Wednesday, November 17, 2010

Memorandum from ISASS

Tom Errico, M.D., the acting President for the International Society for the Advancement of Spine Surgery (ISASS) published a memorandum to its members regarding changes to the spine fusion insurance reimbursement policy for lumbar fusions.  ISASS has learned that effective January 1, 2011, Blue Cross/Blue Shield of North Carolina has issued a more restrictive policy effective lumbar fusion procedures.

This restrictive policy may make it more difficult for patients suffering from low back pain due to spondylolisthesis to receive their needed surgery.  The criteria includes;

  • Patients with degenerative Spondylolisthesis who don't have as much leg pain as back pain
  • Patients with Isthmic Spondylolisthesis that is not progressive but nonetheless painful
  • Patients where fusion for Spondylolysis may be necessary beneficial in situations where there is no slip and only back pain
  • Patients where fusion is the only procedure that will relieve pain and immobility associated with DDD after 6 months of exhaustive conservative measures that failed.
ISASS has reached out to all the legacy companies to enlist their lobbying efforts with BC/BS of NC.  TE welcomes your thoughts on this policy.  E-mail your thoughts to Kristy Radcliff, Executive Director @ ISASS.  kristy@isass.org.  

Question to our readers, how long are doctors going to run from filing a legal challenge to the anti-trust laws that continue to handcuff their efforts in fighting the Orwellian changes that continue to kill the delivery of healthcare in this country, and their ability to be paid for their services?  You know what TSB says, sometimes when your back is against the wall, its time to roll up your sleeves and kick some ass, the question is do the surgeons have the ability to do that?

61 comments:

  1. Surgeons will need to rise to the occassion (as they did several years ago when malpractice premiums were the hot button issue in many markets) & threaten to simply walk out and not treat anyone,, whether it be elective or traumatic, and then, THEN perhaps the insurance companies will begin to take notice.
    It will take only a few friends or family members of those in positions of power that require spine surgery due to dibilitating pain or some other serious medical issue to bring some REAL visibility, and perhaps resolution, to the issue. The other option is that more & more surgeons simply begin to only accept cash as a payment for their services,, that too would create the general public to piss & moan and also put more pressure on the insurance companies to back down on their policies.

    ReplyDelete
  2. As usual, the answer seems to be "let someone else do our dirty work." Do physicians have any balls to stand up and be heard? Stop hiding behind those pedigree educations and your lab coats. Someone needs to challenge you. As a group you are selfish and spoiled, and don't give me that "how hard we work and how little money we make." If you want to continue to earn a good living, still considered better than 90% of the rest of Americans. its time to realize that what effects the average person, affects your future. In the scheme of things, you are another spoke in the wheel, you're not the wheel. Until we mobilize behind our cause and fight against the insurance companies in this country, nothing will change. You'll continue to make concessions and take your frustrations out on everyone else except the people that you need to direct your anger and frustration at. The Big Bad Insurance Industry. You have a choice, you can stand up and fight or you can lay down like a bunch of pansy asses. You make the choice.

    ReplyDelete
  3. Where did this criteria come from? What is it based on? Somehow the Insurance companies were consulted with this information and advised to be more restrictive in these areas.
    maybe some of their peers who are ortho spine specialists have gone corporate and helped developed these guidelines? Docs on the inside vs docs on the outside!
    You are right, it will take a majority; the docs must align and stand up to this.

    ReplyDelete
  4. maybe the doc's are part of the new business model, physician owned insurance companies:)

    ReplyDelete
  5. MM 4:31, well said

    ReplyDelete
  6. 1. If reported correctly, BC/BS clearly demonstrates that they have no idea what they are talking about. Symptomatic spondylolisthesis, whether degenerative or isthmic, is a clear indication for surgery, even in situations where the symptoms are not that bad yet. If they had suggested to impose some treatment algorithms for pure DDD, for example a minimum period during which certain conservative measures should be tried, it would make some sense. Focusing on only on spondys while ignoring DDD is completely ridiculous.

    2. Spine surgeons earn livings which are better than 98% of Americans.

    3. The health insurance industry should be regulated as a utility. Gas, electricity, water and aspirin...

    ReplyDelete
  7. Open Letter to NASS, AAOS, CNS, and AANS:

    Either stand up and be the men that you're supposed to be, or get the f*&% out of the way. Stop with all this politically correct posturing. Your lobbyists are dickin' you around. You have shown your weakness, now show your strength. If not, all you've become is the whipping boys and girls that Congress and the insurance industry slaps around. The people are willing to stand by you, but you must be willing to fight.

    Signed: The People

    ReplyDelete
  8. from where I sit/stand, this industry is getting what it deserves. the outcomes of back surgery/fusion call it what you want, are mixed. That is a fact! I think the healthcare and business communities have "milked, marketed and molested" this dog as much as it will hunt.
    the tide has turned. Get use to it and get ready for more of it.

    ReplyDelete
  9. Does anyone have a link to the memo?

    ReplyDelete
  10. should i start thomas jones or shonne greene as my 2nd running back this weekend?

    ReplyDelete
  11. 7:44 - from where do you sit/stand? The pulpit?

    Everyone else is always the doing the "milking" right?

    Insurance companies are trying to maximize profit just like implant companies. They just do it under the guise of non-profit for tax breaks.

    The other issue is the possible 21% decrease in reimbursement from cms. Does anyone know if that was put on hold?

    ReplyDelete
  12. 8:15. Hahaha! Love it!

    Trade em both!

    ReplyDelete
  13. 7.44

    excuse me sir...the last time I checked, device companies were on the receiving end of the check? not the paying side?

    I wouldn't pay for something that may or may not work either. Who would? Of course, you're right, I forgot...the people who are suffering and have got to the end of their rope and along comes the "A" team consisting of greedy docs (held -up on a pedastal by honorarium/advisory board/consultant "payments") and the profits made by conducting the $80,000 "keep the fingers crossed" procedure...

    Wake up!

    ReplyDelete
  14. (milked, marketed and molested" this dog as much as it will hunt)

    This could not be more on target! Its funny how the ones that bennifit the most are the ones that cry the loudest when the bottom of the honeypot is reached.

    ReplyDelete
  15. "from where I sit/stand, this industry is getting what it deserves."

    and hopefully more to come!

    ReplyDelete
  16. Wow! Feisty words above.... I believe as physicians we are legally precluded from collectively bargaining/legally challenging such restrictions. Our societies and PACs can fight for us, though they seem to do an exceedingly poor job....
    Insurance company 'guidelines' are in fact the 'practice of medicine' and should be held to the same standard. They should be held accountable and need to indemnify the consequences of such decisions the same way physicians must.

    ReplyDelete
  17. Whoa, whoa, whoa... Before we go all communisty (let's regulate the insurers more than they already are) or legalisty (whom do we have to sue to have this changed) or politically (let's get our PAC to legislate what should or shouldn't be covered), how about we just simply recognize that an insurance policy is a product in the marketplace, and BCBS NC just downgraded the quality of the product. Drs in NC should just stick to their guns and recommend the right procedure for the right patient. When enough patients are told their insurance doesn't cover a 50 year old procedure that the doc has been doing all of his professional life, they'll start filing suit against their insurer or simply encourage their employers to change who insures them. I don't think any of us have advocated that communism, legal pursuits, or political routes are the ways to solve our problems in the past, so let's not start now.

    ReplyDelete
  18. ... on another note, haven't read the policy. What grounds did they use for justifying their exclusion of the listed indications? Experimental???? That'll be a hard sell in a court of law for a 50 year old procedure.

    ReplyDelete
  19. http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.notification.pdf

    ReplyDelete
  20. You mean they are not paying for low back pain fusion operations that statistically are not effective in most patients? Amazing that it takes an insurance company to stand up to all the poorly indicated surgeries done for $$$. The leadership of NASS and these other organizations have failed us and our patients by not doing this earlier. Then again, the surgeons running these societies have the most direct and indirect financial gains from the status quo.

    ReplyDelete
  21. 10:30 am........ Nice writeup. I could not have said it any better!

    ReplyDelete
  22. 10:30 That may be part of the problem, Surgeons bitch and moan about everything but don't have the guts to stand up and fight. You hide behind your inability to unify because of anti-trust laws. BS. You're all a bunch of you know what. All talk, no action.

    ReplyDelete
  23. This comment has been removed by a blog administrator.

    ReplyDelete
  24. erudite and fascinating comments.... I suppose we should have cut the school short (way short) and relied on peddling screws to those who have 'no talent' for putting them in...

    ReplyDelete
  25. @ 2:05 PM please accept an apology for 1:16PM. He is most likely not even a spine rep. Even if he is he is one of the few that makes the rest look bad. Most reps respect the long years of schooling, and the intelligence and hard work it takes to get to the point of being a surgeon, and even more so a spine surgeon. We admire what you do. If we are to take pride in being part of your team we obviously think highly of the field and it's practicioners. The unfortunate posting by 1:16 shows that into any field will slip in some bottom feeders. There are those who will attack me now for these comments, but I stand by my words..

    ReplyDelete
  26. 10:30 here. @12:06, actually I'm not a fan of doing the wrong surgery in the wrong patient, and your arguments regarding LBP surgery are valid. But I'm not a fan of the insurer as the regulator of how medicine should be practiced, either. And it seems to me that a substantial number of valid patients will be excluded using the new criterion, even for docs and patients that do understand the limitations of fusion surgery and are only applying it very judiciously.

    ReplyDelete
  27. 1:16s a dope too! TSB these types of comments should be pulled.JMO.

    ReplyDelete
  28. Can't sit at the computer and monitor comments, got to work, but I agree.

    ReplyDelete
  29. and yet the marketing machine NUVASIVE/XLIF continues to slip through the insurance cracks while standard of care procedures for Spondy, DDD, myelopathy etc continue to get denied. These morons (yes, drs) that the insurance companies hire to set their criterias need to be held accountable for driving a stake thru the middle of this industry. Everyone is in bed with everyone, its a joke

    ReplyDelete
  30. Is there legislation that precludes surgeon's from collectively bargaining? Or is it self imposed by oath's. I can't see a group of docs striking that have emergent care responsibilities or that are already treating existing patients. How do you turn down patients? I shudder to think of that hack scabs that would cross.

    Curious what happens when a patient is cleared for an extensive decompression for a spondy and due to iatrogenic removal of disc, bone and ligaments becomes grossly unstable, albeit decompressed. What to do? Fuse and have the hospital eat it. Someone is going to fail miserably immediate post-op and heads will roll. I can see the plaintiff attorneys subpoenaing the bc/bs and/or Milliman guidelines and putting some 28 year old internist on the stand with zero spinal surgical experience and asking how he approved a multi-level decompression that resulted in permanent nerve damage. Here's a great case from Spinal Universe. Tell me this patient shouldn't have been fused first. Please:

    http://www.spineuniverse.com/professional/case-studies/yoon/iatrogenic-facet-instability

    ReplyDelete
  31. @6:57, not sure what you're referring to. NUVA just got NASS to help them successfully argue they are essentially the same as conventional fusion, which they are. If coverage for fusion goes away, it goes away for them too.

    ReplyDelete
  32. Just finished reading the new guidelines from NCBCBS...Come on, man! These are weak and easily surmountable challenges. Surgeons will just have to document a bit better, but there should be no slow-down in surgeries! If this keeps you from cutting as per your current standarsd, then you are not delivering good health care....Come on, Man!

    ReplyDelete
  33. Does anyone really believe there are spine surgeons responding to this blog. If so, no wonder why they have so many issues. As usual, more worried about their wallets than patient outcomes. I'm so tired of listening to docs complain about reimbursement, complain that spine companies make too much money, complain about attorneys, and then sit back and print money, all on the back of the same poor 70 year old woman, in surgery, over and over and over... A miserable bunch that should find another career rather than perform surgery.

    ReplyDelete
  34. @8:03 - Not a great example. The original surgeon likely did not appreciate the fact that he had created iatrogenic instability (if he did and ignored it, then it's malpractice). So if the patient had stenosis, then NO, no reason to book them for a fusion initially.

    ReplyDelete
  35. Take the time to talk w/ someone who has actually had back surgery, ask them if their issues have actually been "cured" or if they still ache & perhaps have new issues on top of the old ones?? Also, anyone want to take a guess at what % of initial fusion surgeries end up as some type of revision case? Yeah, it's pretty high,,
    Bottom line, the insurance companies are simply taking a stand to reduce the ridiculous # of unnecessary procedures being performed in spine.

