William Taylor, MD, vice chairman of academic affairs and neurosurgeon at UC San Diego Health System, discusses the biggest coverage challenges for spine surgery heading into 2013. Dr. Taylor is also a past president of the Society of Minimally Invasive Spine Surgery and continues to serve on the board of directors.
Q. How has coverage for spine surgery changed over the past few years?
Dr. William Taylor: Coverage continues to change on a regular basis, not only for approvals, but for the decisions and surgical intervention for each process leading up to that. There is significant more work, time, effort, energy and requirements needed to proceed with repeat X-rays, CT scans, MRIs and any other preoperative workup. This also includes EMGs and intraoperative monitoring. Also, as we now know, we'll soon begin to cover postoperative complications.
In addition, the people making the decisions will no longer speak with a professional in your office, whether it be your assistant, PA, nurse practitioner or whoever does the approvals in your office. They will only speak with the physician and insist on using, abusing and monopolizing a surgeon's time. My feeling is that knowing how much more difficult it is to provide services for each patient; how time consuming it has become to obtain approvals and that, in many instances, de facto coverage or non-coverage decisions get made based on surgeon availability; and whichever insurance plan is easier to work with or whichever approval is easier to get, the physicians' offices are much more likely to work with the easier plan and patients are much more likely to get their care faster than a person with a difficult insurance.
Q: What factors are driving change in spine surgery coverage?
WT: Stakeholders are attempting to identify procedures which do not offer patients significant chances for better outcomes. They're trying to get rid of repeat surgeries for low back pain, for example. As can be seen from the literature, pain isolated to the low back and not accompanied by appropriate exam or radiologic findings may not be well treated by surgical intervention.
Patients who have received multiple procedures or have limited opportunity for outcome improvement based on the results randomized trials. So they're trying to avoid and deny procedures for patients who have been operated on multiples times. That's really my understanding of what they're trying to go after and where they're trying to limit coverage. If someone had five surgeries, they're not going to be eligible for a sixth or a seventh. Or if a patient has low back pain but doesn't have supporting documentation, they won't usually be eligible for surgery. The insurance companies and stakeholders are trying to limit surgical interventions.
Unfortunately, what happens is many very appropriate patients get swept up into these decisions. People who would clearly benefit from surgery, based on surgeon experience or individual needs get swept up in the non-coverage decisions based on static, limited and arbitrary guidelines. Coverage decisions are increasingly made not on surgeon recommendation of medical necessity but on cost benefit analysis, which works well for a population-based study but not for the individual, struggling patient. Therefore, decisions based on what works well for the entire population may not hold true for the individual. For example, if 30 percent of people see improvement from a procedure, and you're one of the 30 percent, you're happy. But 70 percent are not going to see improvement. Stakeholders are looking at broad coverage decisions rather than individual patients.
Q: What do you anticipate will be the biggest issues facing spine surgeons for covering procedures next year?
WT: I would anticipate a continued erosion of routine coverage for any fusion and/or instrumented fusion procedure, with decisions based on strict, static and unrealistic instability guidelines, which are not realistic for all patients.
In addition, there continues to be a trend towards limiting new, modern, minimally invasive and/or less routine procedures. The best example of this is non-coverage decisions and experimental guidelines put forth by many insurance companies for cervical artificial discs. Total disc replacement of the cervical spine is a very well-studied procedure with multiple level I prospective, randomized, multi-center and blinded studies, all of which have been published along with excellent follow-up.
As an example, it is absolutely clear based on literature that an artificial cervical disc does not represent in any way an experimental procedure. And yet multiple, large insurance companies have branded this as such and are trying to not cover an artificial disc. A procedure which is in any way out of the ordinary will be increasingly scrutinized and/or designated as experimental despite available literature, studies and the preferences of individual surgeons.
Q: How can spine surgeons meet and overcome these challenges?
WT: At the current time, the coverage landscape has been dominated by decisions made from for-profit review companies and institutions hired as outside consultants. Spine surgeons have had to review these articles after they come out and then play catch up rather than be put in a position to lead the charge. Our national institutions and societies have been unable to take a leadership role in advocacy, coverage and decision making, which would prevent other stakeholders from dominating this landscape.
The reality is that an insurance company comes out and indicates they're not going to provide coverage, and then the societies have to respond. The insurance companies are using guidelines often by consultants they support. The literature and track record for the artificial disc in the cervical spine a perfect example. Pushback on its coverage and continuing to call it an experimental procedure demonstrates a limited view of patient needs and individual surgeon preference.
Spine surgeons must financially and professionally support societies that work towards not just preserving existing coverage and coding, but become proactive in identifying areas that would be of benefit to all parties. I would propose and foresee societies supported by surgeons and industry specifically tasked with advocacy and generating surgical guidelines that are based upon patient-centered responses rather than a cost-benefit analysis.
Q: Where do you see spine surgery coverage headed in the future?
WT: Unless a significant effort is made by national and international societies, coverage will continue to erode and new products and new treatments, which may benefit patients, will not be brought to market, tested and/or developed.
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