Richard Wohns, MD, JD, founder of NeoSpine in Puyallup, Wash., discusses the biggest threat he sees to spine care, insurance company denials, and how spending a little upfront could provide better outcomes and significant savings in the future.
Question: What is the biggest trend you are seeing from insurance companies this year?
Dr. Richard Wohns: Putting off the inevitable increases the cost of healthcare. Stated in another way, every time the insurance companies deny necessary spine care presumably thinking that they are saving money, they are actually costing the healthcare system more as degenerative spinal pathology worsens with time, causes more disability, causes more use of opioids, causes more time loss at work, and when the condition worsens and the patient needs care with a more advanced spinal problem, the actual cost of the surgery is greater.
Insurance denials for medically necessary spine surgery brings on the law of unexpected consequences. In their concerted effort to withhold resources for necessary interventions, i.e., saving present day dollars, they will end up increasing healthcare expenditure in the future. They are very short-sighted. The dollars spent in the future will total more than if the dollars had been spent today. They do not understand that in most cases when spine surgeries are necessary now, putting off the inevitable will also lead to worsened outcomes which will cost society more in lost productivity and prolonged, expensive, non-beneficial, non-surgical care, besides increased cost for either the same or possibly more extensive surgical intervention, since degenerative conditions continue to degenerate. It has been shown in a Swedish series that for those patients that clearly require surgical intervention, the earlier that [spinal degeneration] is recognized, approved and performed, fewer healthcare dollars are expended in the aggregate due to better outcomes, speed of return to productive lives, and overall less consumption of non-curative healthcare resources.
Q: How would you fix these issues?
RW: I would propose that we work on a project to quantitate the cost of not providing indicated and necessary spine surgery. This may be more effective than using evidence-based medicine to prove good outcomes and QALYs. The payers' constraints, denials and regulations, are based on presumed cost-savings by denials. They are working under misconstrued logic that a dollar not spent today is a dollar saved. It is exactly the opposite: when something is necessary and indicated today, a dollar saved by denying this necessity compounds the eventual total overall cost of care.
Q: How can the healthcare system achieve cost savings in spine?
RW: I strongly believe that true overall cost-savings can be achieved by earlier surgical interventions when indicated and necessary, and not expending resources on non-curative treatments, palliative approaches, or in general, non-operative care, with an infinite timeline, lost wages and opportunity costs when nowadays a minimally invasive fixed cost early surgical procedure may be curative, allowing the patient back into the productivity mainstream.
Q: How do you identify patients who would benefit most from minimally invasive procedures earlier on?
RW: When a reasonable short course of conservative treatment fails, surgically curable spine pathology should be recognized as such, treated in as timely, cost-effectively (outpatient) and as minimally invasively as possible. An example would be a young working patient, no longer able to work, with refractory back pain and radiculopathy due to spondylolisthesis with or without stenosis. A fusion for the spondylolisthesis with decompression if stenosis is also present, is proposed by the surgeon and now, quite likely than not, denied. The denial is based on insurance guidelines, not clinical guidelines, and often the guidelines quoted are lack of more than 3mm of motion seen on flexion-extension x-rays and/or lack of objective neurological deficits.
The patient continues to be in pain, unable to work, taking narcotics, and undergoing non-curative treatment for an extensive period of time. The patient becomes deconditioned and is no longer a productive member of society. The cost of this scenario is much higher than in the new order, when this patient would be recognized early as one who needs a fusion with possible decompression, and that there is no evidence-based medicine reason to deny the inevitable.
The new guidelines would provide that the intervention is accomplished in an outpatient setting if feasible (saving more than 50 percent of the intervention costs compared to an inpatient procedure), and that the patient is returned to the workforce with an 80-plus percent chance of no longer requiring narcotics, additional care or additional healthcare expenditures for the index problem, which is now fixed and stable.