Tuesday, July 19, 2011

Pay Me Now, Pay Me Later, But Someone Has To Pay

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?

81 comments:

  1. I am in Texas and have heard from some of the surgery schedulers that they have had more scrutiny and had to jump through lots more hoops recently. In the end they still get the surgery pre certified and approved, but now there is lots more Bullshit and administrative processes to navigate through.

    The other issue about outcomes as it relates to conservative care vs. surgery can be easily explained and understood when you take into consideration patient selection. If you operate on an obese smoker and expect fusion you may be in for rude awakening. Some surgeons will explain to patients you need to lose weight and stop amoking and then we "may" consider surgery.

    Surgeons straight out of spine fellowship tend to be much more conservative. Once they get a few years under their scrub strings they start operating on every patient that walks in the office, cause if they don't the hack down the street will slice and dice for sure.....add to that the money thrown at them for consulting and POD and eventually you have every lumbago under the sun getting fused.

    Good luck trying to ever get a true outcome study...at least in private practice.

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  2. Non clinicians making clinical decisions

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  3. On the non-fusion side all but one insurance carrier has stopped paying for lumbar artificial discs where I am. Cervical discs are still getting approved at a decent rate though.

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  4. Dog whisperer is on......yawn

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  5. 9:29 makes a great point. I am a PhD researcher that has been trying to create statistical models for spine surgery success for several years. We infer some relationships between patient and outcome, but we'll probably never find anything spectacular.

    There are countless successes in spine surgery, and most procedures have plenty of empirical merit. So, we are back to trusting surgeons to use sound clinical judgment. The media and congress have made this a tough pill to swallow recently, and surely some surgeons are acting unconscionably, but I would argue the majority are more focused on patient care than alternative revenue streams.

    Thus,

    1. We have procedures with merit
    2. We have surgeons making clinical judgments on behalf of the patient
    3. We have some fast-and-loose types in the industry pushing infuse, PODs, etc.

    Get rid of #3, keep an eye on narcotic use, and we're actually doing okay. These are expensive conditions to treat, bar none. It is just too bad for insurance companies that it is a common condition, too.

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  6. How many patients are fused who would simply benefit from a thorough decompression? One which addressed their stenosis entirely w/ out creating instability due to removal from some or all of the facet?

    Bottom line is that too many surgeons go in, essentially remove all of the important posterior structures, create iatrongenic instabilty, which in turn results in a fusion.

    Is this always necessary? Absolutely not. There are less diruptive ways to decompress adequately and not subject a patient to a fusion.

    Times, they are a changing, and the overuse of implants will come to an end. All you need to do is look at the sluggish results being posted across the industry.

    The days of 3,4, & 5 level lateral cases or multi level TLIFs in 70+ yr. old patients are coming to an end.

    Beware my friends and prepare yourselves for the new generation of spine.

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  7. With 60 to 70% success rates (based on patient symptoms), we are going to continue to see pressures from insurers. But surgery isn't going away, because we (as a society) still spend $67 Billion on suffering associated with back pain (lost wages and productivity).

    With big money and mediocre outcomes, there will continue to be opportunities for new approaches (as 12:16 references), as well as crazy-as*-sh*t. Which keeps this the wild-wild west. It will just be in a different way than big commission checks for every spine case you can grab.

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  8. Anthem Blue Cross/Blue Shield of California is the WORST about denying fusions. These guys want so much proof of instability that there is almost no chance of getting an approval. Why hasn't NuVasive dropped this provider (this is the company that provides NuVa employees with health insurance)? How can they continue to support a provider that is driving a dagger through the heart of our industry?

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  9. Granted, there are certainly surgeons abusing the system more so than others, so it seems it would be more prudent for insurance companies and Medicare to investigate and attack doctors individually.

    Broad reform for an overwhelming ethical majority is only preventing standard of care from reaching those who truly benefit from these procedures. A surgeon I work with is performing 3+ TLIFs on older patients regularly and has a tremendous success rate. These patients are often doubled over in pain, completely debilitated by their back issues going into the OR and after a few weeks of rehab going back to active lifestyles.

    I dare any of you to look your 70 year old Grandmother or Mother in the face and deny them standard of care that would grant them another 10-20 years of quality living.

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  10. Have seen a big increase of denials. Surgeons claim it is harder than ever to get a case approved.

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  11. A recent paper came out providing a cost-benefit of TLIF. Check it out. http://www.ncbi.nlm.nih.gov/pubmed/21529203 These authors arrived at a figure of $43k/Quality Adjusted Life Year. About $21k was attributed to the surgery and that's using the bargain basement CMS rates.

    That still seemed high to me so I sniffed around pubmed.com and found this one from the Sport Study. http://www.ncbi.nlm.nih.gov/pubmed/19075203. $78k/QALY for stenosis surgery and $115k/QALY for fusion for degenerative spondy. These authors noted that the cost was highly dependent on the cost of surgery, which may explain the differences between papers.

