Re­think­ing spine care

Some health sys­tems are mov­ing be­yond surgery in serv­ing back pain pa­tients

Modern Healthcare - - NEWS - By Jaimy Lee

The rapid growth in spinal surgery vol­umes over the past 20 years has prompted pay­ers, pol­icy ex­perts and some spine sur­geon groups to call for a reap­praisal of spine care in the U.S.

That’s partly why Legacy Health, a self-in­sured hospi­tal sys­tem based in Port­land, Ore., in 2012 be­gan re­quir­ing its em­ploy­ees and their fam­ily mem­bers who were seek­ing elec­tive spine surgery to go through a pre-sur­gi­cal as­sess­ment in­clud­ing meet­ings with a phys­i­cal ther­a­pist and a psy­chol­o­gist. Legacy acted af­ter find­ing that a sig­nif­i­cant num­ber of pa­tients in its pain pro­gram were there fol­low­ing un­suc­cess­ful back surg­eries.

Pa­tients of­ten have un­re­al­is­tic ex­pec­ta­tions about spine surgery, said Katie O’Neill, Legacy’s di­rec­tor of clin­i­cal and sup­port ser­vices. She said they may think, “I’m go­ing to get my spine surgery and in three weeks I’m go­ing to walk nor­mally.” But, she added, “that’s not what’s go­ing to hap­pen.”

Legacy’s em­ployee pro­gram ini­tially was re­sisted by surgeons and pa­tients, but many now praise it, she said. While the num­ber of spinal pro­ce­dures has not dropped, the pro­gram has been suc­cess­ful enough that later this year, the sys­tem plans to open a spine care cen­ter that of­fers the same ar­ray of ser­vices for nonem­ployee pa­tients. “It’s not to elim­i­nate surgery, but to (help pa­tients) get to the right surgery,” O’Neill ex­plained. “And if they’re not sur­gi­cal can­di­dates, they (need to) get to the right modal­ity.”

Legacy Health is one of a num­ber of hos­pi­tals and health sys­tems around the coun­try that are re­think­ing how they pro­vide spine care, given the mount­ing re­search ev­i­dence that too many Amer­i­cans are un­der­go­ing un­nec­es­sary spinal pro­ce­dures and ex­pe­ri­enc­ing mixed out­comes. The steep jump in spine surg­eries in the late 1990s and 2000s has prompted many health in­sur­ers to tighten cov­er­age poli­cies for par­tic­u­lar in­di­ca­tions and pro­ce­dures, par­tic­u­larly spinal fu­sion for de­gen­er­a­tive disc dis­ease in the lower back. Stud­ies have found that non­sur­gi­cal treat­ments are more likely to help these pa­tients.

Still, providers rec­og­nize there are no easy an­swers in this area. Pa­tients who seek spinal care of­ten are suf­fer­ing se­vere pain and disability, doc­tors face pres­sure to pro­vide quick re­lief, and clin­i­cal an­swers may be murky. Hov­er­ing over all that are pow­er­ful fi­nan­cial in­cen­tives for doc­tors and hos­pi­tals to per­form surgery. The chal­lenge is fig­ur­ing out the ap­pro­pri­ate in­di­ca­tions for surgery where the sci­ence is in­ex­act.

“By the time people get to a sur­geon, they’re frus­trated and want to be fixed,” said Dr. Christo­pher Kauff­man, an or­tho­pe­dic sur­geon in Nashville who serves on the Amer­i­can Academy of Orthopaedic Surgeons’ cod­ing and re­im­burse­ment com­mit­tee.

Spinal fu­sion, which fuses ver­te­brae to­gether to treat back pain and is com­monly done in the lum­bar re­gion of the lower back, is by far the most com­mon spine pro­ce­dure in the U.S. About 87% of spinal pro­ce­dures in 2013 were fu­sion-based, ac­cord­ing to the re­search firm Glob­alData.

There were more than 465,000 fu­sion op­er­a­tions in the U.S. in 2011, com­pared with 252,400 in 2001, ac­cord­ing to the Agency for Health­care Re­search and Qual­ity. The es­ti­mated cost of spinal fu­sion pro­ce­dures was more than $12.8 bil­lion in 2011, ac­cord­ing to AHRQ. Hospi­tal costs alone for a pro­ce­dure aver­age $27,568. To­tal costs can hit six fig­ures for ma­jor spinal fu­sion pro­ce­dures, ex­perts say.

The vol­ume of spine surgery in the U.S. is about dou­ble the rate in Canada, Western Europe, and Aus­tralia, and about five times the rate in the

United King­dom, ac­cord­ing to Dr. Richard Deyo, a pro­fes­sor of ev­i­dence­based medicine at Ore­gon Health & Sci­ence Univer­sity who has pub­lished stud­ies of spine surgery ap­pro­pri­ate­ness and out­comes.

