Over the past decade the number of spinal fusions performed in the United States has grown immensely, and payers have taken notice. A study published in the January 2012 issue of Spine found a 137 percent increase in spinal fusion from 1998 to 2008 with the bill jumping from $4.3 billion to $33 billion.
Lead author of the study Hyun Bae, MD, offered several factors to the increase:
• Aging baby boomer population entering the demographic most likely to seek spine care;
• Advances in technology allowing physicians to treat a wider variety of spinal conditions;
• Innovation allowing surgeons to achieve fusion more easily and safely;
• Larger number of fellowship-trained spine surgeons;
• And additional research on the indications of spinal procedures.
While fusions experienced tremendous growth over the past decade, large growth is projected in the non-fusion spine device market for the next five years. Technologies such as artificial disc replacement, dynamic stabilization and interspinous process decompression are projected to lead the growth of the global spine market to $8.7 billion in 2018, according to a Research & Markets Analysis.
As a result, insurance companies and consumers are now more interested than ever in controlling healthcare costs, and spine surgery accounts for a large amount of healthcare dollars. In late 2010, Blue Cross Blue Shield of North Carolina announced it would no longer cover lumbar fusions for patients with degenerative disc disease as the only indication, a procedure that had been routinely covered in the past.
Since then, several other insurance companies have set rules based on the Milliman Guidelines, which recommend against spinal fusions for DDD as the only indication. A multitude of studies examining the efficacy of spinal fusions compared with conservative treatment, and now non-fusion surgical treatments, offer competing results as to the efficacy of the procedure. Surgeons are reporting push-back from insurance companies covering certain procedures and many are now providing more patient data than in the past.
"We are seeing payers increasingly push for stronger documentation of conservative treatment plans prior to non-emergent surgery," says Danielle Koelbl, president of MedRev Solutions, a healthcare revenue cycle and receivable management company. "I suggest spine practices make sure their teams are reviewing top volume payer qualities to ensure they are following conservative care pathways. We don't want the payers dictating care, but it's important to know what conservative care treatment plans they require, what they deem standard of care and figure out whether that's in line with what your physicians perform and suggest."
Earlier this year, BCBSNC again tackled spine surgery coverage, but this time for artificial discs. The payer launched the "Let's Talk Costs" website, citing artificial discs as a "less effective" technology for spine care, citing a 2008 article from the New York Times. The International Society for the Advancement of Spine Surgery sent a letter outlining issues with the company's portrayal of spinal arthroplasty.
Surgeons are taking several measures to ensure patients have access to appropriately indicated care. If insurance companies deny a procedure, in many cases surgeons can appeal that decision and will schedule a peer review meeting with the company's representative or medical director.
"I first approach peer review calls with politeness and try to give them as much information as possible," says Paul Slosar, MD, President of SpineCare Medical Group, San Francisco Spine Institute. "If we get a denial I usually write a very direct and specific letter about the case, also adding some information about my credentials as well. There are very few doctors doing these reviews who are as well published or credentialed as I am, and if they are interfering with my care of a patient, I don't hesitate to point that out. I also tell the patients to get involved and call the medical director. If all else fails, I send the case out to the Spine Care Alliance (www.spinecarealliance.org), as they specialize in getting denials approved."
Some insurance companies, such as HealthPartners in Minnesota, promote programs that encourage back pain patients to see a non-surgical specialist before seeing the surgeon to discuss best treatment options. The new program, launched in 2012, aimed to cut the $28.3 million the company spent on spine surgeries in 2011.
Cigna HealthCare partnered with Wyoming Neuroscience and Spine and Elkhorn Rehabilitation Hospital in Casper, Wyo., last year to launch a similar program aimed at reducing spine care costs while improving and maintaining quality care.
"There is a clinic we've set up specifically in Casper that is managed by a physiatrist who is the gatekeeper," says David E. Mino, MD, MBA, Cigna HealthCare National Medical Director, Orthopedic Surgery and Spinal Disorders. "He promoted education of the program within the community. We also work with primary care physicians, rehabilitation staff and others in the local community to disseminate the program. We want to work with primary care physicians and help them provide the typical care to their patients."
In the year since the program began, Dr. Mino reports positive feedback on the multidisciplinary approach to spine care. This month, Blue Cross Blue Shield of Michigan, Blue Care Network, Henry Ford Health System and eight Michigan Hospitals launched an initiative to measure and improve care and outcomes for patients undergoing spine surgery. They hope to reduce complications and revision surgeries by collecting and analyzing data through the Michigan Spine Surgery Initiative.
"We are designing a data registry for this program that will allow participating surgeons and hospitals to do 'real time' analysis of their own results relative to their colleagues around the states," said Stephen Bartol, MD, MBA, Henry Ford Hospital orthopedic surgeon and co-director of MSSIC, in a press release.
Spine surgeons across the country also face accountable care organizations, bundled payments and other value-based performance models as more payers and health systems move away from fee-for-service reimbursement. While spine-specific efforts in new payment models are few and far between, they are gaining traction in orthopedics and a trend toward more multidisciplinary spine care in collaboration with payers seems successful to achieve access to appropriate care for spine patients.
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