The Rise & Rise of Spinal Fusion Surgery · The Rise & Rise of Spinal Fusion Surgery Never ask a barber if you need a haircut! (W Buffet) Brisbane, October 2017. ... Spine fusion

The Rise & Rise of Spinal Fusion Surgery

Never ask a barber if you need a haircut! (W Buffet)

Brisbane, October 2017

INTERESTSI declare that in the past three years I have:

• held shares in: Nil

• received royalties from: Nil

• done consulting work for:

• given paid presentations for: Nil

• received institutional support from: Nil

• AOA Director, 2006-2012

• Past President, Spine Society of Australia 2006-2008

Signed:


High Value Spine SurgeriesLumbar Spinal Canal Stenosis (N.I.C.E)(THJR, Cataracts, Coronary Graft)

Specific Pathologies - Deformity- Infection- Trauma- Neoplasm- Spondylolisthesis - ‘lytic

- degenerativeSpine fusion for non-specific low back pain

- Indications vague- Techniques various- Results unpredictable

Do higher costs produce higher value?


Practice VariationsLow Cost to High Cost - ? increased valueMinimally Invasive Spinal Surgery (MISS)

eg L4-5 Decompression + Fusion for Degenerative Spondylolisthesis.

“Old” “New” (including M.I.S.S.)40303/48648/47729 40303/40330/48654/48684/48648 etc (↑8-10+ items)

Theatre Fee - $3300 Theatre Fee - $6491.50 Bed $1000 x 5 ICU (1 night - $3600Others ? Bed - $1300 x 4Patient goes home! Implants - $10000++

O’biologics - $6400Consumables (MISS) - $1000+Others - ?Patient goes to 1-2 weeks Rehab.If “STAGED” – costs obviously↑↑↑

$10K approx. $40K approx.


Practice VariationsSpine Operations - Numbers and Costs

ALL Spine Operations –(Total N = 27,000 Private Ops)

2011-2 2014-5 ↑%↑ Aust Pop 5.5% N = 6157 N = 6642 8↑ CPI 2.3%

Total Cost ALL Spine Operations $ 128m $ 165m 28(Hosp, Prostheses, Medical)

Mean Cost per Admission $22,505 $24,943 11Mean No Items 3.04 3.22 0 (1->10)Hospital Cost (excl. prostheses) $ 53m $ 71m 35Prosthesis Cost (incl. BMPs etc) $ 44m $ 53m 20I.C.U. $ 2.9m $ 5.2m 73Medical Cost (Medicare/Pte Ins) $ 32m $ 41m 28

NB Hospital & Prosthesis Costs >> Medical Costs


Practice VariationsInterbody Fusion Ops (48654-48675)

Numbers and Costs (N = 27,000)2011-2 2014-5 ↑%

↑ Aust Pop 5.5% N=1521 N=1872* 23↑ CPI 2.3% (2014/15)

Total cost all IBF Ops $ 56m $ 76m 36(Hosp, Prosthesis, Benefits)

Mean Cost per admission $36,163 $40,449 12(all costs)

Mean No Items 4.41 4.65 0 (1->10+)Hospital cost (exclud prostheses) $ 18m $ 26m 45Prosthesis cost $ 27m $ 34m 29I.C.U. cost $ 1.5m $ 2.8m 84Medical Cost (Medicare/Pte Ins) $ 11.2m $ 15.4m 37

*28% of all ops include an Interbody Fusion.Brisbane, October 2017

Evidence – Practice Disconnect.Trends in the surgical treatment of lumbar spine disease in the United States.

Pannell, WC et al, The Spine Journal 15(2015) 1719-1727.

“Despite considerable high-level evidence that most degenerative conditions can be managed with simpler techniques, such as discectomy, decompression, and PLF with or without instrumentation, the routine use of more complex techniques and wide variation persist. This suggests a considerable divide between the available evidence base and regional care standards” - (The Editors) .

My evidence is bigger than your evidence!


BILLING VARIATIONS

OK Lumbar Discectomy (40300 OR 40301 - each a CMS)

NOT OK 40300 AND 40301

Australia wide 2008-9 2014-517% 44%

ACT NSW NT QLD SA TAS VIC WAFY08-09 25% 20% 0% 6% 61% 8% 5% 42%FY09-10 0% 19% 0% 10% 67% 7% 12% 47%FY10-11 0% 23% 0% 14% 77% 15% 22% 65%FY11-12 0% 30% 0% 20% 72% 54% 23% 71%FY12-13 0% 33% 0% 21% 79% 43% 34% 91%FY13-14 0% 33% 0% 29% 82% 50% 23% 75%FY14-15 0% 36% 0% 27% 87% 60% 29% 84%

Total item numbers range 1-5

Many many more bellwether numbers/combinations.


