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Case Study
Treatment of Intervertebral Disc Disorders of the Lumbar Spine: An Analysis Using the Medical Episode Grouper (MEG)
September 2013
Table ofContents
Introduction 1
Lumbar Disc Disorder Prevalence and Price 2
Episode Price Components 3
Inpatient Care 4
Outpatient Care 5
Treatment Pathways 5
Inpatient Care 7
Outpatient Surgery 8
Outpatient Medical 9
Variation in Treatment Patterns 10
The Impact of Severity 11
Geographic Variation 12
Provider Variation 13
Summary 15
1An AnAlysis Using the MedicAl episode groUper
Considerable controversy exists among medical professionals regarding the most effective treatment for lower back spinal disc disorders. Potential treatments include surgery, minimally invasive spinal injections, physical therapy, chiropractic treatment, or a combination of these. The Journal of Bone and Joint Surgery has published a thorough article that summarizes multiple studies regarding the efficacy of various treatment protocols.1
The objective of this study was to analyze the variation present in treatment patterns and to quantify the differences in pricing/payment for the different options. The data source used was the Truven Health MarketScan® Commercial Claims Database, which contains the healthcare experience for more than 140 million privately insured individuals spanning 18 years. The dataset includes professional and facility inpatient and outpatient claims, as well as pharmacy claims and eligibility information. The data are linked by a common enrollee identifier, allowing for person-level analysis across the spectrum of care. A sample of the 2011 MarketScan data consisting of approximately 4.4 million enrollees with 20 million episodes was selected for use in this study.
Introduction
2 An AnAlysis Using the MedicAl episode groUper
Lumbar Disc Disorder Prevalence and PriceWithin the sample population, the musculoskeletal body system (MUS) is the top
contributor to medical payments, representing more than 18 percent of the total as
shown in Figure 1
Figure 1: Episode Medical Allowed Amount Percent of Total by Body System
Figure 2 illustrates that within the musculoskeletal body system, lower back
disorders represent the second costliest episode summary group in terms of total
payments (after Osteoarthritis) and the second most prevalent (after Arthropathies/
Joint Disorders)
Figure 2: Price and Prevalence of Musculoskeletal Episodes
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Muscu
losk
eleta
l
Female
Rep
roduc
tive
Cardio
vasc
ular
Gastro
inte
stin
al
Other
Neuro
logica
l
Respira
tory
Urinar
y Tr
act
Ear, N
ose, &
Thr
oat Skin
Endocr
ine
& Met
abolic
Psych
iatric
Hepat
obiliary
& P
ancr
eas
Hemopoiet
ic & Ly
mpha
tic
Neona
tal, C
ongen
ital
Eye
Nutrit
iona
l
Male G
enita
l
Trau
ma
& Iatro
genic
Infe
ctio
us &
Par
asiti
c
Oral a
nd D
enta
l
Imm
unolo
gic & A
llerg
ic
Genet
ic
Episode Medical Allowed Amount % of Total by Body System
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
0%
5%
10%
15%
20%
25%
30%
Ost
eoar
thri
tis
Sp
inal
/Bac
k D
iso
rder
s, L
ow
er B
ack
Art
hro
pat
hies
/Jo
int
Dis
ord
NE
C
Fra
ctur
e/D
islo
c —
Up
per
Ext
rem
Sp
inal
/Bac
k D
iso
rder
s, E
xcl.