    For some random context, in Finland, the cost/QALY for hip and knee replacement are 7k and 14k Euros respectively. http://www.ncbi.nlm.nih.gov/pubmed/17453401 Clearly these relatively low costs are a combination of lower pricing in Europe and a more successful procedure.

    No matter how you slice it these spine procedures are expensive for the benefit gained. Its tough to blame the insurance companies for pushing back. How many of us would, or could, pay for spine surgery and implants out of our own pockets.

    This market will be totally and permanently altered if an effective conservative therapy is developed.

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  12. 12:43 Is the success rate for lumbar fusion really 60-70 %?

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  13. 1:36- It depends on how you keep score. The way FDA keeps score its 40-65% success.

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  14. I love when idiots compare hip or knee pricing to spine surgery. 1:20. You are an idiot. Also, this is America, not Finland, you donkey kong liberal!

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  15. It is not fair to compare spine pricing to hip/knee but it is fair to look at the improvements in the clinically significant differences between types of surgeries.

    The literature indicates that spine surgery has a greater restorative result than either hip/knee surgery and justifies its cost (despite what insurance is saying).

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  16. Hey 1:50, you're obviously clueless. Cost/QALY is exactly the standard used to compare different procedures. That's what it's for.

    If you have a finite amount of $ to spend on healthcare, value determinations (like Cost / QALY) are how you decide on what it should be spent.

    1:36 - Yes, if you're a patient, and your primary reason for having surgery is back pain, not neurological symptoms, that's what you should count on. And remember, about 1 in 5 will be worse! If you thought your back pain couldn't get any worse before the surgery, you may be underestimating it the risks your facing.

    Hey 1:08, those very words have been uttered by many a reckless surgeon who turns a blind eye to his complications and poor outcomes. Not saying your guy isn't right, and yes, multilevel fusions can have great outcomes in older patients, but unless he's using objective outcome measures and has published his results I'd take his words with a pound of salt.

    Finally, to TSB's point, perhaps one of the largest challenges in patient selection for LBP fusion surgery is simply figuring out who really is likely to benefit.

    If you limit your patient population to exclusively those who are motivated, smart enough and thus:

    - do quit smoking
    - do continue working
    - do lose weight
    - do improve their strength and flexibility with PT
    - are able to find "positions of comfort"
    - do discontinue their pain meds or only use them "on demand"

    ... you'll have a better success rate. However, you likely won't have a lot of patients because most LBP patients don't meet those criteria, have gotten better, or have seen the guy down the street because you demand too much.

    A good friend of mine once said that if the patient has been going to physical therapy, but still can't touch their toes, he won't operate on them. He feels if you haven't even put enough effort into PT, how are you ever going to put the needed motivation into properly recovering from a fusion operation, or properly appreciate the risks and earnestness of the fusion surgery itself. Needless to say, he doesn't do a lot of fusions for LBP.

    And just doing an operation because the idiot down the street will do it if you don't doesn't make it right. I'd rather sleep well.

    Fusion surgery is a long-standing procedure and has multiple indications, some very justified and others less so. But the procedure itself is "grandfathered" into coverage by insurers.

    But with costs and indications escalating, insurers are obviously trying to see if they can curb the extremes of it. Because so much of the patient selection process is subjective, it's very difficult for them to lay down any ironclad criteria. (Because lumbar disc replacement was exclusively approved for LBP, that one was easy to deny.) So unless someone figures out a better way, for the foreseeable future patient selection will be left in the hands of the surgeons who hopefully will be judicious with it, or risk having insurers throw the baby out with bathwater.

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  17. 4:04 I would have to agree with most of what you said. I have been in this business for 12 years now and after many years of playing baseball professionally, I found myself I the table having a 360 done on me about 5 years ago. I too suffered from severe back pain and it was that I was having treated, hell anything to get rid of the f**king back pain. And Blue Shield of Cali only paid for about 65% of the 360. I was left with a bill of over $35K to pay in the long run (every services bills seperatley by the way so I had 10 service bills), and I would do it all over again and probalby pay more. Thats how bad the pain was. I went from a grade 1 spondy to a grade 2 in less than a year and the anterior positioning of the implant and the positioning of me on the bed (as we often see) helped to not only reduce the spondy but the ALIF helped to provide the direct decompression.
    I would also like to add that I had Infuse used on me and while my surgeon told me all the good/bad about the ALIF and Infuse I can say I have 2 healthy young boys.

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  18. 4:04
    Thank god one of the more insightful and accurate postings on this site. Wish we would see more of this and less of the BS/Name calling going on. Thank you for your insight.

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  19. 1:20 again.

    1:50 you are clueless, I'm no 'donkey kong' liberal. While I do love Donkey Kong, I'm a capitalist and if you think QALY isn't driving these decisions you are mistaken.

    Why is it unfair to compare spine surgery to hip and knee surgeries?

    I'm not buying that the literature shows a 'greater restorative result' with spine surgery compared to hip and knee replacement. But, even if that was so, it would make the relative cost of spine procedures per QALY that much better. It doesn't, so spine procedures are that much more expensive or the benefit is that much less. Take your pick, its still not a strength of our industry.

    Are you saying that hips and knees have been around longer so they don't have the R&D expenses? Pedicle screws and cages have been around a while too. Not much R&D there these days.

    So, if there were no insurance, who would pay for their own spine fusion out of pocket? How bad would your pain have to be for you to fork out $40-100k of our own money? That much of your hard earned money to have a 50% chance of getting any better and a 10-20% chance of a getting worse.

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  20. NuVasive currently in talks to acquire LDR.

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  21. ALIF's don't provide direct decompression, but it's a great story - glad to hear it's worked so well for you.

    Nice move NuVa - I'd have LDR in me for an ALIF for sure.

    8:06 - great point about 'if you had to fork out the money yourself' people would get off their ass and exercise, improve their diet, go to yoga, PT, and whine less. No chance of getting worse with that plan.

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  22. 10:21: You can direct decompress quite a few conditions with ALIF. It's like doing a big ACDF, with a lot less chance of neural complications. As long as the herniated fragment is attached, you can get it.

    Curious...NUVA has an ALIF portfolio...what is the point of acquiring LDR? Are they a cheap acquisition now? They also have 2 other cervical discs in Neodisc and PCM...why acquire Mobi-C? Not sure what's in it for NUVA.

    Let LDR blow their cash on the PMA, then buy assets out of bankruptcy...they won't survive. They have credit lines to pay off credit lines. Wonder how long they will still make payroll.

    Bonne au revoir, LDR.

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  23. TSB: response to your post question: insurance is a business. Add ObamaCare liberals to the equation, and most spine fusions go away, while premiums stick around and keep rising. (did I mention that 300 million people will be forced to pay them, no matter how poor the coverage?)

    You will have to suffer with your back pain, living in an endless cycle of depression and pain meds, since there will be no competition for your premium dollar. You have to spend it on crap plan A, crap plan B, or crap plan C. If you're on medicare and want a fusion, forget about it. That money is allocated to your maid's social security check.

    Remember, these overeducated idiots think they are smarter than the disease. They can fix everything with diet, exercise, and PT. They are convinced that back pain is 1) self inflicted, 2) overstated, and 3) reversible. If all of us plebes just weren't so obese, and fed on trans-fats, there would be not DDD.

    May they all suffer DDD and be subjected to the same crap care and physician shortage they are inflicting on us.

    And yes...fusion denials left right and center now. Everything is slowing down. It is happening now.

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  24. Just curious 11:48 can you substantiate your comments with some facts and sources or are you just using this blog as a political forum? Whether it was 44, 43, 42, 41, or 40, the government in this country has always been in bed with big insurance. Think not, go back and read the McCarron-Ferguson Act, it was legislation that was authored by a Democrat and Republican. The snapshot: "Federal anti-trust laws will not apply to the business of insurance, as long as states regulate." Who do you think runs the state Insurance and Banking Commissions, that's right skippy, former insurance and bankers. Next thing you are going to tell us is grandma will be euthanized. Unfortunately our buddy Jack Kervokian has gone on to the after life so you will have to inject yourself with your own pentobarbital. The reason grandma can have surgery is because Medicare, aka as the government and ahem. taxpayers foot the bill. Don't be so angry, everyone will have to tighten their belts, lose a little weight, stop smoking, eat more responsibly and throw in a little exercise and you'll enhance your quality of life. Don't believe me, just ask you spine surgeon consultant friend and they will tell you the same thing they tell their patients.

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  25. 11:48

    If you think that personal maintenance is not important then you really don't understand medicine. Alcohol, poor nutrition, lack of exercise, and smoking have never attributed to anyones demise, has it?

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  26. I've worked as a spine sales rep for more than 7 years and also in spine outcomes measurements.

    There are clinical tools (SF36, ODI, etc) that can help surgeons diagnose and treat patients. The biggest challenge is cost and incorporating the gathering of said information into the surgeons practices.

    Some leading institutions use the MCS (Mental Component Score) of the SF36 to help guide patients treatment. If the score in below a specific target then the patient receives a psych eval before further spine treatment.

    There are a couple of software companies that specialize in this field and have the ability to help patients, surgeons, hospitals and insurers.

    If medicare/caid and insurers made mandatory this type of data to approve surgery for low back pain then things would change.

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  27. Good point 5:56, but that's really where the challenge lies. Like other parameters that have been shown to correlate with outcome, it's sometimes difficult to put into an insurance policy, or even when written it may be difficult to enforce. And it must also be said that just because a patient does have a psych condition, it doesn't mean that they don't have back pain that could be treated. So ultimately the use of our back pain surgery $ will need to remain in the hands of the doctors. But how to create incentives so the docs use the $ wisely is the big challenge. In Europe they handle it by having a low supply of surgeries (i.e. # of surgeons, available OR's, etc.), so the docs are inherently incentivized to limit their surgeries to those in greatest need and for whom the chances of success are greatest. (Hence the famous "long wait times" for elective surgeries. It's one way to also limit "unnecessary" surgeries.)

    Speaking of politics, hey 11:48, why are you mixing two bags together? There's no correlation between political orientation and whether back pain is successfully managed with surgery. Whether we have a private insurance system or a government run healthcare system, unless they're paying out of pocket, the fusion operations are being paid for with MY MONEY!!!!

    So call me heartless, but only after the patient demonstrates they are willing to lose weight, quit smoking, kill off any addictions to meds they might have, do their best to keep working, show they're not a head case, work hard at PT etc. am I willing to fork over my hard earned dollars for their high risk and very expensive operation that may or may not work for them. If they want me to fork over my cash, they better step up to plate first and show that they deserve it. What's wrong with that logic?

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  28. ... I'm happy to fork over $$$ for the young mother suffering from breast cancer, the kid that needs kidney dialysis, and even the older guy who could really use a Dick Cheney jump starter for his ticker.

    But the fat, smoking, out of shape, med addicted, lawsuit wielding slob who didn't show up for half of his PT appointments isn't getting my share of the $80k for the fusion operation. At least I wish he wasn't.

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  29. TSB, 5:49: Don't think 11:48's post says diet & exercise, etc. WON'T help. The post says they're not the cure-all that they are often made out to be. I've seen a lot more spine surgery on normally-sized patients than on fat blobs...don't think he's wrong on that score. Tightening your belts and exercising more won't make DDD and other spine problems go away. I promise. What will go away is treatment for patients who "deserve it" (who gets to decide if I deserve to have my spine fixed...?) and our livelihoods selling the implants needed for the surgeries.

    11:48: nice job outing some lefty cranks with one simple post. MM leads the charge in that category. Explains the bitterness and constant attacks on "greedy companies".

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  30. Here here both 11:48 and 9:48

    For God's sake MM do you really believe the gov't can run healthcare???? forget about even doing it efficiently, just doing it will be impossible! You ask for 11:48 to substantiate his comments, what a joke! Have you ever visited the post office? Been to the DMV? or hounded by the IRS?? Oh yes our gov't run programs are so well versed in customer service. There is your fu*king substantiation!!
    I can hear it now as I venture into the Obama Healthcare Clinic as I am writhing in pain with stage IV pancreatic cancer.... "Yea you think you got problems buddy? Go grab that ticket that reads you are #300 in line to be seen cause we all got problems here"

    It was not us who made healthcare political, it was and is Obama and his fellow democrats who use Healthcare as a political tool to buy more votes!! All hail the democrats because they really just have our best interest at heart (wink, wink). Are you really that gullable? All under the guise of looking out for his poor fellow man who is just so down on his luck he could never ever pay for his own insurance.

    MM you write about Big Insurance and federal Anti-Trust, and that is a good point. Why not increase competition allowing for the sale of insurance across state lines. Let's address that and the tort reform problems instead of shredding the constitution and requiring all of us to pay for something.

    And Medicare is our savior? again what a joke! Medicare will be viable for how long, another 15-20 years? Then what happens? Democrats love to spout off and say Republicans want Grandma to die already anytime reform is mentioned. If you truly did care about Granny or for yourself and children for that matter you would admit that some radical changes do need to be made in order for all of us to continue to have a decent quality of life.

    it is pathetic the way you demagogue and use scare tactics anytime hard decisions must be made for the well being of all of us in society, especially the evil rich. Oh I forget you elites always know so much better than the rest of us how our hard earned money should be spent!

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  31. 10:29 Now that's telling TSB, what a man, no need for testosterone not for you my friend, I have to admit you are pretty funny.

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  32. MM...11:48 here. McCarran-Ferguson was crafted in 1945 in response to the Supreme Court ruling in 1944 that insurance was "not commerce", and therefore not subject to federal regulation under the commerce clause.

    Insurance...not regulated by the federal government, but left to the states to regulate. Seems like a pretty reasonable idea. MF weighed in on what the boundaries of federal regulation vs. state regulation should be in the wake of the Court's decision.

    Not sure what the rest of your rant has to do with that act. Where does euthanizing grandma come in? Why is Medicare the only way possible for grandma to pay for her surgery? Are all grandmothers poor destitute people who, after a full working life, haven't managed to scrape together two nickels?

