When payers deny or delay indicated spine surgery, the cost doesn’t disappear — it moves to patients, surgeons, hospitals, employers and the broader economy, according to a new Orthopaedic Forum paper published Oct. 1 in The Journal of Bone & Joint Surgery.
The paper was written by Kern Singh, MD, and Daniel Park, MD, of Chicago-based Rush University Medical Center, along with co-authors from The Ohio State University, MedStar Georgetown University Hospital, the University of Illinois at Chicago and Case Western Reserve University.
“Delaying or denying indicated surgery does not reduce cost; it simply redistributes it,” the authors wrote.
The paper argues that the true cost of care includes direct medical, administrative, patient, employer, time-value and human costs — not just the dollar amount on a claim. Here are eight takeaways from the report:
- Most prior authorizations end in approval anyway. The authors cite a single-center study in which 67.4% of elective spine surgery patients required prior authorization, but only 6.1% were ultimately denied. Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, with a 7.7% denial rate, according to KFF.
- Delays worsen outcomes. Patients whose lumbar fusions were delayed had longer hospital stays, more deep infections and higher mortality within 30 days of surgery. A large body of research also links longer symptom duration to worse patient-reported outcomes after lumbar decompression and fusion.
- Conservative care piles up costs without eliminating surgery. Denied patients undergo more physical therapy, medications, injections and related travel. Epidural procedures alone cost Medicare more than $800 million in 2018, though the literature suggests they don’t provide durable pain relief.
- The administrative burden is duplicated across stakeholders. Prior authorization alone has been estimated to cost $3,000 per physician per year, part of a broader administrative burden of $68,000 to $85,000 annually per full-time physician. In one survey of orthopedic surgeons, 93% said prior authorization created a high administrative burden, with practices spending an average of 15 hours a week on roughly 18 claims. Payers, meanwhile, must staff medical experts to handle reviews and peer-to-peer calls.
- Delay works like a forced loan. Because money loses value over time, surgery performed three months from now is not financially equivalent to surgery today. A delayed or denied surgery that is later approved “functions as a forced, interest-free loan from the patient, physician, and facility to the insurer,” the authors wrote.
- Denials redistribute utilization. In one commercial health plan’s prior authorization program, lumbar fusion rates initially fell but returned to near baseline within two years. Preoperative costs for patients who eventually had fusion rose by about $3,600 per member, driven by more injections and inpatient admissions, while time to surgery stretched by several hundred days.
- Indirect costs climb. Delayed lumbar disc surgery was associated with an additional $11,753 in mean indirect costs per patient, driven by longer time from consent to return to work. Patients who deteriorated neurologically while on the surgical waitlist had 2.5 times higher odds of an adverse event, longer stays and lower rates of discharge home.
- Counting productivity erases early surgery’s premium. In one randomized trial, early surgery cost more from a direct medical perspective, but the difference disappeared once productivity gains were included.
The authors concluded that the relevant question is not whether fewer surgeries save money on the claim, but whether they improve total value across the full episode of care — and the evidence suggests they don’t.
“When insurance companies deny or delay indicated spine surgery, they potentially end up spending more — and they definitely make it harder for surgeons and more painful for patients,” they wrote.
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