A patient with coronary artery disease walks in to the cardiologist's office in Tucson and the evaluating cardiologist recommends a stent. That same patient could walk into a cardiologist's office in New York City, Dallas or Des Moines, Iowa, and hear the same treatment recommendation. The standard practice for that patient's condition is to implant a stent, and cardiologists across the country agree.
The same isn't true for back pain.
A patient with degenerative disc disease could walk into a spine clinic, see the four different surgeon partners and receive four different treatment recommendations based on pathology, history, and the surgeon's expertise. If all the surgeons in the same practice wouldn't treat a single patient the same way — from the diagnosis to procedure technique to the instruments used — then how can we expect surgeons across the country to define the best course of action?
"We have to figure out what works and what doesn't," says Scott Blumenthal, MD, co-founder of Texas Back Institute in Plano. "Spine surgeries, particularly fusions, are so highly scrutinized today. And surgeons are defending them as good procedures. If they are so good, why are there three or four different ways to approach the same patient?"
Healthcare is moving toward standardization to achieve the best outcomes possible at the best economic value. But variation in the spine market is particularly high, with anterior, posterior and lateral techniques, among others, to choose from. Some tools "feel better" in one surgeon's hand, while in another they are clunky; surgeons develop a rhythm in training and straying heightens any mistakes.
Some surgeons are more aggressive than others, choosing between surgery and nonoperative techniques. Others expand surgical options even further to include fusion or disc arthroplasty.
"To me, when there is more than one way to fix a problem, that tells us we really don't know how to best fix it," says Dr. Blumenthal. "Payers are finding more loopholes today to deny payment for spine surgery."
One area payers are cracking down on now is off-label use. In the past, surgeons tweaked FDA-approved devices for new indications or different uses and could still receive reimbursement; now, some insurance companies hide behind the off-label indications as a reason to avoid payment.
"If we want to apply a device in a custom way for our patient, it's a problem now whereas it wasn't a problem before," says Dr. Blumenthal. "They just won't pay for it. And in some cases FDA approval alone isn't enough for insurance companies to approve coverage."
Case in point, artificial disc replacement. There are cervical and lumbar artificial discs with FDA clearance but some payers don't always approve those surgeries. Even with multi-year data showing equal outcomes — and in some cases superiority — to spinal fusion, insurance companies balk at payment.
"There are very few insurance companies that will pay for two-level disc replacements even though LDR has a two-level approved disc and studies showing effectiveness," says Dr. Blumenthal. "They did all the work to prove it's a high quality procedure."
And technology continues to evolve. Engineers and surgeons are collaborating to develop biologic solutions that slow down disc degeneration, which could add another step to treating back pain. But if insurance companies see biologic solutions as a stop gap before potential fusion they may not pay.
Robotic technology is another emerging trend, although surgeons using the high-cost equipment for increased precision don't receive any more reimbursement than surgeons who use the freehand technique. And there isn't a definitive answer as to which is better.
"I think robotics is the future, along with stem cell and biologic treatments," says Dr. Blumenthal. "Those technologies are hot, but hospitals and insurance companies don't want to pay for them until they're validated."
There are some practices moving toward standardization, including North Carolina Neurosurgery & Spine. All practitioners in the group follow the same, mutually-agreed-upon protocol for treating patients with specific conditions. The treatment pathway and protocols were developed with studies and advanced analytics showing the best value patients — cost and quality.
Standardization will likely grow as healthcare moves toward value-based payment and consolidation. Solo and small group practitioners in many markets are looking for ways to affiliate and align with larger organizations to share the burden of running a practice today. Part of the larger organization will be data gathering through electronic health records, and surgeons can analyze their data — as well as others within their system — to discover new best practices.
"Academic practices — the privademic — will be a trend going forward," says Dr. Blumenthal. "These are the private practices that do research and track data and outcomes, like Texas Back Institute or Rothman Institute. You need to have access to patients because payers won't talk to you unless you have the data showing you are effective. You'll have to integrate with larger entities and participate in data collection; that's the only way we are going to survive."