    You have a very sad world view. Do you see anything other than poverty, greed, and corruption in anyone around you?

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  33. Hey 10:29, nowhere in TSB's or any other posts does anyone advocate government run healthcare. Let's all agree nobody likes it so quit sidestepping the issue.

    Aside from the adverse effects that it will have on all of our bottom lines, is there anyone here that thinks generously dishing out fusions for Low Back Pain is a good idea? You all really think that many of the operations we see on the aforementioned "less well indicated" patients is really healthcare dollars well spent?

    Presuming we all agree that it isn't, how do we make sure that the insurance companies don't take away lumbar fusions entirely. ISASS is off to a good start with their recent policy guidelines, and hopefully measures like that and others will keep the baby in the tub and the docs in control.

    And 9:48, if you have insurance then I and every other premium payer get to decide if you "deserve" to have your spine fixed. I'm paying for it.

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  34. Bump. Best post ever on this site. Deserves repeating:

    For God's sake MM do you really believe the gov't can run healthcare???? forget about even doing it efficiently, just doing it will be impossible! You ask for 11:48 to substantiate his comments, what a joke! Have you ever visited the post office? Been to the DMV? or hounded by the IRS?? Oh yes our gov't run programs are so well versed in customer service. There is your fu*king substantiation!!
    I can hear it now as I venture into the Obama Healthcare Clinic as I am writhing in pain with stage IV pancreatic cancer.... "Yea you think you got problems buddy? Go grab that ticket that reads you are #300 in line to be seen cause we all got problems here"

    It was not us who made healthcare political, it was and is Obama and his fellow democrats who use Healthcare as a political tool to buy more votes!! All hail the democrats because they really just have our best interest at heart (wink, wink). Are you really that gullable? All under the guise of looking out for his poor fellow man who is just so down on his luck he could never ever pay for his own insurance.

    MM you write about Big Insurance and federal Anti-Trust, and that is a good point. Why not increase competition allowing for the sale of insurance across state lines. Let's address that and the tort reform problems instead of shredding the constitution and requiring all of us to pay for something.

    And Medicare is our savior? again what a joke! Medicare will be viable for how long, another 15-20 years? Then what happens? Democrats love to spout off and say Republicans want Grandma to die already anytime reform is mentioned. If you truly did care about Granny or for yourself and children for that matter you would admit that some radical changes do need to be made in order for all of us to continue to have a decent quality of life.

    it is pathetic the way you demagogue and use scare tactics anytime hard decisions must be made for the well being of all of us in society, especially the evil rich. Oh I forget you elites always know so much better than the rest of us how our hard earned money should be spent!

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  35. 1:03. You are WRONG. You get to decide nothing about a persons healthcare that is a customer of the same plan as you are. You aren't pooling your money with others to pay for care. You are BUYING insurance, gambling that you will avoid a catastrophic health and financial event by paying an insurance company a monthly premium. You are buying a product. The insurance company is the one paying the bills. You have no say so in matters of coverage for another member and you aren't FORCED to buy the coverage. In fact, you have options on what company you buy it from and what amount of coverage you want. Those options will be greatly limited by a government imposed "reform". And while everybody will have a shiny new insurance card, the quality and access to care will not improve for the less fortunate, and it will decline for those of us who pay for our own, either directly or via contract with an insurance company.

    But drop the BS about you paying for someone elses care, that is a weak argument on many levels. Particularly if you imply that voluntary purchase of an insurance policy equates to a mandated purchase with mandated coverage types with the added bonus of an entitlement program and government bureaucracy.

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  36. 2:!6 you must really love yourself to post your non-sense twice, spare the rest of us your agony, when your 65 medicare will be your savior

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  37. anyone have an idea if Zimmer Spine has much business in Southern Cali? I heard that they have pretty much lost all the business in Northern Cali due to some key reps that have left over the last 2 years and a distribution change. Anyone have some insight??
    Thanks
    LTK

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  38. 2:38, sorry, but it is you who is completely wrong. And quit implying that I am an advocate for government run healthcare. I'm not. I'd actually like to see a greater free market for insurance.

    Your statement that insurance is like any other product is completely ignorant. I'd love to buy a plan from an insurer that only costs half as much because they don't waste money on things like unnecessary fusions for low back pain. But that doesn't exist because any time an insurer comes along and tries to cut their benefits someone cries foul and that they are trying to screw the beneficiaries. So as healthcare costs go up our insurance premiums have been taken for a ride.

    Yes an insurance company is a business that pools our money to pay for our healthcare expenses. If healthcare expenditures go up, they raise their premiums. Or did you have some magic fairy in mind that somehow is kicking in the extra cash?

    About 75% - 80% of our premiums goes right back out the door to the docs and hospitals to pay for the services, they take 20% for the privelege (which is too much btw), and they make a few percent profit.

