Insurance companies in some states implemented a prior authorization program for low back pain patients before receiving surgical care. How well do they work?
A group of researchers examined the annual lumbar fusion trends over six years for changes in the standardized cost for low back pain related services among a 501-member subset and published their results in Spine. The study examined the Blue Care Network of Michigan program. Patients who underwent lumbar fusion before and after program implementation were included in the study; the study period was January 2008 to December 2013.
The new program introduced a physiatrist PA and for surgical patients a surgical PA.
The researchers found:
1. After the program initiated a physiatrist PA in December 2010, the number of lumbar fusions decreased from 76.27 per 100,000 in 2010 to 62.63 per 100,000 in 2011. But then the lumbar fusions increased to 64.24 per 100,000 in 2012 and 73.84 per 100,000 in 2013.
2. The lumbar fusion patients reported pre-surgical costs increased $2,233 per member with the physiatrist PA.
3. The patients who underwent lumbar fusion surgery reported an additional cost of $1,370 with the low back pain surgery PA.
4. The spinal injections and inpatient admissions were primary factors in increasing overall cost of care.
5. The physiatrist lengthened the episodes of care that ended in surgery by 309 days; the surgery PA lengthened the surgical episodes of care by 198 days.
"Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusion," concluded the study authors. "Instead, these programs were associated with the unintended consequence of increasing costs from more nonoperative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs."