No Spine Care for Congress? | Orthopedics This Week
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No Spine Care for Congress?

Source: Wikimedia Commons and RRY Publications LLC Photo Creation

How upset are spine surgeons in the United States?  On a scale of 1 to 10—about 12.

Here is an excerpt from an email we received from a practicing spine surgeon:

“We should just not electively associate with or treat: attorneys, employees of MCO's or Medicare, government officials, Congress, the Supreme Court, President or bureaucrats or their families for a period of one year—effective 1-1-12.”

And that’s not all. “NO testimony or narrative reports for attorneys for personal injury or any other lawsuits as treating physician or expert witness. NO peer review for insurance companies, etc. Also no participation in ACO's , EHR meaningful use either.”

Clearly this veteran clinician is mad as hell. 

What could possibly have pushed this surgeon to urge his fellow physicians to, in effect, withdraw their talents and skills from attorneys, Medicare and so forth?

Number One Concern of Spine Surgeons for 2012

In Becker’s excellent Orthopedic, Spine & Pain Management web newsletter, writer Laura Miller asked six spine surgeons to discuss their number one concern for spine care in 2012. (Ms. Miller’s entire article is available here). 

To a person, each surgeon said insurers are the #1 concern.

Here are two quotes from Ms. Miller’s article in Beckers (the whole article is very good and we urge our readers to check it out):

“Spine care in America is being destroyed by insurers at an unimaginable and unprecedented rate. Every day spine surgeons are discovering insurance company created roadblocks to their ability to care and provide for their patients. Spine care is very complex and involves many conditions that are difficult to treat. The most common spinal conditions are those causing debilitating pain from the spine. The most common causes of this pain include muscle pain, facet joint pain and pain originating in the spinal disc (discogenic pain). The only treatments available for these types of conditions are medication, therapy, needle procedures and surgery. Every one of these avenues of treatment is currently (and has been for some time) under heavy attack by the insurance industry. Insurers simply don't want to pay for spine care so I predict we will see a dramatic reduction in elective spine care in the near future.” — Ara Deukmedjian, M.D. (Founder, Deuk Spine Institute, Melbourne, Florida)

“The ability to perform procedures due to insurance approval. I have had more denials in the past four months than I had total for the prior two years. Unfortunately, it puts the patients in the middle with nowhere to turn. Another issue is the continuing declining reimbursements while trying to maintain a practice where expenses continue to increase.” — J. Brian Gill, M.D. (Spine Surgeon, Nebraska Spine Center, Omaha)

But Wait, There’s Still More

Eleven months ago we opened OTW up to surgeons with first person accounts of the changing reimbursement landscape.  The response was dramatic.  The message was crystal clear.  Spine patients and their surgeons are in a battle for control of their healthcare.  And they are losing. 

From Indiana:   “We have been dealing with this for over a year. The increasing rate of denials for coverage has resulted in huge frustration for our patients. We have learned that the only way to get them approved is have the patient daily call them and bug them. The insurance companies constantly lie to the patients telling them that it is our fault for not sending appropriate info etc.”

From Arizona:  “65-year-old female (on Aetna) had undergone successful L3-5 laminectomy and fusion for stenosis and degenerative listhesis 2 years ago, achieving a pain free status for over a year. She presented with severe interval degeneration at L2-3 with back pain and stooped forward posture, decreased ability to walk for distance for 1 year. She tried physical therapy, medications, but the back pain and stooping slowly increased. CT scan showed L2-3 stenosis, inadequate lumbar lordosis (flatback), degenerative spondylosis at L5-S1 without stenosis. I recommended hardware removal, laminectomy L2-3, TLIF L2-3 and L5-S1, Ponte osteotomies L2-3 and L5-S1 to recover her lordosis, and posterior fusion with instrumentation L2-S1. — Aetna denied the surgery, stating Milliman Care Criteria.”

From Arizona: “50-year-old male (Aetna) underwent Left L5-S1 laminectomy and discectomy for herniation, with complete pain relief for 5 months. His left leg pain returned though it was most severe along the posterior thigh only, and not down the S1 dermatome. He also developed severe mechanical back pain which was improved by rest. Flexion-extension Xrays did not show instability, but only degenerative disc at L5-S1. New MRI showed typical degenerative L-S1 disc and scar in the operative area but no recurrence of herniation. He tried PT, meds, epidural steroid injections with short term relief only. I recommended fusion at L5-S1, which Aetna denied. ‘This case does not meet the Milliman Criteria’ was the reason.”