    So if they can knock a few points off of their expenditures, then the competition will drive the premiums down and I'll end up spending less every month, which would be nice.

    So as long as it's my premiums they're spending, hell yes I feel entitled to kick and scream when I see it wasted. I want lower premiums.

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  39. Let's get this crystal fing clear...gov't can't run a damn thing...is anyone paying attention? Gov't is critical of the automotive, banking/lending, industries. (that they(gov't) screwed up..and messed up to begin with) To name a few..or have 100's of congressional hearings on this bs or that bs (critizing everyone as if they could do better)....meanwhile they (US gov't) run the greatest nation in the history of the world into the ground..on the brink of collapse...And we should trust them, to all the sudden fix our problems and run healthcare??????????? You people have lost your damn minds. We are all screwed. Nothing in the history of history has been run with more inept then our current US gov't. Period.. I wouldn't trust the gov't to build a dog house in my back yard much less run healthcare!

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  40. Just finished reading this post need to ask Dennis Miller Jr., WTF are you talking about, did you read the same thing that I did? Only quoting you have you lost your mind?

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  41. this blog is getting worse and worse everyday. What started out as a novel and great forum for us "professionals" has turned into now a political free forall. What a joke!

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  42. 7:34
    You are correct that the insurance company pools it's money to pay the costs for contracted members who buy a policy, and they pay it within the terms of the policy. Yes, if healthcare costs go up, they raise premiums. They have actuary data (that is more sophisticated than the data we have for spine surgery) to predict the costs for a certain policy and set the premium in accordance. Yes, they make money as they should because they assume a ton of risk if their data is wrong. As far as how much they make, who are you to decide how much is too much. The only thing for you to decide is which product to buy based on your needs and the value offered to you.

    Insurers cut benefits all the time. Most have a huge list of exclusions for services they will not pay for. Most of those service require certain criteria to be met for coverage, versus a carte blanche approach. It is government regulation that prevents companies from excluding members for such politically incorrect conditions such as obesity, nicotine addiction. With Obama are, they will also prevent exclusion for preexisting conditions and the inability to pay. It will also limit the difference in premium costs for those among us who a the most unhealthy, whether by luck or lifestyle choices.

    Let me ask you a question, since you want to decide if another patient deserves a spine fusion or not, would you be open to letting other policy holders determine if you need a liver transplant, a penile implant, a breast reconstruction or a craniotomy if they were basing their decision on how it would effect their premium? I didn't think so, and thats why you have no say in the matter other than choosing a different carrier.

    I agree that more competition is necessary, particularly in my state. Maybe if government stays out of the business, you may get the opportunity to buy a policy that limits unnecessary care. But be careful who is deciding that because it might be you wanting services that someone like you doesn't feel you deserve.

    And by the way, what am I wrong about?

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  43. Then stop commenting unless you're one of Robin Young's minions looking to bad mouth this blog, heard you guys are losing mucho readers to this blog read em and weep

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  44. 7:29
    When politicians no longer have any control of healthcare, the political posts will end.

    We can always hope!

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  45. Use technology to automate the entire process, make it transparent, reduce excessive costs all parties partake in to manage logistics and the truth will set us free! Until that happens every one and method will ALWAYS be wrong. Automate everything from tracking inventory to patient approvals.

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  46. To 7:29

    then stop reading the blog, and go along your merry way. It is not us "professionals" that desire to have politics injected into these discussions. But our fearless leader has demanded it! To ignore it is just sticking your head in the sand....from now on your name is not "anonymous" It IS "Ostrich" hahahahaha

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  47. 7:38 & 9:04, sounds like you jokes have nothing better to do. I think I will head off to golf while my case coverage bitch covers that 2 level 360.

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  48. makes sense...there are lots of holes on the golf course to stick your ostrich head in!

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  49. I am a spine surgeon and have been around too long. Over the years I have seen various theories used to justify doing spinal fusions with instrumentation for back pain. They all suffer from illogic.
    Internal disk disruption was a scam started in Texas. Basically, all the tests were normal so let's do a discogram and then a fusion. Unfortunately the discogram was never able to predict the important thing, which patient will do well with a fusion. Now Carragee has shown that discography causes disk degeneration.
    In this blog I saw another common piece of illogical arguement. To set things straight I offer the following.If a patient has chronic disabling back pain and non-surgical management fails, this does not mean that surgery is indicated. European studies show repeatedly that the non-surgical group does better than the surgical group. People have to get away from the concept: "The patient has back pain and therefore we have do do something." Many get better on their own. Surgery makes many worse.
    The definition of instability in the lumbar spine has been clouded by surgeons who are trying to justify expensive fusion operations. Some of my fellow spine surgeons are just lying through their teeth. It used to be more than 1 cm of movement forward on flexion. Now it is all nonsense.
    Degenerative disease of the lumbar spine is universal. To use changes on imaging studies to justify fusion for back pain is foolish. Most people have degenerative disease of the lumbar spine with little or no symptoms.
    I am surprised that anyone pays for lumbar fusion for back pain. Also, there is no proven benefit to: "motion preservation".

