Becker Spine produced an extremely informative piece on Cigna's recent report on lumbar spinal fusions. You can find the piece below and a direct link at the bottom.
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. Build the interdisciplinary relationships necessary to ensure your neighbors are afforded every option prior to surgery.
From Becker Spine, "In 2011, Cigna examined spinal fusion patients and found 87 percent of customers who had fusions were still experiencing pain and undergoing additional therapies or drugs two years later, according to a report from the Tampa Bay Times.
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, according to a Medscape report.
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. Earlier this month, anarticle in a local Kansas newspaper reported that the 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 Research and Markets to predict 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. Spinal fusion rates were highest in these areas:
• Idaho Falls, Idaho
• Missoula, Montana
• Mason City, Iowa
• Bradenton, Florida
• Casper, Wyoming
The rates were lowest in these areas:
• Bangor, Maine
• Covington, Kentucky
• Terre Haute, Indiana
• Grand Forks, North Dakota
• Newark, New Jersey
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."
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