    ReplyDelete
  36. What can we learn from the entire Spine market and specifically this topic? With a short reference to two cynical topics, Religion and Politics....Treat others like you want to be treated AND in the leader of the nation we all CHOOSE to live in, be careful what you wish for. Stay the course, work hard, treat people the right way and in the end everything will be fine.

    ReplyDelete
  37. Sorry, but this is getting ridiculous. Aside from 12:37 going all Kumbaya on us (what the hell does that have to do with anything...) 11:36 somehow has the impression that spine surgeons continue to operate on their patients with the complete disregard that apparently EVERY SINGLE PATIENT that comes back for a follow up visit is actually telling them that they are worse off than before if the doc actually took the time to really listen to them! Listen, you putz, I'm up for a fair and critical analysis of spine surgery as the next guy, but your statement is as asinine as the surgeon who gets up a the meeting and says they never have a complication and everyone has done great! (... with the obligatory "knock on wood" following to express some form of humility and recognition that it's by the grace of God, of course.)

    Anyone who believes that spine surgery categorically provides no benefit to any patient is too ignorant for their own good.

    The bottom line on this policy is this: if you read the policy itself, it states:

    Lumbar spinal fusion is also considered not medically necessary if the sole indication is any one or more of the following conditions:
    • Disk Herniation
    • Degenerative Disk Disease
    • Initial diskectomy/laminectomy for neural structure decompression
    • Facet Syndrome

    In my opinion this goes well beyond restricting purely unnecessary surgery and steps in to the realm of dictating medical care. It means to me that a patient coming in with a degenerated disc or two, a very large disc herniation, progressive radiculopathy and a significant amount of back pain, for example, doesn't have fusion as an option. In some of these cases a fusion may be the best choice even in the eyes of a conservative surgeon and it should be on the table. And that should be a choice made by the surgeon and their patient, not their insurance company.

    ReplyDelete
  38. 3:07

    Absolutely dead on the money.

    ReplyDelete
  39. This is why I do Pediatric Scoli's. No insurance denials, and it actually helps.

    ReplyDelete
  40. 10:30/2:37 and 3:07,

    Thanks for the comments. And the "going all Kumbaya on us"? Nice.

    ReplyDelete
  41. Can you not see it? Is this not another example?

    The Future Lies in the Free Market!

    They will pay CASH!

    ReplyDelete
  42. Young Johnny (Dangerously): Dr. Magnus, how's my mother?

    Dr. Magnus: It's her pancreas again, Johnny. She's gonna need an operation immediately.

    Young Johnny: How much is it gonna cost?

    Dr. Magnus: $49.95

    Young Johnny: $49.95?

    Dr. Magnus: This week only.

    Young Johnny: Where am I gonna get that kind of money?

    Dr. Magnus: Why don't you knock over a gas station?


    http://www.imdb.com/title/tt0087507/quotes

    ReplyDelete
  43. I see much of the contraction in this space coming from fringe companies with fringe surgeons performing non-indicated fringe surgery. Smaller companies with "me too," commodity products relying on a questionable customer base would be a great short but they'll never go public.

    ReplyDelete
  44. One is public. Starts before B in the alphabet and lives in California??

    ReplyDelete
  45. 1:47PM
    I see no validity to your statement.

    ReplyDelete
  46. Young Johnny:
    what's wrong with my Mom?

    Dr. Magnus: it's her pancreas. Years ago we would have done surgery but today her conditions do not meet all the requirements. Besides she is old and there is a 20 percent chance it will not work.

    Young Johnny: Dr. Magnus I will pay you twice the reimbursement rate for you to do the surgery.

    Dr. Magnus: Sorry Johnny your Mom is on medicare and it would be illegal for me to accept cash for service.

    Young Johnny flies his takes his Mom to a surgeon that is not enrolled in Medicare and pays cash. Outside the US if necessary. Mom lives 15 years longer. Young Johnny never regrets it!

    NatureBoy

    ReplyDelete
  47. I am not suggesting that everyone can afford it. I am suggesting that those who can afford it will pay for it. First class is always full. Even on a 50 minute flight!