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  50. So...Nuvasive is looking at LDR?

    Hmmm...looks like Zimmer missed this boat too.

    Not surprised though with Zimmer's ineptness!

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  51. have heard LDR has been shopping itself around for long time but they want too much money... they think their disc is worth a lot and besides stand alone cages, rest is weak. hope they and many other are bought or go out of business tho... we could use a lot less companies

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  52. 8:45

    Who would oversee your standardization of 17% of our economy? Don't you think that would cost monday to regulate on a national level? Who would pay for it? Do you really want to give all of that power to over?

    Government already standardizes the industry. Do a little research, please.

    Oh, what is the "technology" that instantly automates more information than imaginable to HIPPA standards? I think you meant "magic," which is a brilliant idea.

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  53. 2:36,

    Do a search for "Unique Device Identification" or "UDI FDA". Alakazam...wheels are in motion! There are several companies already setting up the framework to support it.

    with love from Automated Magic Land - 8:45

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  54. 1:02- Yup. The U.S. is pretty much the only country that do a fusion for 'back pain.' Internal disc disruption. I always wondered why that was an indication for surgery. Would be interesting to see a study on how many 'normal' people have disruption at a given age.

    I'm still curious to know how many here would pay for their would pay for their own spine fusion if insurance were not an option. This post was about insurance wasn't it?

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  55. Oh yeah. Roll Out was planned for last year. Why do they have sponsers? Weird.

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  56. anyone have an idea if Zimmer Spine has much business in Southern Cali? I heard that they have pretty much lost all the business in Northern Cali due to some key reps that have left over the last 2 years and a distribution change. Anyone have some insight??
    Thanks
    LTK

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  57. LDR/Nuvasive.....don t think so
    LDR is preparing his IPO to launch their Mobi C in the US

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  58. LDR has a couple nice products, but is really lacking in market presence and not considered a significant threat to anyone really.

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  59. MDT announced they will be letting sales reps go in anticipation of a dismal Q1 performance. The good news is that they will have a better opportunity securing a job since they'll be on the street before the Synthes reps figure it out.

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  60. I am in need of a good head hunter in the caliornia market. Please email me at:
    onespineguy@hotmail.com

    Thank you

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  61. 10:59 yessir
    Poor Synthes reps believing they will have a nice new home with Depuy spine. Kudos to Depuy Spine for being so convincing. hahahahahaha Synthes Suckers !!

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  62. MDT reps and Synthes reps hitting the unemployment ranks. Oversupply of reps will lead to lower commissions all around. We're all the suckers together in that one. Stash some cash in the mattress folks. Spine CFO's will be salivating at the chance to tighten up those cash flow statements.

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  63. MDT and Synthes reps don't sell they maintain bought business.

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  64. 4:05, what do you sell?

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  65. Bcbs of minnesota is denying surgeries like crazy. For over a year now, I have heard surgeons complaining about it. I have heard that the surgeons at minnesotas twin cites spine center have 3 months of surgeries that they are waiting for approvals.

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  66. 6:46,

    Are the surgeons you mentioned payor mix mostly private or non-private?

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  67. Right in MDT's backyard. Wow.

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  68. Payors all over the country are denying surgeries like crazy. BCBS is offender #1 because their counterpart in North Carolina was the first to make the leap of denials with the DDD stipulations. Now they are of the mind that if they deny 100 surgeries and 5 of them end up getting cancelled because the doctor is sick of doing peer to peer's etc.. then its a win win for them.
    If a physician spends the time to appeal and do peer to peer's with the carriers they will overturn the denial 9 times out of 10, its just a matter of the physician taking time to do so. I am recommending to all of my customers that they actually hire someone that is in charge of denials mgmt. outside of their scheduler, it will pay off.

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  69. 10:14, what you say is certainly what we are seeing in Florida. But the insurance strategy (from their point of view) is sound. There is no problems on gross instability defined by spondylolithesis with flex/ext motion, or multiple recurrent HNP's patients. But pure DDD fusions have not demonstrated predictable outcomes, and currently are being denied. My problem is with the denial on fusions on some of the severe stenosis patients, which I have concerns about post laminectomy instability. Unfortunately, some of these patients have been decompressed, only to need a fusion a few months later.

    The appeal process is a pain in the a##, but you are right. After a few hours on the phone, usually it is authorized.

    But now, there is an economic disincentive to go through this process. It is onerous, time consuming, and staff labor intensive. It is costing me another layer of overhead.

    So, if I hire a new staff member to process this, it may pay off for me, but certainly it will pay off for you. I am not a proponent of POD's, but you can see how that revenue stream has a certain attraction in this environment. "It is just to offset additional costs" now seems to make sense.

