, if orthopaedists use evidence-based medicine and follow evidence-based clinical practice guidelines that are based on the best available scientific evidence, our patients will be the ultimate winners.