Dr. Chris Bono: 5 Trends in Coverage for Spinal ProceduresWritten by Laura Miller | July 05, 2011
Insurance carriers across the country are scaling back the coverage indications for spine surgery, which could potentially leave spine surgeons without the ability to treat thousands of patients who could benefit from surgical intervention. Spine surgeons and societies have been working to increase awareness of the efficacy of surgical intervention for the appropriate patients, but it hasn't been an easy road.
Chris Bono, MD, spine surgeon at Brigham and Women's Hospital in Boston and chair of the Professional Economic and Regulatory Committee of the North American Spine Society, discusses five points on coverage for spinal fusions.
1. Making coverage decisions based on research. Over the past few years, insurance companies have been increasingly basing their coverage decisions on the research available, and the quality of research on spinal procedures isn't always very strong. "Up until recently, there were several studies showing that a procedure like vertebroplasty worked and many surgeons thought it showed good outcomes," says Dr. Bono. "Then, there were one or two high level studies that weren't supportive of the procedure and the whole world turned upside-down."
For procedures such as vertebroplasty, insurance companies latched onto newer studies questioning its efficacy. "The insurance companies are using these studies as sole inputs into evidence-based medicine, but for now they are just the one component — the evidence," he says. "By definition of evidence-based medicine, you also have to consider the patient's expectations and the experience of the treating clinician. These factors are effectively being ignored by the insurance companies right now because they are making decisions based on scientific studies only."
2. Combining evidence-based research with professional expertise. Evidence isn't only the component directing patient care; it also includes a component of professional opinion from the specialists. Unfortunately, most insurance companies are only focused on the research element when devising an algorithm for treatment. "In the past, insurance companies would rely and accept almost solely on the physician's judgment for treatment, but I think those days are over," says Dr. Bono.
To combat the "no data, no coverage" approach, NASS is in the beginning stages of developing appropriate use criteria that includes both research and clinician experience for the treatment of various different clinical scenarios. "On the organizational level, societies like NASS will continue to respond and address policies in which we call for appropriate use for our patients heading into the future," he says.
3. Decreasing the cost of care. Insurance companies today are deeply invested in decreasing the cost of care, which has played a role in some of the new coverage policies and decisions. Earlier this year, the Blue Cross Blue Shield of North Carolina tightened its coverage policy on spinal fusions, and now denies coverage for patients with degenerative disc disease. Insurance providers in several states are also drafting policies based on the Milliman Guidelines, which recommend against spinal fusions for DDD patients.
"The insurance companies say they want to do what is best for the patients, but a second upfront reason for these changes has to do with decreasing costs," says Dr. Bono. "Right now, the pendulum is swinging against procedures such as vertebroplasty and lumbar fusion. NASS has looked at the coverage policies that have been revised and updated, and they all have a decreasing number of clinical indications that will be considered medically necessary and approved."
4. Pushback from companies even when the indications are met. Dr. Bono says insurance companies are more diligent than ever in reviewing coverage for spine surgery, especially for lumbar fusion. "There have been a few instances where I thought my patient had clear indications for fusion, but then I still had to answer probing questions from the insurance company," says Dr. Bono. "I followed their checklist of best practices and made sure the patients had conservative treatment and injections before undergoing surgery and that the decision to proceed with fusion was based on the best evidence and practice. However, the insurance companies are still checking up to make sure."
The physicians reviewing coverage requests for the insurance company often aren't spine surgeons, which presents ongoing problems for the surgeons trying to receive coverage for the appropriate patients. "It's going to be a constant battle for the next five to 10 years," says Dr. Bono. "I think there are some procedures and products that will go away, and they probably should. Other products, such as bone morphogenic proteins, will be used in a much more reserved fashion for fewer cases. However, if the surgeon feels it should be used, they will need to fight for it regardless of the initial coverage decision."
5. Challenging coverage decisions. Surgeons can challenge coverage denials for patients on an individual level by appealing to the insurance company. "If a procedure is denied and you feel it would be best for the patient, you can make the case for coverage to the insurance company," says Dr. Bono. "Unfortunately, not all the time when someone is appealing is it justified, and the insurance companies have to weed through and see where it is important and where it isn't. They sort through the appeals to make sure someone isn't trying to make an extra buck, that the patient is really in need of the proposed procedures."
Some surgeons have asked NASS for data on the different procedures to help with the appeals process. The success rate for receiving coverage is really hit or miss, says Dr. Bono, but making sure the patient has undergone the conservative treatment modalities can help strengthen the case for elective surgical intervention.
Learn more about Dr. Chris Bono.
Related Articles on Spine Surgery:
Spinal Fusion Reimbursement: Q&A With NASS President Dr. Greg Przybylski
Spinal Fusion's Place in the Future: 9 Points on Fusion Efficacy and Coverage
5 Points on Spine Patient Advocacy
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