Going forward, surgeons must be able to demonstrate to payors the value of performing complex procedures, above and beyond the risk of complications. In order to ensure reimbursement from payors and satisfy patients, it will become essential for surgeons to improve diagnostic precision in assessing spinal disorders.
Given the clinical uncertainties and financial costs associated with surgery, a case for overall “value” requires an evidence-based approach. While one patient may benefit from spinal fusion surgery, another patient with the same disorder – but different biopsychosocial factors – may not. Stratification of patients according to the appropriate diagnosis will become increasingly important when measuring outcomes.
A number of theories have been posed to explain the increase in fusion procedures, including the availability of new diagnostic tools. Often a combination of factors (a patient in pain who wants immediate relief, a physician who genuinely believes in the benefit of surgery as the cure, limited use or exploration of non-surgical treatments, financially motivated surgeons whose incomes benefit from surgical intervention but not alternatives, etc.) create an environment in which surgery becomes the immediate – and often, only – choice considered.
Regardless of the reasons for the increase and possible overuse of spinal surgeries, the core issue at hand is that providers have not done an adequate job of empirically establishing which procedures are effective for which patients and under what circumstances. While surgical advances have certainly been made in what is possible, there is too much variability in patient outcomes, and treatment guidelines should be re-examined.
The fact that current guidelines do not take into account cost is problematic, in light of patient outcomes and payor demands for this data. Clear indications for why surgery is preferred will become increasingly important, particularly in dealing with payors. As such, providers will need to be able to effectively use guidelines to determine when surgery is preferred over nonsurgical options to give patients the greatest likelihood of a positive outcome.
For example, improved assessments of a patient’s overall situation will enable the physician to better understand the proper diagnosis. Better diagnoses will require a better understanding of the patient’s history – not just their condition – to fully understand the value of specific treatment options. Also, patients need to understand that a “quick fix” from surgery may not be the answer, and may even result in further complications. This type of understanding can only be developed by physicians who fully grasp their patients situation, and capably communicate diagnoses to their patients.
Many studies indicate that certain patients respond better to nonsurgical rehabilitation than surgery for their chronic back pain. Instead of a pro forma six weeks of physical therapy before recommending surgery, value-based guidelines may call for consideration of the impact of such factors as the patient’s weight, exercise routine, ergonomics in the workplace, use of pain management techniques or an assessment by a physiatrist. But it is up to the physician to properly evaluate each situation to understand when a surgical diagnosis is really the best – or only – way to proceed.
And by setting clear guidelines, physicians can figure out the best care path to take for each patient that is also the most cost-effective – which will also appeal to payors. If surgeons can’t come up with more discriminating criteria for operating, payors and government will, and will burden surgeons with more arbitrary rules and bureaucracy in the process.
Improving diagnostic specificity and developing an evidence-based approach toward more selective use of surgery that takes into account the patient’s specific situation may not only result in a less costly approach to treatment, but will also provide better outcomes. The patient selection process needs an overhaul, and value-based guidelines could play a crucial role in improving spinal treatment care paths. Value-based guidelines have the potential to provide greater value to many patients.
1. Deyo RA, et al. Spinal-fusion surgery-The case for restraint. New England Journal of Medicine. 2004. 350(7): 722–726.
2. Carragee EJ. The role of surgery in low back pain, Current Orthopaedics. 2007. 21(1): 9-16.
Rita E. Numerof, Ph.D., is President and Stephen Rothenberg, J.D. is a Consultant at Numerof & Associates, Inc. (NAI). NAI is a strategic management consulting firm focused on organizations in dynamic, rapidly changing industries. We bring a unique cross-disciplinary approach to a broad range of engagements designed to sharpen strategic focus, increase revenues, reduce costs, and enhance customer value. For more information, visit our website at www.nai-consulting.com. Dr. Numerof and Mr. Rothenberg can be reached via email at info@nai-consulting.com or by phone 314-997-1587.
