Dr. Slosar's Blast Email
Two weeks ago, 38 (and counting) emails piled into my inbox from an impressive list of U.S. spine surgeons. Throughout the day, emails streamed in as one surgeon after another banged out their reactions to one, single, particular email.
Dr. Paul J. Slosar’s email.
Dr. Slosar hit the send button on Monday November 29th. “I’d asked my wife to read it before I sent it out. I didn’t want to send out a long and rambling email. But I started thinking about what to say while I was sitting at a faculty conference a couple weeks ago. I’d gotten wind of a new Blue Cross Blue Shield policy on spine fusion reimbursement. Frankly, it made me acutely depressed and angry.”
On Tuesday four guys responded. On Wednesday the responses doubled. On Thursday all hell broke loose. The reaction to Slosar’s email showed that he had tapped into a well of frustration among spine surgeons. Each surgeon post triggered another one, then another one. By mid-day on Thursday, the online dialogue had grabbed the attention of probably a hundred practicing surgeons, a handful of surgery department heads as well as the presidents and boards of the North American Spine Society (NASS) and the ISASS (formerly SAS) and the CEO of one billion dollar spinal implant manufacturer.
The source of this spontaneous group reaction was a proposed spine fusion reimbursement policy from Blue Cross Blue Shield of North Carolina. For some reason the BCBSNC note—more than other recent news, and there has been other policy and reimbursement setbacks for spine surgeons lately—plucked a nerve.
Slosar’s two page “Call to Action” opened with these words: “I apologize for the length of this communication….but (I am writing this because of) my emotional concerns for the health and well-being of my patients as well as my love for my profession.”
Dr. Slosar, 48 years old, conducted his residency at Loyola University in Chicago, has degrees from the University of Illinois/Rush Medical College and is a spine surgeon at SpineCare Medical Group in Daly City, California.
“Dr. Slosar”, I asked, “What was it about this specific Blue Cross Blue Shield policy statement that prompted you to write your note?”
“Where I practice, in Northern California, it is progressively more difficult to get approval for spine fusion surgery. When we ask why we received a rejection letter, we often hear something about the Milliman guidelines which no one seems to have a copy of. We’re getting rejection letters for cases and plans of treatment that we’ve been doing every day for years. Bread and butter stuff. Spine surgeons who treat low back pain have been singled out unfairly.”
“In our clinic I practice state-of-the-art spine surgery using standard indications for lumbar fusions. We get the best results we can for our patients and they are good to excellent with 75-80% of our patients reporting that they are significantly improved and satisfied with their results after fusion surgery. We’ve had elite athletes who are now pain free. Recently I operated on a law enforcement officer who can now return to duty again. I could go on and on.”
“When I heard about and then read this BCBS policy statement it just hit me. I can’t do the job that I have trained my whole life to do. It sucked the wind right out of me. How many patients will have to live lives of debilitating pain because of this proposed policy? I don’t think my patients realize what draconian restrictions are being placed on standard-of-care treatments by the insurance companies.”
The Proposed Blue Cross Blue Shield Spine Fusion Policy
On September 28, 2010, BCBSNC issued a policy statement regarding coverage for lumbar spinal fusion which BCBSNC said would take effect in January 1, 2011. The relevant section is excerpted in the following:
(From the 9/28/10 policy statement from Blue Cross Blue Shield of North Carolina):
When Lumbar Spine Fusion Surgery is covered: BCBSNC will provide coverage for Lumbar Spinal Fusion procedures for any one of the following conditions:
- Spinal Fracture with instability or neural compression
- Spinal repair surgery for dislocation, abscess or tumor
- Spinal Tuberculosis
- Spinal Stenosis with ALL of the following:
- Associated spondylolisthesis demonstrated on plain x-rays; and
- Any one of the following:
- Neurogenic claudication or radicular pain that results in significant functional impairment in a patient who has failed at least 3 months of conservative care and has documentation of central/lateral recess/or foraminal stenosis on MRI or other imaging. or
- Severe or rapidly progressive symptoms of neurogenic claudication or cauda equina syndrome.
- Severe, progressive idiopathic scoliosis (i.e., lumbar or thoracolumbar) with Cobb angle > 40 degrees.
- Severe degenerative scoliosis with any one of the following:
- Documented progression of deformity with persistent axial (non-radiating) pain and impairment or loss of function unresponsive to at least 3 months of conservative therapy, or
- Persistent and significant neurogenic symptoms (claudication or radicular pain) with impairment or loss of function, unresponsive to at least 3 months of conservative care.
- Spondylolisthesis, isthmic (type II), with documented progression of slippage, and with persistent back pain (with or without neurogenic symptoms), with impairment or loss of function, unresponsive to at least 6 months of conservative nonsurgical care.
