7 observations on lumbar total disc replacement — what if payers granted coverage?


Spine produced a December special section with articles based on discussions at the First Annual Lumbar Total Disc Replacement Summit.


While evidence shows favorable safety and cost effectiveness for lumbar total disc replacement, most insurers in the U.S. do not cover the procedure, which presents a significant barrier to entry. "Although economic considerations in a fee-for-service model should not be a determining factor in patient access, concerns regarding the budget impact of lumbar TDR surgery may unfortunately underlie coverage decisions," according to the article featuring expertise from Faheem Sandhu, MD, Scott Blumenthal, MD, Betsy Grunch, MD, Bent Kimball, MD, Nicole Ferko and Sarah M. Hollmann, all of whom were featured on a panel discussion at the summit.


Here are key trends from the panel:


1. Panelists agreed there was a potential for growth in lumbar TDR utilization if insurance companies covered the procedure. However, adoption of lumbar TDR "would result in minimal or not budget impact for commercial insurance plans."


2. Currently, ideal candidates for lumbar TDR may not receive the procedure because their insurance company doesn't cover it.


3. Insurance companies often consider lumbar TDR "experimental and investigational" which leads to the noncoverage. The panelists were unsure why these policies are in place, as the FDA has approved lumbar artificial discs supported by five-year safety and efficacy trials.


4. Data presented at the summit predicts lumbar total disc replacement wouldn't have a budget impact on healthcare and could result in an estimated $169,144 cost savings per 1 million insured patients, assuming the number of patients undergoing lumbar spine surgery didn't increase with the adoption of TDR.


5. Panelists predicted around 20 percent to 100 percent increase in the number of lumbar TDRs they'd perform in their practice if the procedure were covered by insurance companies. However, the number of patients overall undergoing lumbar spine surgery would not dramatically increase, according to the report. "Essentially, coverage is not expected to change the number of candidates eligible for TDR but will instead shift the majority of patients from higher burden fusion procedures."


6. Lumbar TDRs could be beneficial for bundled payments, as studies show a reduced operating time and hospital length of stay for TDR compared to fusion, which ultimately lowers the cost of care for the entire episode. Studies also show there are lower reoperation-related costs for TDR when compared with fusion.


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