Ex­perts ex­pect the vol­ume in the U.S. to con­tinue to grow over the next five years. That will be driven by ag­ing but still-ac­tive baby boomers, the shift to less-in­va­sive pro­ce­dures per­formed in out­pa­tient set­tings, ag­gres­sive mar­ket­ing by surgery cen­ters and de­vice man­u­fac­tur­ers, and fi­nan­cial in­cen­tive ar­range­ments be­tween man­u­fac­tur­ers and surgeons. Medi­care ben­e­fi­cia­ries are ex­pected to be the fastest grow­ing mar­ket.

Spine surgeons have prof­ited from the fu­sion boom. Me­dian com­pen­sa­tion for U.S. or­tho­pe­dic spine surgeons in 2012, not in­clud­ing an­cil­lary in­come, was $730,246, mak­ing them the sec­ond high­est-paid surgeons af­ter or­tho­pe­dic hip and joint surgeons, ac­cord­ing to the 2013 MGMA Physi­cian Com­pen­sa­tion and Pro­duc­tion Sur­vey. That com­pared with me­dian com­pen­sa­tion of $538,533 for all or­tho­pe­dic surgeons.

“Spinal fu­sion is one of the top 10 (pro­ce­dures) that most pay­ers are look­ing at the rate of in­creased uti­liza­tion, ag­gre­gate spend­ing and the like­li­hood of con­tin­ued in­creases based on de­mo­graph­ics,” said Dr. Sean Tunis, CEO of the Cen­ter for Med­i­cal Tech­nol­ogy Pol­icy in Bal­ti­more.

In 2011, Blue Cross and Blue Shield of North Carolina, fac­ing a nearly 50% jump in costs for spinal fu­sion surgery from 2004 to 2009, be­came one of the first in­sur­ers to tighten its cov­er­age pol­icy for the pro­ce­dure, ex­clud­ing cov­er­age for de­gen­er­a­tive disc dis­ease. The in­surer—which found that more than half the pa­tients who had un­der­gone spinal fu­sions had never seen a phys­i­cal ther­a­pist be­fore surgery— now rec­om­mends three months of non-sur­gi­cal treat­ment be­fore surgery can be ap­proved. Within one year of the new pol­icy, it saw a 30% de­crease in pro­ce­dures. While there was a 10% uptick in spinal de­com­pres­sion op­er­a­tions, over­all costs for pa­tients with lower back pain dropped sig­nif­i­cantly.

“Spine surgery is nu­mero uno… in

“Spine surgery is nu­mero uno… in the top ech­e­lon of top cost driv­ers.”

—Dr. Andy Bonin, med­i­cal di­rec­tor of ap­peals for Blue Cross and Blue Shield of North Carolina

the top ech­e­lon of top cost driv­ers,” said Dr. Andy Bonin, med­i­cal di­rec­tor of ap­peals for the in­surer.

Cigna also changed how it cov­ers lum­bar fu­sion, said Dr. Julie Kes­sel, Cigna’s se­nior med­i­cal di­rec­tor for cov­er­age pol­icy. The in­surer in late 2010 re­quired that pa­tients par­tic­i­pate in a physi­cian-su­per­vised pro­gram in­clud­ing ex­er­cise, phys­i­cal ther­apy and be­hav­ioral ther­apy for six months be­fore they can be au­tho­rized for surgery.

These changes fol­low grow­ing alarms from med­i­cal ex­perts about the in­ap­pro­pri­ate use of spinal fu­sion. In a 2011 pol­icy state­ment on lum­bar fu­sion, the In­ter­na­tional So­ci­ety for the Ad­vance­ment of Spine Surgery said “in­creas­ing suc­cess and op­ti­mism may be leading some surgeons to overuse pro­ce­dures be­yond what the cur­rent state of med­i­cal ev­i­dence re­ally sup­ports.” The vary­ing rates of spine surgery, it added, sug­gest “a lack of col­lec­tive ad­her­ence to the cur­rent state of med­i­cal ev­i­dence.”

Many ex­perts say fu­sion should not be rou­tinely used for steno­sis, her­niat- ed discs, or disc de­gen­er­a­tion where ac­com­pa­ny­ing prob­lems of spinal in­sta­bil­ity or de­for­mity are not present. A 2006 Medi­care eval­u­a­tion by a panel of physi­cians found that it was less than rea­son­ably likely that spinal fu­sion would pro­vide a long-term ben­e­fit for pa­tients suf­fer­ing from de­gen­er­a­tive disc dis­ease. That find­ing was never trans­lated into Medi­care cov­er­age pol­icy.