- Recurrent, same level, disk herniation, at least 6 months after previous disk surgery, with recurrent neurogenic symptoms (radicular pain or claudication), with impairment or loss of function, unresponsive to at least 3 months of conservative nonsurgical care, and with neural structure compression documented by appropriate imaging, and in a patient who had experienced significant interval relief of prior symptoms.
- Adjacent Segment Degeneration, at least 6 months after previous fusion, with recurrent neurogenic symptoms (radicular pain or claudication), with impairment or loss of function, unresponsive to at least 3 months of conservative nonsurgical care, and with neural structure compression documented by appropriate imaging, and in a patient who had experienced significant interval relief of prior symptoms.
- Pseudarthrosis, documented radiographically, no less than 6 months after initial fusion, with persistent axial back pain, with or without neurogenic symptoms, with impairment or loss of function, in a patient who had experienced significant interval relief of prior symptoms.
Please Note: This policy addresses specifically the circumstances under which arthrodesis (fusion) surgery of the lumbar spine is considered medically necessary. It does not address decompression surgery.
When Lumbar Spine Fusion Surgery is not covered: BCBSNC will not provide coverage for lumbar spine arthrodesis (fusion) surgery when it is considered not medically necessary.
- Lumbar spine arthrodesis (fusion) surgery is considered not medically unless one of the above conditions is met.
- Lumbar spinal fusion is also considered not medically necessary if the sole indication is any one or more of the following conditions:
- Disk Herniation
- Degenerative Disk Disease
- Initial Discectomy/laminectomy for neural structure decompression
- Facet Syndrome
Several elements of the BCBSNC statement caught the attention of spine surgeons. Here are the top four.
Lumbar spine fusion surgery for degenerative disc disease (DDD) only is not covered—DDD is the most common diagnosis for lumbar fusion surgery. A significant number of patients report debilitating pain as a result of disc degeneration. Prior to the advent of low profile, internal fixation devices, minimally invasive surgical procedures, biologic adjuncts to fusion or advanced nerve monitoring and surgical positioning systems, the predominate indication for lumbar fusion surgery was spinal deformity or extreme instability (spondylolisthesis, trauma or tumor). The BCBSNC policy by disallowing DDD is being perceived as an attack on a “bread and butter” treatment alternative for spine surgeons and would push the practice of spine surgery back to an earlier era.
Reimbursement is allowed for adjacent DDD but not for primary DDD—It’s hard to understand this distinction. Natural degenerative processes of all aspects of the human musculoskeletal system are well documented in the literature and, to be perfectly plain about it, in the daily practice of medicine. In the case of a perhaps “more noble” degenerative process (osteoarthritis of the hip or knee) there is NO debate regarding reimbursement. But adjacent level disc degeneration instead of primary disc degeneration? Seriously?
The threshold curvature for scoliosis reimbursement is >40o—According to a small sample of spine surgeons we interviewed, the most recent and best scientific studies indicate that threshold curvature is closer to 30o but that, at any rate, the lumbar fusion surgery decision for scoliosis is multi-factorial and new diagnostic techniques (like ScoliScore) can improve outcomes by employing this multi-factorial approach to patient selection and treatment.
Lack of peer review science and the appearance of bias in the BCBSNC guidelines—Thousands of peer review journal articles are already available which provide the statistical foundation for improving patient outcomes with surgery when conservative care has demonstrably failed. Instead of looking at those outcome studies, BCBSNC cited articles by long-time fusion critics Deyo and Weinstein to support their guidelines.
ISASS or NASS?
The public forum that flashed into existence from Slosar’s email included comments from and about two of the spine surgeon societies—North American Spine Society and the International Society for the Advancement of Spine Surgery (formerly SAS). ISASS Executive Director Kristy Radcliffe reminded Slosar’s audience that ISASS had sent an email alert regarding the BCBSNC policy before Slosar’s email and was in the process of rallying other societies. Current ISASS President Tom Errico. M.D., who sent out a blast email alert to ISASS members of the BCBSNC pending policy statement said: “I believe that our society, in responding to the North Carolina situation and others like it, needs to take a strong stand at this time.”
NASS Executive Director Eric Muehlbauer watched all of the email traffic on Thursday and then early on Friday weighed in saying: “The most respected organizations are the ones who are strong enough to make reasonable statements, acknowledge weaknesses in arguments and highlight areas where further action and discussion are needed. NASS has been at this a long time. Insurers often come to us for our opinion and we are very judicious about our responses.”
Regardless, the most significant aspect of last week’s spine surgeon email wave is that it occurred spontaneously. In that golden moment the spine surgeon community said very clearly that they are deeply worried and that their core interests are beyond any particular society or company but rather, as Dr. Slosar said, for “…for the health and well being of my patients, as well as my love for my profession.”