Current and Emerging Payment Models for Spine Pain Care: Evidence-Based, Outcomes-Based, or Both?

This chapter describes two major payment models relevant to the diagnosis and treatment of spine pain. The first is the assessment of the actual outcomes of care delivered, with emphasis on patient-reported outcomes such as pain and functional capacity (“outcomes-based”). The second comprises aggregated past observations in patient groups comparable to the current patient scheduled to receive a treatment (“evidence-based”). Payment decisions are then based upon whether differences were observed in the outcomes of treatment and control groups in the prior studies, preferably conducted as prospective randomized controlled trials. In practice, these two approaches are linked: evidence is typically gathered to assess specific outcomes, and findings of effects upon outcomes contribute to selecting one among many possible treatments and strategies to monitor that treatment’s effectiveness. We further describe a widely used computerized adaptive testing instrument (the Patient-Reported Outcomes Information System, “PROMIS”). We note actions underway by the US Federal insurance system to apply financial, merit-based performance incentives (“MIPS”) to encourage systematic collection and comparisons of treatment outcomes in a range of patient care settings. We conclude by touching on blockchain technology, an innovation that may grow in importance in health care by virtue of its facilitation of collection and pooling of individual patients’ detailed characteristics, care received, and outcomes achieved while maintaining their anonymity.