Low
Inju
ry —
Kne
e
Bur
siti
s
Fra
ctur
e/D
islo
c —
Ank
le/F
oo
t
Inju
ry —
Mus
culo
skel
etal
, NE
C
Rhe
umat
oid
Art
hrit
is
Mus
culo
sk D
iso
rd, C
ong
enit
al
Fra
ctur
e/D
islo
c —
Hip
/Fem
Hea
d
Hal
lux
Def
orm
itie
s
Fra
ctur
e/D
islo
c —
Leg
, NE
C
Inju
ry —
Che
st W
all
Mus
culo
sk D
iso
rd, A
uto
imm
une
Infe
ctio
ns —
Mus
culo
skel
etal
Fra
ctur
e/D
islo
c —
Fac
ial B
one
s
Fra
ctur
e/D
islo
c —
Kne
e/P
atel
la
Can
cer
— P
rim
ary
Bo
ne
Tum
ors
— M
uscu
losk
, Ben
ign
Ost
eop
oro
sis
Go
ut
Mus
culo
sk D
iso
rd, N
EC
Musculoskeletal Episodes
% Allow Amt % Epis Mean Allow Amt
3An AnAlysis Using the MedicAl episode groUper
There are two episode groups that fall within the low back disorders summary group:
Intervertebral Disc Disorders: Lumbar and Lumbosacral and Other Spinal and Back
Disorders: Low Back The two groups contribute similar total allowed amounts
despite the fact that there are far fewer disc disorder episodes The disc episodes also
have a considerable amount of variation despite being a more specific diagnosis See
Table 1
Table 1: Low Back Disorder Episode Groups
Medical Allowed Amount
Episode Group Episodes % Total $ Mean $ Standard Deviation $
Intervertebral Disc Disorders: Lumbar and Lumbosacral
24,138 44.13% $4,320 $12,319
Other Spinal and Back Disorders: Low Back
220,141 55.87% $600 $3,549
Episode Price ComponentsTo analyze the significant price variation within the low back disc disorder episodes,
the 24,138 low back disc disorder episodes identified in the prior section were
limited to those that started and ended between March and October of 2011 This
is to exclude possible “incomplete” episodes that may exist at the beginning or end
of the data time period (episodes for which not all claim data is present in the 2011
dataset) In addition, only episodes paid under a fee-for-service arrangement with
medical allowed amounts greater than zero dollars were included in the sample so
that in-depth financial analysis could be performed Finally, episodes for individuals
who were not continuously enrolled between March and October were excluded
A total of 9,862 low back disc disorder episodes remained in the dataset with an
average medical allowed amount of $3,388 The list was then further constrained
to only qualified episodes to ensure that rare outlier episodes were excluded The
qualification criteria for low back disc disorder episodes are shown in Table 2
Table 2: Low Back Disc Disorder Disease Stages
Stage Qualifying Criteria
1.01 – 1.02 >= 1 face-to-face visit or >= 1 admission or >= 1 major procedure*
2.01+ >= 1 admission or >= 1 major procedure*
* Major procedures include: laminectomy or other decompression; vertebral corpectomy; lumbar fusion; epidural or subarachnoid injection (lumbar or sacral); injection of anesthetic agent and/or steroid and transforaminal epidural, with imaging guidance (lumbar or sacral).
4 An AnAlysis Using the MedicAl episode groUper
Excluding the nonqualified episodes resulted in a dataset of 9,075 episodes with
an average medical allowed amount of $3,532 (Table 3), which were used for the
remainder of the study
Table 3: Episodes in Sample
Qualified? # Episodes Average Medical Allowed Amount
No 787 $1,210
Yes 9,075 $3,532
Total 9,862 $3,347
The distribution of allowed amount within these episodes is quite high, even after
limiting to qualified episodes, as shown in Figure 3
Figure 3: Episode Distribution by Medical Allowed Amount
Because the Medical Episode Grouper (MEG) retains a link to all claim-level
information included in the episode, one can determine what types of treatment
were included in a given episode of care
Inpatient CareInpatient care is uncommon among low back disc disorder episodes, with only 431
of the 9,075 episodes (4 7 percent) including an inpatient admission The admissions
that occur are overwhelmingly for surgical spinal procedures The two main types
of procedures performed are disc surgeries (excision or repair of disc) and spinal
fusion, with the former being much more common and less expensive (Table 4)
The Journal of Bone and Joint Surgery article (referenced earlier in this paper)
does not address fusion surgery as one of the surgical treatment options for disc
disorders The Milliman Care Guidelines for lumbar fusion consider the procedure
medically necessary in only very specific situations involving lumbar disc disorders:
“As a surgical adjunct to disc excision or reoperative discectomy in patients
with radiculopathy secondary to a herniated disc in whom there is documented
