Are financial incentives sparking rise in Pennsylvania-based spinal fusions? 6 insights

Written by Megan Wood | November 21, 2016 | Print  |

Up from 12,794 in 2004, 21,393 adults in Pennsylvania received spinal fusions in 2014, based on a state-released study, according to the Post-Gazette. This rise in the number of spinal fusions is drawing concern, however, as the procedures are costly and complicated.

Here are six insights:

 

1. The government paid an average of $24,000 for one in seven Pennsylvania-based fusions covered by Medicare.

 

2. Of the spinal fusion patients, 3.3 percent experienced complications in the hospital and 5.4 percent were readmitted, according to the Pennsylvania Health Care Cost Containment Council.

 

3. A Dartmouth Institute for Health & Clinical Practice study found Medicare beneficiaries in Pittsburgh were 44 percent more likely to receive lumbar fusions, compared to the national average, between 2001 and 2011.

 

4. Three former University of Pittsburgh Medical Center employees filed a lawsuit against UPMC in 2012, which alleged the center "systematically overbilled the government by giving doctors too much incentive to conduct surgery." The DOJ reported the Pennsylvania federal court qui tam suit alleges "neurosurgeons billed for assisting in or supervising procedures by other surgeons, residents, fellows and physician assistants that they weren't participating in to the required degree," according to Law360.

 

In July 2016, UPMC settled the case alleging violation of the False Claims Act for $2.5 million. Under the settlement, UPMC did not claim any liability.

5. Physicians' work volume is quantifiable in work relative value units. Medicare then reimburses a physician based on the procedure's unit number. Commercial payers often offer higher payments than Medicare reimbursements for similar procedures.

 

6. With the shift to value-based care, however, the question is whether this pay-for-volume contract mindset will change.

 

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