Spine surgeons, focusing on spinal fusion, identify five ways to lower the cost of spine care when all other treatment methods are exhausted.
1. Appropriate indications for spinal fusion. A lot more money stands to be made on performing spinal discectomies instead of decompressions, and some surgeons may perform unnecessary surgeries for financial gain. However, even well-meaning spine surgeons may be driving up the cost of spinal healthcare by performing fusions on patients who are at a high risk for needing revision surgeries, such as young patients or patients with adjacent level disease.
"If someone has a fusion at one level, does all conservative therapy and the operation is a success, there's still a chance the patient will come back with an adjacent level disease," says Michael Finn, MD, a neurosurgeon in the department of neurosurgery at the University of Colorado. "If the patient has arthritis at one level, they are predisposed for adjacent level disease because of their medical history and because the degeneration is quickened by stress from the previous fusion."
Other times, surgeons perform fusions on patients who would benefit from conservative treatment. When a patient comes in for the initial visit, some surgeons assume they have exhausted all non-operative methods already. However, this isn't always the case. "You want to get to know the patients before surgery and make sure they have done the whole gamut of conservative management and really have a motivation to get better," says Sumeer Sathi, MD, a neurosurgeon with Long Island Neurosciences in East Patchogue, N.Y.
2. Treating patients with multi-level disease. In the late 1990s, Dr. Sathi says many surgeons felt a strong push from the spine community to treat chronic low back pain with a variety of approaches. At the same time, there was a strong push from the interbody device companies to perform surgical interventions.
"Our feeling is that with a limited number of patients, this type of procedure can be successful," says Dr. Sathi. "When we limit our procedures to single-level patients and choose them carefully, our success rates are in the 90 percent range. When we do less discriminating, our results are similar to the literature saying there is a 50-70 percent success rate. It's not worth rolling the coin to say they might be better or they might not. If they have multiple-level disease, we steer them toward minimally invasive procedures." Not all spine surgeons are this cautious, which may have contributed to the rise of spinal fusions, failed back surgery syndrome and multi-level fusions over the past few years.
In his practice, Dr. Finn has found that patients with degenerative disc disease or back pain correlating with certain characteristics on imaging studies, such as disc space collapse or loss of fluid signal on the disc, tend to experience good outcomes from the single-level fusions. However, when patients have a fusion at more than one level, the predictability of the outcome goes down, he says.
3. Increased scrutiny from private payors. Spine surgeons across the country are experiencing increased scrutiny from private payors, possibly due to the increasing number of unnecessary spinal fusions in some regions. "I've noticed a difference in the payor's willingness to reimburse for some spinal procedures," says Dr. Finn. "I think that makes sense because there are a lot of patients who come in with failed back surgery syndrome who have had multiple-level fusions that shouldn't have been performed in the first place." In some states, such as Minnesota, private payors are asking for intensive non-operative treatment before pre-approving spinal fusions to make sure surgeons are using operative treatment as a last resort.
Some insurance companies have spine surgeons or other medical physicians review cases before approving them for surgery, which is something Dr. Sathi has experienced. "We've been able to proceed with the surgery because our indications are strong," he says. "Sometimes, we have to speak with these physicians personally before they will give us authorizations. We are also finding these physicians aren't experienced spine surgeons or orthopedic surgeons, but any physician. They are following protocol and policy to see if it fits the criteria for having surgery. I don't have a problem with scrutiny from the appropriate people, but it would be helpful if it were someone who is an experienced spine surgeon who understood the conditions and can render a helpful decision."
Future reimbursement for spinal procedures will most likely require high levels of evidence proving a procedure is effective for the patient. "We're going to have to come up with a little better evidence and rationale if we want to keep getting paid for what we do," says Dr. Finn. "It's disheartening for surgeons who have been performing the surgeries for only the appropriately indicated patients."
4. Even studies show mixed results on the efficacy of fusions. There are a few indications, such as patients with tumor or instability, where most professionals agree spinal fusions are necessary. However, even the high-level studies we currently have render mixed results for spinal fusions performed on patients with degenerative disorders or low back pain. Part of the reason for the differences in outcomes is from the patient's medical and physical background. Beyond physical traits and characteristics, it's also difficult to randomize and control studies on spine surgery. "You can't take 100 patients with disc herniation and not give them a choice as to whether they want surgery or to continue conservative treatment," says Dr. Finn. "You have to include the patient in the decision making."
Even in the SPORT trial, patients who were initially put into the conservative treatment group, but obviously needed more care, crossed groups to receive surgery. Several studies are not considered when creating guidelines for spine surgery because they aren't class one data. "We have to be able to rely on more than class one data," says Dr. Finn.
Additionally, studies are now relying more on patient evaluation methods, such as the Oswestry scale and disability scale, instead of purely clinical or radiographic measurements to show good outcomes. "We can see a difference in patients who come to us in pain and then report better pain scale scores after treatment," says Dr. Finn. "From these scores, I think we can make a reasonable claim when patients feel better after surgery."
5. Treatment for workers' compensation patients. It's important to indicate the appropriate patients for surgery to achieve the best possible outcomes. However, appropriately indicating patients for surgery goes beyond examining their physical characteristics. Surgeons must also assess the patient's psychological health and motivation to recover. In many cases, workers' compensation patients can be problematic because they often have psychological instabilities and little motivation to return to work, says Dr. Sathi. "We try to minimize exposure to workers' compensation patients unless there is a motivation from the patient to get better," he says. These patients have also often been on pain medication for an extended period of time, which can cause further complications.