radiographic evidence of preoperative lumbar spinal instability (e g , anterolisthesis,
retrolisthesis, spondylolisthesis) ”2 In other words, disc herniation alone is not
justification for spinal fusion; an instability issue in the spine must also be present
0%
10%
20%
30%
40%
50%
60%
70%
80%
$250
$500
$1,0
00
$2,0
00
$4,0
00
$6,0
00
$8,0
00
$10,0
00
$12,0
00
$14,0
00
$16,0
00
$18,0
00
$20,0
00
$22,0
00
$24,0
00
$26,0
00
$28,0
00
$30,0
00
$32,0
00
$34,0
00
$36,0
00
$38,0
00
$40,0
00
>$40,0
00
Episode Distribution by Medical Allowed Amount
Qualified Episodes, n=9,075
5An AnAlysis Using the MedicAl episode groUper
Table 4: Top Inpatient Admissions in Low Back Disc Disorder Episodes
Base DRG % Cases Avg Length of Stay (LOS)
Average Admission Allowed $
490 Back and Neck Procedure Excluding Spinal Fusion
54.8% 1.49 $14,581
459 Spinal Fusion Excluding Cervical 28.9% 2.72 $52,714
551 Medical Back Problems 10.1% 2.87 $9,845
Outpatient CareThe following are the most common service types occurring in the outpatient setting
for these episodes The listed service types were selected based on their inclusion in
at least 15 percent of the episodes
Table 5: Top Outpatient Service Types in Low Back Disc Disorder Episodes
Service Type % Episodes With Service Type
Average Allowed Amount for Service Type per Episode
Specialist Office Visits 49% $171
Radiology 40% $734
Nonspecialist Office Visits 34% $175
Physical Therapy 26% $479
Injections and Medications 23% $450
Major Procedures 20% $4,819
Chiropractic Services 19% $166
Radiology: For these episodes, radiology services consist of a mix of major imaging
procedures (CT and MRI) as well as X-rays The average allowed amount for an X-ray
is about $100, while for a CT or MRI, the price ranges from $500 to $1,000
Injections and Medications: For these episodes, the most common injections used in
treatment are spinal injections of either a steroid or nerve-blocking agent
Major Procedures: This category clearly represents the biggest contributor to
outpatient medical payments within these episodes Most of the major procedures
within these episodes consist of low back surgeries (most often laminotomies)
Treatment PathwaysWith the previous major price contributors identified, the episodes were examined to
identify common patterns in treatment The following basic treatment profiles were
identified:
§ Inpatient (IP) Surgical
§ IP Medical
§ Outpatient (OP) Surgical
§ Physical Therapy (PT)/Chiropractic
§ Spinal Injections
§ PT/Chiropractic and Spinal Injections
§ No PT/Chiropractic or Spinal Injections (office visits with or without imaging)
6 An AnAlysis Using the MedicAl episode groUper
PT/Chiropractic are identified by ranges of procedure codes that often overlap and
have similar pricing profiles, therefore these two types of treatment were combined
into one treatment pathway
Spinal injections include both nerve block and steroid injections — patients
typically had one or the other, not both
Figure 4 describes the frequency and average medical allowed amount associated
with each pathway
Figure 4: Treatment Pathways for Low Back Disc Disorder
All Qualified Episodesn=9,075
Avg $ = $3,532
Outpatient Care n=8,644$2,145
Inpatient Admission
n=431$31,349
Surgicaln=389
$33,364
Medicaln=7,995$1,160
Surgicaln=649$14,278
Medicaln=42
$12,694
w/ OP PT or Injections
n=165, $36,181
no OP PT or Injections
n=224, $31,288
w/ OP PT or Injections
n=360, $14,835
no OP PT or Injections
n=289, $13,584
PT/Chiropracticn=2,484, $800
Spinal Injections n=1,788, $2,057
PT and Injections n=499, $4,065
No PT / Injections
n=3,274, $546
7An AnAlysis Using the MedicAl episode groUper
Specific characteristics of the various treatment pathways are shown in Table 6
Table 6: Treatment Pathway Characteristics
Average Number of Visits/Episode
Treatment Pathway
% Episode
Average Medical
$ Per Episode
Average Episode Length (Days) Injection PT* Chiro* Office
Major Image
IP Surgery Alone 2.47% $31,288 37.00 - - - 1.96 0.57
IP Surgery With Other OP Treatments
1.82% $36,181 96.42 0.88 4.75 0.64 4.19 0.89
IP Medical 0.46% $12,694 36.43 0.48 0.79 0.12 1.81 0.45
OP Surgery Alone 3.18% $13,584 29.59 - - - 2.23 0.60
OP Surgery With Other OP Treatments
3.97% $14,835 72.25 0.83 3.63 1.06 3.75 0.76
Injection 19.70% $2,057 33.97 1.42 - - 2.18 0.33
PT/Chiro 27.37% $800 36.78 - 4.38 3.10 1.68 0.16
PT/Chiro and Injection
4.95% $4,065 88.24 1.69 6.12 2.36 4.62 0.72
No Major Treatment
36.08% $546 15.06 - - - 2.14 0.24
* Note that these are visits with a PT or Chiropractic procedure code — these visits may sometimes overlap and be performed during the same encounter.