    Wooooo!

    ReplyDelete
  48. First class is always full because of the free upgrades, you dummy.

    ReplyDelete
  49. I'm looking forward to the decrease in my health insurance premiums due to these new guidelines :)

    ReplyDelete
  50. 3:29 - Beautifully said! To one half of us the comment will be dripping with sarcasm, and to the other, dripping with hopeful optimism. No idea which one you meant, but it doesn't matter and only time will tell which half of us is right!

    ReplyDelete
  51. Look like this new policy may kill-off the facet fusion allograft market, as many of those procedures are performed in combination with an 'initial diskectomy / laminectomy for neural structure decompression', which will not be covered under the new guidelines.

    ReplyDelete
  52. 4:17 is on to something...what about all the Spire plate/Aspen interspinous devices that went after the coding of a fusion...gotta believe they are gonna get crushed by this....

    ReplyDelete
  53. 4:11, do you seriously think they'll lower premiums?! Keep clicking those ruby slippers.

    ReplyDelete
  54. 5:58, I didn't actually say which half I was in. Will neither confirm nor deny the accuracy of your implication. But just for the sake of arguing the side you suggest I'm on, keep in mind the insurance marketplace is a competitive one, and highly price sensitive at that. If an insurer can reduce their costs, and gain share by undercutting the price of their competition, it's reasonable to presume they will. That's not a fallacious argument. Whether they are actually able to reduce costs, well that's another question. Because even if they end up paying for a few fewer spine surgeries, the costs of healthcare have been going through the roof and this is arguably just a drop in the bucket.

    ReplyDelete
  55. The Aspen device should still be ok with regard to this new policy, as it states BCBSNC will pay for a fusion if a patient has a spondylolisthesis and central stenosis (neurogenic intermittent claudication). I don't know about the Spire Plate, but if you have an interspinous process device and it's indicated for fusion, then you still should be ok. In fact, this new policy might be a huge plus for those types of devices.

    Facet fusion with bone dowels will die with this new policy.......R.I.P. Of course I think that 'R.I.P.' stands for 'Rippin-off Insurance Payors' in this case. That's what may have led to this change in the policy in the first place.

    ReplyDelete
  56. 8:25, you may just be onto something there.

    ReplyDelete
  57. facet fixation will not exist by the end of next year.

    ReplyDelete
  58. 8:32, I think facet fixation will still exist, but just not with allograft-based implants. I still have yet to see any company with clinical results on the allograft-type products.

    ReplyDelete
  59. Just like my old college roommate used to say, "no means yes, and yes means anal." You guys know what I'm talking about.

    ReplyDelete
  60. I think it's funny just how many people claim to be anti-Obama care on here and then how many people follow it up with "insurance should cover this..." It seems that we are all for the free-market when it suits, but when it doesn't we want to create our own policies. Sit back and think about why the policies you dislike are in place. More likely than not, the guy on the other side of the isle paid somebody in Washington or contributed to the insurance commissioner’s campaign fund in an effort to have those laws put on the books. Either go free-market or don't but this wishy-washy crap is what is killing our industry and stifling the competition. As so many people alluded to above, cash is King, and I believe it’s inevitable that cash based operations will become more common as insurance attempts to cut out the costliest parts of our healthcare system. The free-market should eventually take over, if we can get the government out of it altogether. But, I’m not convinced that that’s what we all really want now… is it?

    Oh, and @ 6:08... I'm glad my roommate never said that to me ;)

    ReplyDelete
  61. I have seen some of the most extreme intellectual hypocrisy among us at the meetings in the U.S. lately.

    I could literally write a list of 100 things...but the top has to be

    To hear most of "us" talk, Medicare should simultaneously be discontinued and have its budget tripled.

    Private insurance companies need to listen to the "Government" when it approves something...

    The "Government" needs to listen to private companies to decide what to approve...

    We want FDA to approve what we tell them to approve, but we want FDA approval to shield us from liability.

    We file patents for unique inventions and 510(k)'s for Me-too copies; of the same exact drawing.

    Its actually quite hilarious to listen to people argue with themselves sometimes.

    ReplyDelete