6 Points on Managing the Cost of Spine Care

Laura Dyrda -   Print  |
Increasing volume and cost for spine surgery has recently come under scrutiny as legislators and healthcare professionals seek to lower the cost of effective care. There are many factors that contribute to the high cost of spine surgery. "We're in a cost oasis that isn't going to last forever," says Chris Zorn, vice president of Spine Surgical Innovation. "Bringing down the cost of spine procedures is being driven by the ultimate consumer pressure: purchasing groups and payors." Here are six points on combating the high cost of spine care in the United States.

1. Increase in potential patient population. The large baby boomer population is aging quickly, which means an increased number of patients with back pain and spinal degeneration. However, these patients expect to remain active longer, which requires more rigorous treatment.  Patients who might have been able to manage pain with medication or physical therapy in the past now need surgeries to sustain their normal, active routine. "Now we are more aggressive with our care because these patients want to get back to their activities," says Sheeraz Qureshi, MD, MBA, a spine surgeon at Mount Sinai Medical Center in New York City.

2. Non-surgical treatment and pain management. Many patients can manage their back pain through lifestyle changes, physical therapy or medication, which can be cheaper and safer alternatives to surgery. Almost all insurance companies require their patients to go through these steps before paying for epidural injections or surgery, even if it's clear to the surgeon that the patient will eventually need surgery, says Dr. Qureshi. "There are patients that have 10 to 20 injections and others who have physical therapy for several years, and they still end up needing surgery," he says. "These conservative treatments significantly contribute to the cost of care." Additionally, the patient is often unable to remain productive during long periods of failed therapy and conservative care, which has an economic impact on that person's life and community.

There is currently a lack of organization as to where back pain patients should begin their care and how long they should spend with each step before resorting to surgery. Physical therapist, pain management physicians and spine surgeons tend to treat patients individually instead of taking a multidisciplinary approach, which can lead to patients spending too long with one method or receiving the wrong type of care as their condition progresses. "Sometimes it might be better to start with an upfront plan and let the person ultimately decide about treatment,” says Dr. Qureshi. He suggests creating a plan stating the length of time for physical therapy and number of injections that must fail to alleviate pain before pushing forward with surgery.

"It can streamline the whole problem," he says. "There should be more of a process involved, instead of having a random amount of therapy assigned to each patient." Sometimes, if the patient stays in conservative treatment for too long, their condition worsens and will require a more complex and expensive surgery.

3. New surgical technology. Spine surgery is a quickly advancing field, but new technology is expensive and unless it proves a vastly better outcome than the standard surgery, it won't last. The FDA approval process for medical devices and technology demands a high level of effectiveness, and declining reimbursements from insurance companies mean that fewer patients are able to undergo new types of procedures. "Technology will never replace the surgeon's ability, talent and skill," says Mr. Zorn. "At best, technology can augment and support it. You can get too deep with technology and think it's the answer. I think the answer is trying to do tried and true procedures in a very simplistic, effective and minimally traumatic way for your patients."

For example, many device companies now are focused on developing percutaneous systems for fusions. "These systems are often technically challenging procedures for your above-average surgeon to learn and be proficient at, and it's a change from the traditional approach," says Mr. Zorn. "There's a lot more equipment involved in doing one of these cases, so there's also a cost factor in that."

4. Learning new procedures.
When new technology does come out that shows clinical benefits for the patients, such as some minimally invasive spine procedures, it usually takes a great deal of training for the surgeons to become proficient. This means time, energy and money spent away from the practice. "The learning curve for the surgeon and surgical team is often extreme, and that can add up," says Mr. Zorn. "It takes a long time to be proficient at these surgeries, and in some cases we don't know who will be paying for the new technology in the future. Some surgeons invest time in learning the latest and greatest thing, but we don't know whether anybody will be able to pay for it a few years down the road."

5. Implants. A large portion of the bill for many spine procedures is the cost of implants. These rods and screws have come at an astronomical price for many surgeons in the past, however the price is slowly coming down, says Mr. Zorn. "Let's say you're performing a common fusion procedure, which requires four screws and two rods and an interbody device," he says. "As an example, these screws two years ago were averaging $1,500 per screw in the United States. Now that's down below $1,000 per screw."

These prices are still well above the average price for these commodities worldwide, which can be purchased for $150 overseas. There are about 80-100 vendors selling pedicle screws of various designs, in the U.S. currently, and they are selling into a market with an increasing volume of procedures. But, they are also selling at a rapidly decreasing price per implant, as companies scramble to remain price-competitive.

When the price of one implant is drastically higher than another, device companies must convince insurance companies that their product is different and worth the extra cost. "The real question for many payors is: 'are these implants truly differentiated and can that price be substantiated?'" says Mr. Zorn. "You have to make sure they will be willing to pay for the difference."

6. Failed back surgery. While the cost of one surgery might be cheaper than another, surgeons might choose the more expensive surgery to decrease the risk of complications or failed back surgery. Patients who return to surgeons for adjacent level fusions or revision surgeries drive up the cost of care, so spending more on the initial surgery could curtail the costs associated with future surgeries. "You don't want to do a cheaper surgery if it is going to fail," says Dr. Qureshi. "On the other hand, you have to see how much more effective a treatment will be if it is more expensive."

In many cases, surgeons don't see much of a compensation increase by performing more complex surgeries. For example, complex fusions don't reimburse much higher than simple fusions.

The cost of complex fusions is higher because the surgeon is inserting a cage in addition to the traditional rods and screws for increased support. "Studies show that increasing support has better results and a higher success rate, which is why surgeons might choose to use them," says Dr. Qureshi. "The surgeon isn't compensated much more for performing the complex as opposed to the simple fusions."

Learn more about Spine Surgical Innovation.

Learn more about Dr. Sheeraz Qureshi.

Read Articles Related to Spine Healthcare:
5 Points on Lowering the Cost of Spinal Fusion Care

Spinal Fusion's Place in the Future: 9 Points on Fusion Efficacy and Coverage

10 Biggest Concerns Facing Spine Surgeons From Healthcare Reform

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