Inpatient Care Episodes including inpatient surgical procedures are the most expensive of the low
back disc disorder episodes Episodes with inpatient medical stays are the third most
expensive, although they are extremely rare The price variation is significant within
these inpatient episodes as shown in Figure 5
Figure 5: Distribution of Medical Allowed Amount, Episodes With Inpatient Care
50%
40%
30%
20%
10%
0%
Qualified Episodes, n=9,075
Qualified, IP Surgery, n=389
Qualified, No Surgery, IP Medical n=42
$25
0
$50
0
$1,0
00
$2,
00
0
$4
,00
0
$6
,00
0
$8
,00
0
$10
,00
0
$12
,00
0
$14
,00
0
$16
,00
0
$18
,00
0
$20
,00
0
$22
,00
0
$24
,00
0
$26
,00
0
$28
,00
0
$30
,00
0
$32
,00
0
$34
,00
0
$36
,00
0
$38
,00
0
$4
0,0
00
>$
40
,00
0
8 An AnAlysis Using the MedicAl episode groUper
Episodes including inpatient surgeries vary significantly on the length of time
between the start of the episode and the surgery date The average lag is 37 days
However, a significant number of episodes start with an inpatient surgery within
the first two weeks This implies that no prior diagnoses of low back disc disorder
occurred for these patients Figure 6 shows the average total episode medical
allowed amount vs inpatient allowed amount based on the lag prior to surgery
Figure 6: Lag Time Effect of Price of Inpatient Surgical Episodes
The data show that the later the surgery, the more expensive the total episode
(most likely due to other modalities of treatment being attempted prior to surgery)
Interestingly, longer lag times are also correlated with more expensive inpatient
surgeries This is due to a higher likelihood of a spinal fusion procedure being
performed, rather than a less expensive disc surgery As mentioned in the Inpatient
Care section (page 4), disc surgeries have an average price of approximately $15,000,
while fusion surgeries are typically much higher (average of $53,000) Of the
surgeries that took place at the beginning of the episode, only 24 percent were spinal
fusion surgeries, while of those taking place more than 60 days into the episode,
43 percent were spinal fusions
Outpatient SurgeryWhile less expensive than inpatient surgery, outpatient surgery is still a significant
contributor to episode price, and is by far the most expensive outpatient treatment
option Typically, only disc surgeries are performed on an outpatient basis (spinal
fusions usually require inpatient admission) Although the average price of
outpatient surgery is lower than inpatient disc surgeries, the price variation is still
significant within these outpatient surgical episodes as shown in Figure 7
0%
5%
10%
15%
20%
25%
30%
35%
40%
$0
$10,000
$20,000
$30,000
$40,000
$50,000
1-15 Days 16 to 30 Days 31 to 60 Days > 60 Days
Per
cent
of
Ep
iso
des
Allo
wed
Am
oun
t
Days from Episode Start to Surgery Date
Price and Frequency of Inpatient Surgical Episodes by Lag Time
Avg Episode Allowed Amt Average Inpatient Allowed Amt Percent of Epis
9An AnAlysis Using the MedicAl episode groUper
Figure 7: Episode Price Distribution: Episodes With Disc Surgery
Similar to inpatient surgeries, outpatient surgical episodes vary in terms of the lag
from when the episode starts until the surgery date Figure 8 shows that while the
average wait is 38 days, there is wide variation in this average
Figure 8: Lag Time Effects on Price of Outpatient Surgery
Unlike in the case of inpatient surgery, outpatient surgeries that are delayed do not
necessarily result in higher total episode price, nor in higher average surgical price
Outpatient MedicalFor episodes without surgical intervention, there are two main treatment modalities
— spinal injections and PT/Chiropractic (or a combination of both) As shown in
Figure 9, episodes including spinal injections have a significantly higher price
profile than those with PT/Chiropractic alone Episodes with neither of these
treatment protocols are the least expensive
0%
5%
10%
15%
20%
25%
30%
35%
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$18,000
1-15 Days 16 to 30 Days 31 to 60 Days > 60 Days
