David A. Wong, MD, past president of the North American Spine Society and current co-chairman of the NASS Value Task Force, recently moderated a panel on the value of spine care at the North American Spine Society Annual Meeting.
He also gave a presentation titled "Specific Examples of CER: establishing "value" for reimbursement."
"If you hear someone talking about value based care, you read that as cost containment because that's what the whole deal is about," said Dr. Wong. "The proviso of the whole thing is in order to do that, you've got to do a number of things. You've got to have a system in place to measure, analyze and target down to specific elements to where you might have some influence in your system."
He went on to discuss the basic economic analysis methodologies:
• Cost minimization
• Cost utility
• Cost effectiveness
• Cost benefit
Each method either defines the quality outcomes or cost differential between treatments to decide which is most beneficial for coverage. As administrators decide whether to approve or pay for surgical or non-surgical interventions, if the outcomes are the same they are more likely to pay for the lower-cost option.
"As we all know, with the practice of clinical medicine, the devil is in the details and part of the problem is how you apply the different methodologies," said Dr. Wong.
He used the example of a 2000 study published in Spine titled "Cost-Effectiveness of Fusion With and Without Instrumentation for Patients with Degenerative Spondylolisthesis and Spinal Stenosis." The study showed similar fusion rate and clinical improvement between patients undergoing laminectomy and non-instrumented fusion with patients undergoing laminectomy and instrumented fusion.
The non-instrumented fusion showed $56,000 per QALY with assumed 70 percent fusion rate 80 percent clinical improvement and the instrumented fusion showed $3.1 million per QALY with assumed 90 percent fusion and 80 percent clinical improvement. However, if you assume a 90 clinical improvement on the instrumented fusion, the cost effectiveness ratio goes down to $82,400 per QALY.
"It's an interesting deal and if you remember back to the Herkowitz studies to where two years after doing the randomized control trial, fusion or no fusion about the same in terms of clinical outcomes. When Kornblum looked at the same group at eight years, that's how long it took to see the difference clinically between the people who had fusion versus no fusion," said Dr. Wong, begging the question of what timeframe it's appropriate to apply the comparative effectiveness research methodologies.
Another study out of Denmark published in the European Spine Journal in 2007 looked at incremental cost effectiveness ration for 136 consecutive patients undergoing a lumbar spinal fusion for chronic low back pain. The patients undergoing uninstrumented PL fusion reported $16,500 on average while the instrumented PL fusion was $17,400 on average. The average for PL fusion with interbody was $22,600.
"If you are talking to the administrator who is pulling the data from one side, you have to be aware of some of the things that make your case a little better," said Dr. Wong. He moved on to another study showing that the cost per QALY over time gets lower if you get a durable result. "If you get a good result that goes out four or five years, that's where all of a sudden the cost effectiveness description and cost per QALY goes down to a pretty acceptable type rate."
Finally, Dr. Wong addressed total disc arthroplasty; most cost effectiveness studies are focused on cervical arthroplasty. He found a difference in using the SF-36 data instead of the NDI data of around $10,000 when looking at the cost per QALY data.
"We just have to be aware of things so we aren't taken by surprise and beaten down by the folks out there that are looking to just save costs. We've got to be our own patients' advocates in this and advocate for ourselves as well," said Dr. Wong.
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