Back pain imaging and vertebroplasty or kyphoplasty for osteoporotic vertebral fractures were among the list of Medicare's "low-value" procedures in 2009, and new studies are examining whether these procedures are overused.
A study published in JAMA Internal Medicine this past week showed even though waste has been identified among some Medicare services, there are few direct measures developed to combat overuse.
"Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial portions of beneficiaries may be reflective of overuse more broadly," the authors concluded. "Performance of claims-based measures in supporting targeted payments or coverage policies to reduce overuse may depend heavily on how the measures are defined."
Here are five thoughts on reducing waste and overuse in spine care:
1. A 2011 study shows intraoperative waste in spine can exacerbate an already costly procedure, estimating more than $126 million in healthcare spending is attributable to intraoperative spine waste. Over a 25-month period when data was collected at one academic medical center, intraoperative waste initially occurred in 20.2 percent of spine procedures; after implementing an educational program, intraoperative waste occurred in 10.3 percent of the procedures. Monthly costs associated with surgical waste also dropped from $17,680 to $5,876.
2. The North American Spine Society began participating in the "Choosing Wisely" campaign last year, and identified imaging tests for lower-back pain as a potential area to reduce unnecessary imaging and costs. A study examining 1,800 people with back pain found those who had imaging tests soon after reporting a problem did not have better outcomes than those who did not have imaging tests, and in some cases did worse. The images also deliver radiation to patients. The cost for lower back X-rays can be $200 to $290 and MRI ranges from $880 to $1,230.
3. A study published in Spine found most patients undergoing single- or multilevel lumbar instrumented fusion don't require routine postoperative radiographs. The researchers followed 63 patients who all received plain radiographs at 269 subsequent visits. During those visits, only approximately 6.3 percent of these visits specialists detected abnormal findings using the radiographs.
When patients presented with new symptoms or deterioration, abnormal findings were reported 22 percent of the time. Only 2.7 percent of asymptomatic patients reported abnormal findings, leading the authors to suggest radiographs be used as indicated clinically instead of routinely.
4. Defensive medicine adds millions to the cost of spine care every year, yet surgeons continue to perform tests with little or no value to the patient to protect themselves from potential medical liability lawsuits. According to a 2006 Harvard School of Public Health Study, 28 percent of all tests and procedures and 13 percent of all hospitalizations were performed to avoid lawsuits. Additional studies show medical liabilities forced 44 percent of neurosurgeons and 55 percent of orthopedic surgeons to stop treating some complex cases. An HHS report from 2003 shows between $70 billion and $126 billion is spent each year on unnecessary tests and procedures, driven in large part by physician concerns about malpractice liability.
A North American Spine Society survey conducted in 2007 showed the average estimated liability premium between 2002 and 2006 was just under $50,000 in 2002 to $60,000 in 2006. However, some individual states have enacted medical liability reforms. After Texas enacted tort reform, there was a 25 percent — or $9,000 — rate drop in two years. Additional medical liability reforms could eliminate spending on unnecessary tests and create substantial savings on spine care.
5. There are several strategies spine surgeons can use to cut waste in their practice, including:
• Not opening supplies until they are used
• Ordering custom supply packs and keeping the packs updated
• Surgeon education on the cost of materials
• Eliminating "upselling" from the operating room
• Develop protocol for imaging and treatment
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