Allo
wed
Am
t M
ed
Days between Epis Start and Surgery
Price and Frequency of Outpatient Surgical Episodes by Lag Time
Avg Epis Allowed Amt Average OP Surg Allowed Amt Percent of Episodes
80%
70%
60%
50%
40%
30%
20%
10%
0%
$25
0
$50
0
$1,0
00
$2,
00
0
$4
,00
0
$6
,00
0
$8
,00
0
$10
,00
0
$12
,00
0
$14
,00
0
$16
,00
0
$18
,00
0
$20
,00
0
$22
,00
0
$24
,00
0
$26
,00
0
$28
,00
0
$30
,00
0
$32
,00
0
$34
,00
0
$36
,00
0
$38
,00
0
$4
0,0
00
>$
40
,00
0
Qualified Episodes, n=9,075
Qualified, IP Surgery, Disc Only, n=239
Qualified, OP Surgery, n=649
Qualified, No Surgery or Admit, n=7,995
10 An AnAlysis Using the MedicAl episode groUper
Figure 9: Episode Price Distribution, Episodes Without Surgery or Inpatient Care
Finally, the use of major imaging (CT/MRI) has a significant effect on any outpatient
medical episode Major imaging is used with varying degrees of frequency depending
on the treatment pathway as shown in Table 7
Table 7: Use of Major Imaging by Treatment Pathway
Treatment Pathway % With Outpatient Major Imaging
Average Episode $ With Imaging
Average Episode $ Without Imaging
IP Surgery Alone 49.11% $33,685 $28,976
IP Surgery w/ Other OP Treatments
69.09% $38,362 $31,305
IP Medical 38.10% $12,743 $12,664
OP Surgery Alone 54.67% $14,410 $12,588
OP Surgery w/ Other OP Treatments
70.28% $16,429 $11,067
Spinal Injection 31.38% $3,162 $1,551
PT/Chiropractic 15.38% $2,431 $504
PT/Chiropractic and Injection
67.71% $4,645 $2,847
No Major Treatment 22.66% $1,700 $207
Variation in Treatment Patterns The above analysis shows that the type of treatment provided is a very significant
contributor to the total price of a low back disc episode The next question is
whether these treatment variations are justified by the severity of the particular case,
or whether they are more likely to represent preferences of the provider or patient
Disease Staging within MEG offers a simple way to assess the severity of patients
70%
60%
50%
40%
30%
20%
10%
0%
$25
0
$50
0
$1,0
00
$2,
00
0
$4
,00
0
$6
,00
0
$8
,00
0
$10
,00
0
$12
,00
0
$14
,00
0
$16
,00
0
$18
,00
0
$20
,00
0
$22
,00
0
$24
,00
0
$26
,00
0
$28
,00
0
$30
,00
0
$32
,00
0
$34
,00
0
$36
,00
0
$38
,00
0
$4
0,0
00
>$
40
,00
0
Qualified, No Surgery or Admit, n=7,995
Qualified, No Surgery or Admit, PT/Chiro, n=2,933
Qualified, No Surgery or Admit, Injection, n=1,788
Qualified, No Surgery or Admit, PT/Chiro and Injection, n=449
Qualified, No Surgery or Admit, No Major Treatment, n=3,274
11An AnAlysis Using the MedicAl episode groUper
The Impact of SeverityThe following Disease Stages are defined for low back disc disorder episodes
Table 8: Disease Stages for Low Back Disc Disorder Episodes
Stage Description
1.01 Prolapse of the intervertebral disc (herniated lumbar disc with localized symptoms/no nerve impairment)
1.02 Symptomatic prolapse of the intervertebral disc § pain radiating to leg(s) or arm(s) § OR weakness of arm(s) or leg(s) § OR cervical radiculopathy [physical examination or EMG report] § OR lumbar radiculopathy [EMG report]
2.01 Intervertebral disc disorder with loss of bladder or bowel control
2.02 Intervertebral disc disorder with cauda equina syndrome or conus medullaris syndrome
2.03 Intervertebral disc disorder with paraplegia
2.04 Intervertebral disc disorder with quadriplegia
2.05 Intervertebral disc disorder with pneumonia (aspiration or bacterial)
3.01 Intervertebral disc disorder with sepsis
3.02 Intervertebral disc disorder with shock
It is reasonable to assume that for the higher severity cases (those above stage 2), a
more aggressive treatment might be the most appropriate option for rapid resolution
of symptoms Although The Journal of Bone and Joint Surgery article describes
the lack of evidence indicating that surgical intervention is more effective than
other treatments for symptomatic disc herniation, it does indicate that “for patients
with a progressive neurological deficient and cauda equina syndrome, urgent
decompression provides the best functional improvement ” An article published in
