Recently one of our fellow bloggers inquired whether TSB could pen-a-post regarding the current state of the insurance industry, and how it relates to an increase in spine procedure denials. Supposedly, there has been an influx of denials in the Sunshine State. Low back pain has been one of the greatest challenges for the patient, spine surgeon and the insurance industry. It is a given fact that back pain is one of the most expensive ailments to treat. You don't need another data base to verify this fact. Considering that spinal fusions have increased dramatically over the past ten years, its a wonder why insurance companies are placing greater scrutiny on lumbar fusions, or lumbar related procedures. The question must be asked, what is reasonable and what is unreasonable when it comes to surgical intervention? The argument can be made that it is difficult to measure instability in certain clinical circumstances. As insurance companies look to push the envelop on denying coverage, a greater onus is being placed on both companies and surgeons to establish a more defined criteria. If conservative management was a panacea, why would anyone need back surgery? Physical Therapy, NSAID"s, and epidural relief are far less expensive than surgery. Is there a magic bullet in determining whether a patient will have an excellent outcome without the obvious factors that contribute to poor prognoses? Why do some patients do better than others? Because at the end of the day, isn't it really about the outcomes? Could part of the challenge be that the definition of instability is not uniform in acceptance? At best, the studies that exist have provided mixed outcomes. As insurance companies continue to scrutinize spine surgery, they have negotiated with the surgical community by allowing respective spine societies to comment on their concerns, and even influence and modify coverage, witnessed by the recent lumbar procedures taken hostage in the BCBS of North Carolina standoff with SAS, NASS, and AANS. Does this bode well for the industry?
In order to obtain more comprehensive data, spine companies will have to work closer with payers, witnessed by NuVasive's pro-active position with XLiF, and surgical societies must be willing to provide greater detail in how their outcomes are measured. Most patients present with degenerative disc disease (DDD), if the pain generator is not primary, then the challenge is to quantify the secondary and/or tertiary pain generators. If conservative therapy does not help the patient, the surgeon and patient collaborate to operate. So why do insurance companies behave the way that they do? Simply stated, it's their job. As has been stated on this blog, and at many industry related forums, the insurance industry is about risk management. Insurance companies view spine surgery as potential risk by calculating the probability of an adverse event, the surgery, they estimate the financial impact, how much will it cost and look to minimize their loss. That's why data is imperative. They are no different than Goldman Sachs or Citigroup when it comes to managing their portfolio. What most people fail to understand or accept is that medical care is more art than science, everyone cannot always have a good result. But the reality is that for many years spine was a carte blanche procedure, and it was just a matter of time before it came under attack, so in closing TSB wants to know who has seen an increase in denials, what states have been effected, and is this an anomaly or truly a growing trend?