    It is hot today. Stay cool.

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  70. You must not do very good alifs because they are very predictable and work well for DDD. The patient with one or two level narrowing desiccation and pain with motion are the best candidates. Post discectomy narrowing and DDD is the classic good patient. Those where their leg pain was relieved and now they have only back pain get good relief with ALIF plif or tlif. This is really denying patients good treatment because of money. It is not that hard to pick the clinically correct patient for these proceedures. Choose patients without psyco social problems and your patients will think you are graet. I love seeing my post op patients, they are why I do this. Every office day I can usually count on having my paints reap huge thank yous and gods blessings on me for just doing my job. Unless you visit your doctors office and shadow him you won't really realize how often the fusion patients do well. We just don't have great studies to document this. If you look at the control groups from the arthroplasty studies you'll see darn good results for fusion. Let's stop bashing what is a very reasonable surgery.

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  71. RE: Zimmer Spine in California distribution question ... Yes, Zimmer Spine is done in California, Arizona and all of the Mountain and Pacific Time zones. Pretty much anywhere where Dan Kirkpatrick went during his tenure as interim VP of Sales = talented tenured reps getting lied to and led astray. That man single handedly destroyed what was left of that company and Warsaw just doesn't care. Mike Watts is culpable as well (genius behind moving distribution from Memphis to one hour away from the Austin, TX airport). Give Dan some more time and he'll run off Zimmer Spine's largest distributor.

    Truth hurts. None of the Abbott alums liked being bought (they thought they would be acquiring). Zimmer Corporate looked the other way when it was obvious to EVERYONE the integration was going horribly wrong. Add that to the Dynesys denial and Zimmer Spine has been bleeding talented people and market share ever since. The numbers don't lie.

    I'm expecting another down quarter based off a 2010 number that was already way down.

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  72. 3:04 thanks. I would have to agree with you. I was with Spine Tech/Zimmer Spine for 8 years and towards the last 3 of them, it was a cluster f**king mess! Blue Blue has zero idea what it takes to run a Spine Company. All the old boys are gone from ZS and its a shame. We used ot have some rocking good old times are National Sales mtgs. Back when Tim and Bob Milani were running things.
    Does anyone know where the reps from Northern Califonia went that left Zimmer Cook?

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  73. I thought that the distributor for spine in N Cal was the joint distributor. Sounds to me they made a good choice.

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  74. @2:14

    I can see how other revenue sources are starting to look more attractive. Is the reward worth the risk in these situations though?

    Not sure what vendors you currently work with but I know that my company actually offers a denials mgmt. service to our customers. To go one further its actually available to you even if you are not our customer, and its no cost to you. They have a 90% turn rate on denials, it can sometimes take a few weeks but it is a free service.

    Check with your vendor, you may have options you are not aware of.

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  75. This site is stale. Maybe we should change the name of it to the Sameoldshitdifferentdayblogger?

    All this blog is doing anymore is recycling the same old stories, same old comments and I really feel like it should just be left behind like dust in the wind.

    And to think people give a fuck about your identity...so immature.

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  76. Overheard a rep from 1 of the big 3 commenting- My doc trained on my companies products during fellowship so he is never changing. I wanted to tell him, "so he's not really "your" doc, you inherited a surgeon who will use those products regardless of you. But he's right. The doc is insecure using anything else but (company name) Meanwhile, that 'rep' or case coverer is living in a huge home and makes 450K /year. and he bitches when the surgeon takes longer than normal during a case and it cuts into his after work activities. ???

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  77. To 3:04. Interesting comments. Kirkpatrick has never had responsibility for the West, ever. Mike Watts had nothing to do with with changing distribution centers, that was an operational decision, not finance, and by the way, Memphis was the most un-organized, dis-functional group many had encounter in a long time. And, there are TWO distributorships in CA, so don't lump them. No. CA was replaced, So. CA is alive and doing well.

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  78. 12:35. Every decision at Z is a financial decision. Also, Kirkpatrick was interim VP of Sales and all of his "boys" reported to him. He most definitely made decisions through Crawford. Both CA distributors blow. You know it.

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  79. Spine Surgery India offers info on Spine Surgery India,Spine Surgeon,Spinal Surgery India,Back Pain,Spine Implant,Cost Spine Surgery Hospital India.Here i suggest peoples to go INDIA for srgery, then you must search for Spine surgery India, Laser spine surgery India, Best spine surgeon India, Spine surgery best hospital India & spine surgery cost india

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  80. Well, for the last 3 years I have been dealing with Blue Shield of California and their denials of my L4-L5 disc replacement. Two years ago I filled a federal law suit to have them remove the "experimental" labeling for this surgery the case is almost done and according to my understanding everything is going well and most likely I am going to win this...

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  81. This comment has been removed by the author.

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