Adding to the scru­tiny is that the cost of de­vices used in spinal pro­ce­dures has risen, driven in part by new and in­no­va­tive prod­ucts. Those higher de­vice costs have led in turn to the rise of physi­cian-owned distrib­u­tor­ships (PODs), which are med­i­cal sup­ply com­pa­nies owned by doc­tors that prom­ise to of­fer hos­pi­tals lower prices for com­mod­ity-type prod­ucts such as sur­gi­cal screws and plates.

Federal of­fi­cials, tra­di­tional de­vice mak­ers and hospi­tal sys­tems have be­come in­creas­ingly con­cerned that PODs give surgeons who in­vest in them an in­ap­pro­pri­ate fi­nan­cial in­cen­tive to per­form more spine pro­ce­dures. Last year, the HHS’ Of­fice of

the In­spec­tor Gen­eral re­ported that hos­pi­tals pur­chas­ing spinal im­plants from PODS have higher rates of spinal pro­ce­dures than hos­pi­tals that don’t deal with PODs. That scru­tiny has prompted some ma­jor hospi­tal sys­tems to an­nounce plans to stop buy­ing sup­plies from PODs.

Some surgeons and spinal de­vice man­u­fac­tur­ers have crit­i­cized the new, more re­stric­tive in­sur­ance poli­cies, ar­gu­ing that the doc­u­men­ta­tion process for ob­tain­ing payer ap­proval is overly time-con­sum­ing and the cri­te­ria can in­ap­pro­pri­ately limit ac­cess to needed surgery. Spine surgeons and their in­dus­try al­lies have been po­lit­i­cally suc­cess­ful in the past in block­ing tougher scru­tiny of back op­er­a­tions.

“It’s got­ten to the point where you’re rec­om­mend­ing an oper­a­tion, and the in­sur­ance com­pany is say­ing no. The pa­tients feel as though they are stuck in the mid­dle,” Kauff­man said.

Hos­pi­tals have re­lied on spine surgery as a top-per­form­ing ser­vice line, and it’s still a ma­jor source of rev­enue. But they are re­think­ing their ap­proach. “Un­til now, spine surgery was a big win­ner for gen­er­at­ing rev­enue for hos­pi­tals and surgeons. That

Putting back pain pa­tients un­der one roof re­duces in­ap­pro­pri­ate vari­a­tions in care.

hasn’t com­pletely changed,” Deyo said. But “with health­care re­form and more health plans go­ing to some form of a cap­i­tated model, the fi­nan­cial in­cen­tives are chang­ing.”

With the grow­ing con­sen­sus about overuti­liza­tion of surgery, some hos­pi­tals are turn­ing sur­gi­cal pro­grams into com­pre­hen­sive spine-care pro­grams that of­fer an ar­ray of treat­ments, in­clud­ing phys­i­cal ther­apy, pain man­age­ment, psy­cho­log­i­cal care and dif­fer­ent types of sur­gi­cal pro­ce­dures. It’s es­ti­mated that only one in 10 pa­tients with lower back pain will need surgery, surgeons and ex­perts say.

These com­pre­hen­sive spine pro­grams “are not as lu­cra­tive as surgery, but the vol­ume is there,” said Shruti Tiwari, a con­sul­tant for the Ad­vi­sory Board Com­pany’s re­search and in­sights di­vi­sion. “Spine surg­eries are still go­ing to in­crease. (But) the rapid growth we saw in the last decade is not go­ing to hap­pen any­more.”

Beth Is­rael Dea­coness Med­i­cal Cen­ter in Bos­ton es­tab­lished its Spine Cen­ter in 2008 and now serves as a one-stop-shop for back pain pa­tients. The cre­ation of the cen­ter was driven by a need to bet­ter co­or­di­nate care, said Dr. Kevin McGuire, a spine sur­geon and the Spine Cen­ter’s co-di­rec­tor. “It takes off some of the pres­sure on the pri­mary-care doc­tor about who to send the pa­tient to,” he said.

The cen­ter is staffed by four surgeons and 11 non-sur­gi­cal providers in­clud­ing po­di­a­trists and pain-man­age­ment spe­cial­ists and sees be­tween 500 and 600 pa­tients per month. Some may be ap­pro­pri­ate can­di­dates for spinal fu­sion or other sur­gi­cal pro­ce­dures. But most will end up re­ceiv­ing non-sur­gi­cal treat­ment, McGuire said.

Putting back pain pa­tients un­der one roof re­duces in­ap­pro­pri­ate vari­a­tions in care. “We pro­vide bet­ter care for the pa­tient now than we did be­fore,” he said.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.