the European Spine Journal indicates that in the case of advanced symptoms (such
as those presented in stage 2 01 and higher), there should be no question of whether
surgery should be attempted, but instead the question is how quickly the surgery
should be performed to minimize long-term effects 3
Figure 10 describes the distribution of treatment pathways by stage
Figure 10: Distribution of Treatment Pathway by Disease Stage
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1.01 1.02 2.01+
Distribution of Treatment by Disease Stage
No Major Treatment
PT/Chiro and Injection
PT/Chiro
Injection
OP Surgery
Inpatient Care
12 An AnAlysis Using the MedicAl episode groUper
As expected, patients with stages above 2 0 are far more likely to receive inpatient
(usually surgical) intervention Lower severity patients are much more likely to
receive care in an outpatient setting The profiles of stage 1 01 and 1 02 patients are
very similar
The vast majority of episodes (89 percent) have the lowest severity stage, that is,
localized symptoms without any nerve impairment (see Table 9) It is those cases
where one might expect to see the greatest impact of preferential treatment rather
than severity-based treatment decisions Therefore the remaining variation analysis
is focused on stage 1 01 only
Table 9: Distribution and Allowed Amount by Stage
Disease Stage Episodes Average $
1.01 8,093 $3,477
1.02 967 $3,635
2.01+ 15 $26,914
Total 9,075 $3,532
Geographic VariationGeographic variation is frequently seen in patterns of treatment for various
conditions Analyzing treatment patterns for low back disc episodes by geographic
area reveals the differences for patients in stage 1 01 described in Figure 11
Figure 11: Distribution of Treatments by Division
The West North Central and East South Central divisions have the highest rates of
surgery overall, while the South Atlantic division has the highest rate of inpatient
surgery Spinal Injections are far more common in the West North Central and East
South Central divisions as well The Mountain division is most likely to use no
significant treatment modalities, while PT/Chiropractic care are most common in the
Pacific and New England divisions
The use of major imaging also varies by geographic region as shown in Figure 12,
which compares the episodes without any major treatment protocol (no surgery, PT,
or spinal injections)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
No
rth
Cen
tral
Reg
ion
Eas
t N
ort
h C
entr
al
No
rth
Cen
tral
Reg
ion
Wes
t N
ort
h C
entr
al
No
rthe
ast
Reg
ion
Mid
dle
A
tlan
tic
No
rthe
ast
Reg
ion
New
E
ngla
nd
So
uth
Reg
ion
Eas
t S
out
h C
entr
al
So
uth
Reg
ion
So
uth
Atl
anti
c
So
uth
Reg
ion
Wes
t S
out
h C
entr
al
Wes
t R
egio
n M
oun
tain
Wes
t R
egio
n P
acifi
c
Distribution of Treatments for Stage 1.01 Episodes by Geographic Division
No Major Treatment
PT/Chiro and Injection
PT/Chiro
Injection
OP Surgery
Inpatient Care
13An AnAlysis Using the MedicAl episode groUper
Figure 12: Rates of Major Imaging by Division (Limited to Episodes With No Major Treatment)
The highest rates of major imaging are found in the West North Central and East
South Central divisions
Provider VariationMEG assigns both a managing and primary physician to each episode While
the primary physician is the physician with the most work effort in the episode
(measured by relative value units), the managing physician is the physician with
the most evaluation and management involvement with the patient The managing
physician, therefore, is the physician assumed to be directing the care pathway
for the patient Although MarketScan data do not allow for the identification of
individual physicians, the data do allow for the identification of physician types
The most common managing physician types for stage 1 01 low back disc episodes
are displayed in Figure 13
Figure 13: Distribution of Episodes by Managing Physician Type
0%
5%
10%
15%
20%
25%
30%
35%
East North
Central
West North
Central
Middle Atlantic
New England
