5 Points on Incorporating Nonsurgical Treatment Into Spine Care

Rita E. Numerof, Ph.D., Stephen Rothenberg, J.D., of Numerof & Associates, Inc. -   Print  |
By Rita E. Numerof, Ph.D., Stephen Rothenberg, J.D., of Numerof & Associates, Inc. Adapted from the authors’ contributed chapter [Developing Value-Based Guidelines for the Treatment of Spinal Disorders] in the newly-published book, Defining the Value of Spine Care, Jeffrey A. Rihn, M.D., Alexander R. Vaccaro M.D., Ph.D., Todd J. Albert, M.D. and David B. Nash, M.D., editors, 2012.

In recent years, growing concern about the overuse of certain spinal procedures, especially spinal fusion, has led to a more restrictive attitude by payors about such interventions.Skepticism about the clinical value – coupled with concerns about ballooning cost – has led to a higher bar for approval and reduced coverage for spinal fusion surgeries. Payors are insisting that these surgeries only be performed after other, less expensive and invasive solutions have been tried.  
In order to counter this understandable resistance by payors, the spine surgery community needs to develop more precise differential diagnosis to determine when surgery can be helpful for a particular patient, to empirically demonstrate both reliable economic and clinical value of surgical interventions, and to ensure that nonsurgical procedures are given due consideration in the treatment process. Working toward these ends suggests the following steps that surgeons should take that will facilitate progress.

1. Gather additional information from patients.
Physicians may need to spend additional time gathering information from patients to improve differential diagnostic accuracy so they can more effectively identify patients likely to respond to specific surgical treatments. Physicians may also need to further educate patients and offer assistance in determining the best approach,rather than providing a pro form a 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 – all of which may help demonstrate reliable value.  

2. Explore relationships with allied health professionals.
To better understand the value of nonsurgical treatment – or perhaps even to leverage it to their advantage – physicians can explore relationships with allied health professionals. For example, some studies have found that lumbar fusion surgery for discogenic axial low back pain appears to offer only limited relative benefits over cognitive behavioral therapy and intensive rehabilitation, and that as few as 50 percent of fusion patients are likely to have high-quality outcomes.  

While additional studies in this area will be beneficial, there is evidence that use of non-surgical treatments, such as through an integrated care program, substantially reduced disability resulting from chronic low back pain in the patient's private and working life. There is also evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain, while less intensive interventions did not show improvements in clinically relevant outcomes.   

Physicians could potentially better utilize these, or similar procedures in the overall treatment of their patients, rather than immediately seeking surgical options.  

3. Make the choice between nonsurgical options easier. Presently, nonsurgical treatment is underutilized,in part because both doctors and patients find it difficult to choose among the variety of nonsurgical options. While current guidelines acknowledge that patients can benefit from a nonsurgical approach, nonsurgical options may not be adequately explored and are more often treated as a prelude to surgery.It's clear that current guidelines must develop a care path to help choose from available treatments prior to considering surgery.

It is important to note that no clear line identifies spinal surgery as offering greater relief than nonsurgical treatment for patients with degenerative disc disease, disc herniation, or low back pain. Compounding the problem, the increase in spinal fusion surgery has resulted in greater complications, longer hospital stays, and increased readmissions. This means greater costs without improved outcomes. Overall, costs for spine care have increased substantially, with national expenditures associated with spine problems totaling $86 billion in 2005, an increase of 65 percent since 1997.

4. Don't treat nonsurgical care as the step before surgery. In today's transitional healthcare environment, physicians can't simply view nonsurgical treatment as an obligation before ultimately getting a patient into the operating room. Nonsurgical treatment must become a strategic option in deciding a patient's care path in light of questions about the effectiveness of surgery and pushback from payors. The trend toward more restrictive use of surgical intervention, and reduced reimbursement for it, will continue and accelerate in the absence of hard data and advances in differential diagnosis. Spine surgeons need to take on this challenge themselves in order to have any counter-argument to payer cost-reduction policy actions.

Further evidence of this trend can be seen in the Institute of Medicine (IOM) report identifying spine care as one of its priority areas for Comparative Effectiveness Research (CER). The goal of CER will be to develop predictive care paths and change quality metrics, ultimately leading to lower costs and improved outcomes. According to the IOM, "there frequently are no studies that directly compare the different available alternatives or that have examined their impacts in populations of the same age, sex, and ethnicity or with the same comorbidities as the patient. [CER] is designed to fill this knowledge gap."

CER will compare the effectiveness of surgical vs. nonsurgical treatment strategies for different types of spinal disorders and pain broadly, and also within more specific demographics. This will include comparing spinal fusion to pharmacologic treatment with physical therapy, and establishing prospective registries to understand outcomes of different surgeries compared to nonsurgical treatment, to name a few. Whatever the outcome of CER, physicians should expect payors to adopt the results in making payment determinations.  And as described above, recent research has indicated that nonsurgical treatments will need to be taken seriously as payors restrict access to surgical options.  

5. Work with payors on payment structures for nonsurgical treatment. Since the traditional model so clearly provides financial incentives to surgeons for emphasizing surgery over nonsurgical treatments, physicians will need to work closely with payors to establish balance in payment structures and incentives for the effective use of conservative or nonsurgical treatments. Guidelines and compensation must be aligned to make sure that value for payors, physicians and patients alike is addressed.Accordingly, staying ahead of the curve by adopting nonsurgical treatment as a bigger part of their practice will enable physicians to maximize their opportunities for reimbursement.

The benefit of spinal treatment will ultimately be judged by the patient based on clinical outcomes, and by the payor on elimination of the need for future treatment – economic outcomes. Finding a balance between quality and cost requires a better understanding of the predictors of success for surgical candidates and more effective use of nonsurgical treatments. Physicians must work with and educate patients about the potential pitfalls of surgery and fully explore the range of nonsurgical options.

Similarly, patients must be engaged in understanding their options and physicians must examine how to adapt and effectively use a set of nonsurgical approaches to treat specific individuals' spinal disorders – one size doesn't fit all. The key to success is getting everyone on the same page in understanding the value of nonsurgical treatment. Accordingly, it's necessary that improved guidelines for spinal care incorporate effective use of nonsurgical treatments for those conditions that may not be amenable to surgery.   


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.

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