Spine Fusion's Line in the Sand

The flash spine-doc mob has had its virtual and symbolic storming of the castle of Blue Cross/Blue Shield in North Carolina (BC/BS). 

Now, the establishment of spine care professionals, including: NASS (North American Spine Society); ISASS (International Society for the Advancement of Spine Surgery, formerly knows as SAS); AANS (American Association of Neurological Surgeons), CNS (Congress of Neurological Surgeons); SRS (Scoliosis Research Society); and perhaps AAOS (American Academy of Orthopaedic Surgeons), will step in to make a quiet, thoughtful and evidence-based case to BC/BS.

The societies will attempt to convince their medical peers at the insurance company that the insurer’s proposed policy of coverage for fusion related to degenerative disc disease (DDD) is too broad and unreasonable and will throw the baby out with the bathwater.

Response Pending

Or as Chris Bono, M.D., one of the lead authors of a letter under development by the spine societies told us, "In trying to stop unnecessary or questionable fusions, the policy will throw out appropriate fusions."

A quick review. 

On September 28, 2010, BC/BS issued a policy statement regarding changes in coverage for lumbar spinal fusion that are scheduled to take effect on January 1, 2011. Among other things, the proposed policy stated that lumbar spine fusion surgery for DDD only will no longer be covered. What really seemed to burn some spine surgeons was that the insurer targeted DDD and stated that it was an insufficient diagnosis for lumbar fusion. 

The letter under development by Bono and Joseph Cheng, M.D. of AANS is currently being reviewed by the various societies’ policy committees. When completed and negotiated between the societies, a joint letter will be sent to BC/BS. We were told by participants that the goal is to get the letter to the insurer the week of December 13.

Tom Errico, M.D.Then the politics of influencing an insurance company begins. The politics of who best represents the interests of spine surgeons will also continue.

As former U.S. Speaker of the House Tip O'Neill famously said, "All politics is local." Insurance companies are regulated by state governments and political pressure from surgeons in New York, Chicago and San Francisco doesn't carry a lot of water.

Line in the Sand

Tom Errico, M.D., president of ISASS told us as much. Errico also said he has been trying to reach out to spine surgeons in North Carolina and isn't sure that the local docs are sufficiently engaged to pressure BC/BS.

Errico told us that spine surgeons need to "draw a line in the sand" in North Carolina. But before drawing the line, he said surgeons need to get their heads out of the sand. He sees North Carolina as a stalking horse for all other insurance carriers across the country looking for ways to cut their expenses.

Insurance carriers have a financial self interest at stake. "Where's Senator Charles Grassley in this issue?" asked University of Minnesota spine surgeon David Polly, M.D. 

Surgeons aren’t looking for a blank check. Not all fusion surgery performed today delivers consistent and reliable outcomes. Many of the emails from Paul Slosar's "email flash" a couple of weeks ago acknowledged that surgeons and the broader spine community need to do a better job of patient selection and outcome tracking for lumbar fusion surgery.

Collaboration and Calm Urged

Charles Branch, M.D.One North Carolina surgeon with his head clearly out of the sand is Charles Branch, M.D., a former president of NASS, who is actively involved in responding to BC/BS. Branch is a neurosurgeon at the Wake Forest University School of Medicine

Branch told us that before ranting at BC/BS, spine surgeons need to work collaboratively and thoughtfully to convince the carrier that the proposed policy changes are unreasonable given the evidence.

Branch said that some of the insurer's proposed changes are reasonable, but that key elements are missing. As an example he noted that someone with a severe collapsed disc would not get coverage.

Dr. Bono offered us another example of a hypothetical patient who would be denied reasonable and necessary care under the proposed policy.

The Patient

Louise is a teacher. She is 42 years old and has been teaching for 20 years. 

In 2007 she began to experience back pain. After seeing her chiropractor and then her primary care physician without getting rid of the pain, she took a medical leave and stopped working. She suffers from low back pain and some left leg pain attributable to a dysplastic spondylolisthesis.

"Under the current BC/BS policy Louise would have been referred to a spine surgeon who would have OFFERED HER AN L5-S1 FUSION WITH OR WITHOUT A DECOMPRESSION [Bono’s emphasis]. Statistically, her chances of success in eliminating or reducing the pain so that she could go back to work would have been 75%, " said Bono.

Under the proposed policy, Louise would not qualify for reimbursement because she didn’t present with an isthmic spondylolisthesis.

“Louise is the patient we want to help, ” said Bono.

Now is not the time to ratchet up the rhetoric, said Branch. The societies will make their case to the carrier that revisions to the proposed policy are needed to make it reasonable. How the carrier responds to the evidence submitted by the societies will determine what spine surgeons will do next.

Industry, Physicians and Politics

Alex LukianovOne industry leader, NuVasive's CEO and Chairman Alexis Lukianov got involved quickly in joining the fray to draw a line in the Tar Heel sand.

Lukianov confirmed to OTW that he pledged $100, 000 to ISASS in the Slosar email stream to aid the society in advocacy efforts in North Carolina as well as providing leadership for patient advocacy in Washington, D.C.

We had to ask, "NASS went to bat for you on XLIF. Why $100, 000 to SAS and not NASS?"

In an email reply, Lukianov wrote, "SAS stepped up almost immediately and is working to drive positive outcomes. My intent is to help them use whatever means available to work thru North Carolina so there is not a domino effect on January 1, 2011. I am also availing NuVasive's resources both financially, as well as organizationally and functionally, in the way of our expertise."

Lukianov added that there have been "concerning” emails from the reimbursement and advocacy docs at NASS implying they are not in favor of supporting DDD as an indication. "Certainly everyone agrees that back pain without failed and prolonged physical therapy is unlikely to need fusion. There are however very clear DDD indications that can be defended for fusion. A straight out exclusion is not reasonable. That is one reason [for ISASS support].

“Secondly, ” said Lukianov, “surgeons are frustrated that NASS is not actively representing surgeons. NASS was once 100% surgeons and is now 60-70% surgeons. SAS is 100% surgeons. NASS has not responded to the BC/BS crisis. When they do we will consider how to support them."

NASS Successes

Dr. Branch bristles at comments that NASS has not been responsive to surgeons. He cited a successful NASS-led response to a Washington State worker's comp policy proposal a couple of years ago that would have limited coverage. He also noted how NASS succeeded in keeping Medicare coverage for fusion intact with evidence presented at a MEDCAC meeting a few years ago.

NASS was also successful in working with a national insurance carrier earlier this year to properly code XLIF procedures and continue providing coverage for the lateral access fusion procedure.

On the Ground

If BC/BS stonewalls and doesn't modify their proposed policy, then local politics in North Carolina take over. Surgeons from outside the state will have very little standing in influencing a local political battle. BC/BS is a giant corporate presence in North Carolina and is regulated by an elected insurance commissioner. It will take our hypothetical Louise to contact the insurance commissioner and her legislator.

There is a Health Care Review Program in North Carolina where, Louise, the insurance policyholder, can request a review of a coverage denial. If Louise is still not satisfied after that, she can request an external review by an independent reviewer. The insurance company is then obligated to follow the findings of that review.

If that fails, then the line in the sand moves to the state's legislature where unions, employers, citizens with back pain and their surgeons can find a sympathetic committee chair to call public hearings.

The decision by BC/BS to propose an "unreasonable" policy change for fusion surgery has incited the most spirited surgeon reaction we've seen in some time. We think Dr. Errico can rest assured that his colleagues have pulled their heads out of the sand and are drawing the line.

In the meantime, the debate over who will be the surgeons' (and patients') most effective advocate continues.