East South
Central
South Atlantic
West South
Central
Mountain Pacific
% Epis with no Major Treatment with Major Imaging
$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000
0% 2% 4% 6% 8%
10% 12% 14% 16% 18%
Primar
y Car
e
Orthopae
dic Sur
gery
Chiro
pract
or/DCM
Neuro
logica
l Sur
gery
Medica
l Doct
or — M
D
Anest
hesio
logy
Pain M
gmt/
Pain M
edici
ne
Other
Sur
geon
Neuro
logy
Physic
al Med
icine
and
MultiS
pecial
ty P
hys G
rp
Distribution of Stage 1.01 Episodes by Managing Physician Type
Percent of Episodes Average Med Allowed Amt
14 An AnAlysis Using the MedicAl episode groUper
Different managing physician types show different preferences in treatment protocol
as shown in Figure 14
Figure 14: Distribution of Treatment Pathways by Managing Physician Type
Not surprisingly, surgeons are more likely to manage patients who receive surgery
or spinal injections while other nonsurgeon physicians are more likely to promote
physical therapy It is likely that even within specialty groups, certain individual
physicians show a preference for specific treatment protocols In datasets with
consistent unique provider identifiers, MEG would enable this type of analysis to be
performed
Use of major imaging is also affected by provider type Figure 15 shows that after
limiting to episodes with no major treatment, considerable variation exists in terms
of the percentage of episodes that included major imaging
Figure 15: Major Imaging Rate by Managing Physician Type (Limited to Episodes With No Major Treatment)
0% 5%
10% 15% 20% 25% 30% 35% 40% 45%
Primar
y Car
e
Orthopae
dic Sur
gery
Chiro
pract
or/DCM
Neuro
logica
l Sur
gery
Medica
l Doct
or — M
D (NEC)
Anest
hesio
logy
Pain M
gmt/
Pain M
edici
ne
Other
Sur
geon
Neuro
logy
Physic
al Med
icine
and
Reh
ab
MultiS
pecial
ty P
hys G
rp
% Epis with no Major Treatment with Major Imaging
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
PCP
Orthopae
dic Sur
gery
Chiro
pract
or/DCM
Neuro
logica
l Sur
gery
Medica
l Doct
or — M
D (NEC)
Anest
hesio
logy
Pain M
gmt/
Pain M
edici
ne
Other
Sur
geon
Neuro
logy
Physic
al Med
icine
and
Reh
ab
MultiS
pecial
ty P
hys G
rp
Distribution of Treatments for Stage 1.01 Episodes by Geographic Division
No Major Treatment
PT/Chiro and Injection
PT/Chiro
Injection
OP Surgery
Inpatient Care 0%
10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
PCP
Orthopae
dic Sur
gery
Chiro
pract
or/DCM
Neuro
logica
l Sur
gery
Medica
l Doct
or — M
D (NEC)
Anest
hesio
logy
Pain M
gmt/
Pain M
edici
ne
Other
Sur
geon
Neuro
logy
Physic
al Med
icine
and
Reh
ab
MultiS
pecial
ty P
hys G
rp
Distribution of Treatments for Stage 1.01 Episodes by Geographic Division
No Major Treatment
PT/Chiro and Injection
PT/Chiro
Injection
OP Surgery
Inpatient Care
15An AnAlysis Using the MedicAl episode groUper
SummaryThrough use of MEG, we have analyzed the relative expense of low back disc
disorders in comparison to other musculoskeletal conditions We have also been
able to identify treatments that are the primary drivers of that expense, identify the
most common treatment pathways, and examine variations in utilization of those
pathways by geography as well as by provider type This type of analysis would
be extremely difficult to accomplish using claims data in an ungrouped form The
ability of MEG to group the related treatments, recognize the severity of the patient’s
condition, maintain links to the detailed claim data, and identify the managing
physician were all critical elements to this analysis
References1 Rhee JM, Schaufele M, Abdu WA Radiculopathy and the Herniated Lumbar
Disc. Controversies Regarding Pathophysiology and Management J Bone Joint
Surg Am 2006;88-9:2070-2080
2 Reducing Utilization Concerns Regarding Spinal Fusion and Artificial Disc
Implants Published online by AllMed Healthcare Management
(www allmedmd com)
3 Gardner A, Gardner E, Morley T Cauda equina syndrome: a review of the current
clinical and medico-legal position Eur Spine J 2011 May; 20(5): 690–697
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