Read other coverage on spinal fusions:
- Spinal Fusion's Place in the Future: 9 Points on Fusion Efficacy and Coverage
- Spinal Fusion Reimbursement: Q&A With NASS President Dr. Greg Przybylski
- ISASS President Dr. Thomas Errico: Spinal Fusion Coverage Update
1. Appropriate indications for spinal fusion. A lot more money stands to be made on performing spinal discectomies instead of decompressions, and some surgeons may perform unnecessary surgeries for financial gain. However, even well-meaning spine surgeons may be driving up the cost of spinal healthcare by performing fusions on patients who are at a high risk for needing revision surgeries, such as young patients or patients with adjacent level disease.
"If someone has a fusion at one level, does all conservative therapy and the operation is a success, there's still a chance the patient will come back with an adjacent level disease," says Michael Finn, MD, a neurosurgeon in the department of neurosurgery at the University of Colorado. "If the patient has arthritis at one level, they are predisposed for adjacent level disease because of their medical history and because the degeneration is quickened by stress from the previous fusion."
Other times, surgeons perform fusions on patients who would benefit from conservative treatment. When a patient comes in for the initial visit, some surgeons assume they have exhausted all non-operative methods already. However, this isn't always the case. "You want to get to know the patients before surgery and make sure they have done the whole gamut of conservative management and really have a motivation to get better," says Sumeer Sathi, MD, a neurosurgeon with Long Island Neurosciences in East Patchogue, N.Y.
2. Treating patients with multi-level disease. In the late 1990s, Dr. Sathi says many surgeons felt a strong push from the spine community to treat chronic low back pain with a variety of approaches. At the same time, there was a strong push from the interbody device companies to perform surgical interventions.
"Our feeling is that with a limited number of patients, this type of procedure can be successful," says Dr. Sathi. "When we limit our procedures to single-level patients and choose them carefully, our success rates are in the 90 percent range. When we do less discriminating, our results are similar to the literature saying there is a 50-70 percent success rate. It's not worth rolling the coin to say they might be better or they might not. If they have multiple-level disease, we steer them toward minimally invasive procedures." Not all spine surgeons are this cautious, which may have contributed to the rise of spinal fusions, failed back surgery syndrome and multi-level fusions over the past few years.
In his practice, Dr. Finn has found that patients with degenerative disc disease or back pain correlating with certain characteristics on imaging studies, such as disc space collapse or loss of fluid signal on the disc, tend to experience good outcomes from the single-level fusions. However, when patients have a fusion at more than one level, the predictability of the outcome goes down, he says.
3. Increased scrutiny from private payors. Spine surgeons across the country are experiencing increased scrutiny from private payors, possibly due to the increasing number of unnecessary spinal fusions in some regions. "I've noticed a difference in the payor's willingness to reimburse for some spinal procedures," says Dr. Finn. "I think that makes sense because there are a lot of patients who come in with failed back surgery syndrome who have had multiple-level fusions that shouldn't have been performed in the first place." In some states, such as Minnesota, private payors are asking for intensive non-operative treatment before pre-approving spinal fusions to make sure surgeons are using operative treatment as a last resort.
Some insurance companies have spine surgeons or other medical physicians review cases before approving them for surgery, which is something Dr. Sathi has experienced. "We've been able to proceed with the surgery because our indications are strong," he says. "Sometimes, we have to speak with these physicians personally before they will give us authorizations. We are also finding these physicians aren't experienced spine surgeons or orthopedic surgeons, but any physician. They are following protocol and policy to see if it fits the criteria for having surgery. I don't have a problem with scrutiny from the appropriate people, but it would be helpful if it were someone who is an experienced spine surgeon who understood the conditions and can render a helpful decision."
Future reimbursement for spinal procedures will most likely require high levels of evidence proving a procedure is effective for the patient. "We're going to have to come up with a little better evidence and rationale if we want to keep getting paid for what we do," says Dr. Finn. "It's disheartening for surgeons who have been performing the surgeries for only the appropriately indicated patients."
4. Even studies show mixed results on the efficacy of fusions. There are a few indications, such as patients with tumor or instability, where most professionals agree spinal fusions are necessary. However, even the high-level studies we currently have render mixed results for spinal fusions performed on patients with degenerative disorders or low back pain. Part of the reason for the differences in outcomes is from the patient's medical and physical background. Beyond physical traits and characteristics, it's also difficult to randomize and control studies on spine surgery. "You can't take 100 patients with disc herniation and not give them a choice as to whether they want surgery or to continue conservative treatment," says Dr. Finn. "You have to include the patient in the decision making."
Even in the SPORT trial, patients who were initially put into the conservative treatment group, but obviously needed more care, crossed groups to receive surgery. Several studies are not considered when creating guidelines for spine surgery because they aren't class one data. "We have to be able to rely on more than class one data," says Dr. Finn.
Additionally, studies are now relying more on patient evaluation methods, such as the Oswestry scale and disability scale, instead of purely clinical or radiographic measurements to show good outcomes. "We can see a difference in patients who come to us in pain and then report better pain scale scores after treatment," says Dr. Finn. "From these scores, I think we can make a reasonable claim when patients feel better after surgery."
5. Treatment for workers' compensation patients. It's important to indicate the appropriate patients for surgery to achieve the best possible outcomes. However, appropriately indicating patients for surgery goes beyond examining their physical characteristics. Surgeons must also assess the patient's psychological health and motivation to recover. In many cases, workers' compensation patients can be problematic because they often have psychological instabilities and little motivation to return to work, says Dr. Sathi. "We try to minimize exposure to workers' compensation patients unless there is a motivation from the patient to get better," he says. These patients have also often been on pain medication for an extended period of time, which can cause further complications.
Read other coverage on spinal fusions:
- Spinal Fusion's Place in the Future: 9 Points on Fusion Efficacy and Coverage
- Spinal Fusion Reimbursement: Q&A With NASS President Dr. Greg Przybylski
- ISASS President Dr. Thomas Errico: Spinal Fusion Coverage Update