General Session: Value and Outcomes in Spine Surgery

Presented by: P. Park - View Audio/Video Presentation (Members Only)


R. Goodman(1), C. Powell(2), P. Park(3)

(1) Blue Care Network of Michigan, Southfield, MI, United States
(2) University of Michigan, Center for Statistical Consultation and Research, Ann Arbor, MI, United States
(3) University of Michigan, Neurosurgery, Ann Arbor, MI, United States


Importance: Low back pain (LBP) is prevalent. Concern exists that spinal fusion is over-utilized for LBP.

Objective: To evaluate the impact of a health plan's prior authorization (PA) programs on use and cost for LBP in a non-Medicare population by assessing changes in pre-surgical non-operative care; lumbar fusion trends; and overall back surgery rates compared to another health plan with a similar program and national benchmarks. The PA programs require mandatory physiatrist consultation before allowing referral for surgical consultation, with subsequent additional LBP surgery PA. Setting: Health maintenance organization (HMO) with commercial membership averaging > 500,000 annually. Participants: HMO commercial members aged 18-65 years, and a subset of 501 members who underwent lumbar fusion during the period 1-1-2008 through 12-31-2013. Main outcomes and measures: Annual rates of lumbar fusion trending over 6 years. Standardized costs for LBP-related services among the 501-member subset.

Results: After initiation of the physiatrist PA in December 2010, lumbar fusions decreased from 76.27/100,000 in 2010 to 62.63/100,000 in 2011. However, there were subsequent increases to 64.24/100,000 and 73.84/100,000 in years 2012 and 2013, respectively. For members who had lumbar fusion, there were increased per-member, pre-surgical costs of $2,233 with the physiatrist PA and an additional $1,370 with implementation of the LBP surgery PA (March 2013). Spinal injections (23.2%) and inpatient admissions (18.5%) were the two greatest contributors to the overall increase in pre-surgical costs. The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days, respectively.

Conclusions: Mandatory referral to a physiatrist prior to surgical evaluation did not result in persistent reduction in lumbar fusions. Instead, these programs were associated with increased costs from more non-operative care and only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs.