Spinal Fusion Costs Spur Insurance Changes
Written by Editor   
Tuesday, July 08, 2014 07:20 AM

Over the past two decades, the search for relief from back pain led skyrocketing numbers of Americans to a costly procedure that bonds vertebrae together. But as evidence mounted that spinal fusion surgery was used too often for the wrong people, insurer Cigna decided in 2011 to see how its own members had fared.  The news was startling: 87 percent of customers who had spinal fusion to treat pain due to wear and tear on spinal discs were still in so much pain two years later that they needed more therapies or drugs. Nearly 15 percent had more surgery. Total cost of the post-surgery claims: $11 million. That's on top of the initial fusion surgeries, which can carry price tags of $100,000 each, though insurers don't pay that much.

There is a growing number of private insurers that limit the circumstances in which they'll pay for spinal fusions. In part because of this trend, the phenomenal growth in spinal fusions — a case study in the debate over runaway health costs — should slow down, according to a report last month from London-based industry analyst GlobalData.

But the nation's biggest insurer, Medicare, has no authority to require up-front approval for the procedures. It can only try to recover money it has paid for surgeries later deemed unnecessary.  Medicare's own auditors say the government insurance program for seniors and the disabled is wasting money on many fusions for lower back pain. In 2012, the program improperly spent $120 million on lumbar spinal fusions, according to the auditors' November report.

A former senior official with the Centers for Medicare & Medicaid said spinal fusion is a prime example of Medicare's failure to control questionable spending. Congress would have to give Medicare wider latitude to pre-approve payments, he said, in order for it to get a better handle on costs for certain elective treatments. But leaders show no signs of acting on a recommendation that likely would infuriate Medicare patients, physicians, and the medical industry.

While spinal fusion can be profitable, that isn't the only issue driving the increase, experts say. Back pain is notoriously difficult to treat, and patients who are suffering may demand what they perceive as more powerful treatment than conservative measures like medication, physical therapy and for overweight patients, weight loss.

The North American Spine Society this year recommended nine indications for lumbar fusions. Degenerated discs are included but only when they meet certain criteria, including a failure to respond to conservative therapies.  

Spinal fusion surgery is a major procedure that permanently connects two or more vertebrae, stabilizing a damaged spine.  Surgeons place bone or bone-like material between the pair, and may use devices such as plates, screws and/or rods to hold them together. Fusion changes the way the spine moves, which can mean additional stress above and below the fusion, possibly leading to disc degeneration there.

Source:  http://www.tampabay.com/news/health/spinal-fusion-costs-spur-insurance-changes-but-can-medicare-follow/2185334


In another source it is reported that many patients unfortunately believe that lumbar fusion will result in local pain relief. The goals of lumbar fusion are typically to provide stability and provide relief from radicular pain. This disconnect may account for some of the 87% of patients who were still experiencing pain two years post-surgery. In any case, papers like the one below show us that patients should exhaust ALL conservative care prior to surgery in non-emergency situations.

The article questioned whether other insurers and Medicare would follow suit. Here are five findings from the report:

1. Almost 15 percent of patients who underwent spinal fusions had more surgery. A study of Medicare claims from 2005 to 2009 shows readmission rates for spinal stenosis decompression were 8 percent to 10 percent with and without fusion.

2. The total cost of post-surgery claims was $11 million. An Agency for Healthcare Research and Quality statistical brief shows spinal fusions are one of the costliest procedures in the United States. In 2011, spinal fusions cost an average of $12.8 million, with the average cost per hospital stay at $27,600. There were around 465,000 hospital stays for spinal fusion in 2011.

3. Cigna tightened coverage after seeing the results of the report. Several other insurance companies have changed their coverage protocol over the past few years, adding stricter indications for spinal fusion.  Blue Cross and Blue Shield of Kansas made spinal fusion coverage changes in 2013 and one year later patients feel their access to care is limited even after multiple in-network surgeons deem the procedure medically necessary.

4. Medicare doesn't have upfront approval for spinal fusions, but can recover money for surgery later deemed unnecessary. A report shows Medicare improperly spent $120 million on lumbar fusions in 2012. The tighter indications for spinal fusion and a challenging reimbursement market led to predictions that in the United States' share of the spinal fusion market will shrink from 71 percent in 2013 to 63 percent in 2020. At the same time, developing markets are expected have larger growth; China will gain 5 percent market share, making their entire market share 10 percent in 2020.

5. A Dartmouth Atlas Health Care report found where patients get surgery depends more on where they live and how surgeons practice medicine there than overall protocol for medical necessity. The report examines Medicare enrollees in 2002 and 2004, showing surgical rates varied by a factor of more than 20 across the country.  The report also found that in 80 hospital referral regions, lumbar fusion rates were around 30 percent higher than the United States average. However, in 98 hospital referral ranges, rates were more than 25 percent lower than the national average."

Source:  theevidencebasedchiropractor.com