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 evidence-based 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 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.”