From Arizona: "52-year-old male (Humana) with severe back pain for 2 years, bilateral leg pain and numbness, stooping posture, ambulatory with a quad-cane, could walk less than 1/2 block. Xrays showed 18 degrees of degenerative scoliosis L2-5 with rotational listhesis L2-3, L3-4, and flatback. He was severely out of balance in the sagittal plane (stooping forward). MRI showed severe stenosis at L4-5 with less stenosis L2-3, L3-4. I recommended L2-5 laminectomies, Ponte osteotomies to regain lordosis and correct the curve, TLIF and posterior fusion L2-3. Humana denied the surgery because the ‘sports medicine orthopod’ that reviewed it stated that ‘TLIF is an experimental procedure’. I pursued an appeal with someone with spine knowledge, and the reviewing neurosurgeon said ‘there are too many of these fusions being done’. Threatened legal action finally won approval for surgery.”

From Georgia: “I have a patient who is an international jazz singer. Due to L4-5, 5-S1 disc degeneration, she could no longer stand on stage. Her proposed 2-level ALIF was denied based on the Milliman criteria (BCBS). She waited until her husband could change the insurance carrier for his business so that she could proceed with the proposed treatment. She has had an excellent outcome, and is now back touring Europe.  She has indicated her willingness to share her story, as she and her husband were suitably outraged over the whole mess.”

From Oregon: “I was copied on an email this morning indicating that Regence BCBS has adopted the Milliman guidelines, which are perhaps causing surgeons to receive increased denials for fusions for degenerative conditions in Oregon.”

From another surgeon in Arizona: “Today I was told by one of the Aetna reviewers that a patient with a Grade 1 isthmic spondylolisthesis with bilateral foraminal stenosis and bilateral progressive L5 EMG proven radiculopathy did not meet criteria for surgery because she did not have a Grade 2 spondy. It took significant work to get the surgery approved.”

From Massachusetts:  “I have just had a denial on a very solid gentleman in his 40s. He has had increasing pain for over 10 yrs. He has a normal lumbar MRI with the exception of prominent degenerative changes at L4-5. After exhausting conservative measures including injection therapy, he went through a discogram which confirmed L4-5 as his pain generator. After sitting with he and his wife, we decided to pursue an L4-5 fusion. The patient has been saving his vacation time and working in severe pain so that he can use those days for his recovery. MA BC/BS has denied his surgery (and denied his appeal). He will likely go on to lose the job he loves and endure pain with no end in sight. At least the executives at MA BC/BS will get their bonuses.”

Who Decides Treatment?

Joining U.S. surgeons in an increasingly crowded operating room are attorneys, reimbursers, Medicare, Milliman, hospital administrators, Congress and the administration.  Who decides treatment? 

More often than the general public realizes, it is not the person trained for the job.  The clinician.

The issue of course is money.  The entities that control the purse strings are using that power to drive treatment plans—to the deep frustration and, we fear, detriment to both the patient and the front line surgeon. 

Who Will Advocate for the Surgeon?

When Blue Cross Blue Shield of North Carolina proposed to, in effect, stop paying for degenerative disc disease (DDD), NASS (North American Spine Society) rallied eight of its fellow surgeon societies to present a unified case for surgical intervention to treat DDD. It was a magnificent effort and for a while there was hope that rational minds would prevail.  Last we heard, unfortunately, BCBS of North Carolina had not changed its policies.

Then in June, NASS’s PR staff revved up the promotion for Dr. Eugene Carragee’s flawed studies of BMP2 and put the phrase “living dangerously” into the popular lexicon when referencing spine surgeons. 

The Wall Street Journal and the New York Times were just two of the many publications that picked up NASS’s press releases and amplified the ‘living dangerously” theme initiated by Carragee.

With the imprimatur of both NASS and The Spine Journal on the concept that spine surgeons were irresponsible in their treatment of patients, the effort to build support for spine surgeons among the reimbursing agencies took a heavy blow. 

What if Atlas Shrugged?

The level of frustration at the hospital and clinic level is high and rising.  These comments in Beckers and OTW are the tip of the iceberg.  At some point, surgeons will find ways to reclaim some measure of control over the treatment of their patients. 

Will surgeons have to start withholding treatment in order to restore sanity to clinical care?

That same surgeon who emailed his colleagues to suggest exactly that approach also offered the following three solutions which, in his view, would return reason and order to treatment of spine disease. 

Comprehensive national tort reform is law

A multidisciplinary “stakeholder" panel consisting of spine care providers, researchers, patients, health insurers, medical device and pharmaceutical companies will convene to review EBM guidelines—such as NASS (some of them, anyway) and make National Coverage /Medical Necessity Guidelines by majority vote of the panel—the majority of voting members shall be physicians with recognized expertise in the subject voted upon and take this power of "right to determine Medical Necessity" out of the hands solely of for-profit insurers and the obvious conflict of interest/compliance issue this creates. The panel is elected by the members of the society they serve and have term limits...unlike the current proposed "Independent Advisory Board"

Medicare SGR payment reform is completed. No more year end "doc fix" band aids “

Too bad surgeons may have to shock the system into paying attention to such common sense proposals.

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