July 2015-June 2016 State TotalNSW VIC QLD SA WA TAS ACT NT

Services Services Services Services Services Services Services Services Services48639 239 1,283 56 45 57 16 2 5 1,703

July 2010-June 2011 State TotalNSW VIC QLD SA WA TAS ACT NT

Services Services Services Services Services Services Services Services Services48639 214 406 23 28 13 19 3 5 711

BILLING VARIATIONS –Fusion in Degen. Dis.

48639 – Vertebral Body, total or subtotal excision of…

48639 contraindicated in ~ all ACDF and ALIF variants due to likely cage subsidence.

AMA MT 140 : $5120. MBS : $1365


Is Funding for Spinal Surgery Sustainable?Aust Govt Dept of Health 4/2014

CMBS Review “Spinal Fusion for Back pain” → ALL Spinal Surgery

Is Medicare Sustainable?

“A Healthier Medicare” 22 April 2015

Whole of Medicare/CMBS Review – Prof Bruce Robinson


Spine Surgery Outcomes in a Workers’ Compensation Cohort.

Harris et al, ANZ J Surg 82 (2012) 625-629(N=476 1/1/2004 → 31/12/2006)

Key message – Return to (any) work at 2 years post-op.R.T.W. (any) 50.3%Pre-injury duties 14.2%Ongoing treatments 77.7%

Limitation: “WorkCover (NSW) could not directly identify patients who had undergone spine surgery;….”Search criteria - Diagnosis Upper or Lower Back

- Payments ≥ $2000/month – Medical/Hospital


Appointment of Surgical Advisory Panel (S.A.P.) early 2016. Lisa Boyd• 2 Orthopaedic spine surgeons Director,• 5 Neurosurgeons Worker Support &

Health1. Retrospective data review → Items/Payments → Enforcement (repayments)2. Prospective requested Item Number review ≥ 29/6/2016.3. Introduce MultiDisciplinary IME (MD IME)

- Surgeon and Pain Physician- Review Request for Surgery- Suggest alternatives- Communicate to Insurer and Treaters

4. Future - Reaccreditation of IMEs – emphasis on expertise.- Other reviews e.g. I.P.M./Orthopaedic etc.


Big Data(2015-6)

Population Victoria 6.25MWorkers 3.05MWSV 2.39M (5 Insurers)

Total WSV Claims 72,841Payments $284M

Total Back Claims * 9300 *Med & Hosp ~ $19MPost-Op Rehab 26% fusion

8% non-fusionCost Rehab $740,000

What is VALUE and how do we assess it?

Different for patients, treaters and Insurers!


1. Review

Lumbar Spine Fusions ≥ 2008-2014 (retrospective)> 2 year follow-up (limited *)N = 553.

Group 1 Predictors abysmal results –N ≈ 140 Off work > 12/12/opioid use/Mental Health Service use/

Common Law-Impairment Benefit/”At risk”.

Group 2 Excellent resultsN ≈ 40 None of the above (?? Is operation appropriate?)

Awaiting further analysis…….


2. Item Number Requests(All Spine)

Item number parameters set by S.A.P.→ Prospective S.A.P. assessment of requested MBS Item Numbers

Period 29 June 2016 → 30 June 2017Patient Numbers

Total request for Operation 923Denied at agent level 239Unresolved 38Approved 646

On parameters referred to S.A.P. 300 (46%!!)

Neck (ACDF) 61L. Laminectomy 27

Various Lumbar Fusions 212


2.Item Number Requests(All Spine)

N = 300 Operations/ReviewsRequested Approved *

Total Item Nos 1607 939 *(170 in 92 pts “bellwether”)

Item Nos/case 5.36 2.79 *Total $ costs $2,992,232 $1,792,241 *Cost per Op $9974 $5974 *

Saving Total $1,199,991 * (40% saving*)Saving per Op $ 4,000 *

[N.B. If menu numbers used for refused items, savings ≈ 50% above]


2. Item Number Reviews

0

10

20

30

40

50

60

70

80

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73

TOTAL number of requests WITH a billing review July2016 to June 2017

July 2016 to June 2017

Number of Elective Spinal

Surgery Requests made to


2. Item Number Reviews

Future Actions1. WorkSafe Victoria Spinal Surgery Billing Position Statement

25 May 2017 (= QComp Spinal Surgery Guidelines)→ sent to all Providers and Agents; ongoing review

2. Ensure Agent Compliance –→ Call in 100 random accounts over SAP Billing Review period→ Likely call in ALL proposed Spine Surgery Item Number requests

for 6-12 months.

3. Continue Agent education.→ Menu of appropriate item numbers for common spine ops. created →

Agent Medical Advisors.→ Refer to S.A.P. if outside men


3. MD IME

Early days – 1st on (17.7.2017)

Panel appointees 6 Spine Surgeons6 Pain Physicians

Each MD IME 1 Surgeon and 1 Pain Physician2 Hour sessions

Answer 4 Questions –1. What is the diagnosis/condition with respect to the claimed injury?2. What are the injured workers expectations of the surgery outcomes? In your

opinion are these expectations reasonable?3. Is the service of (the operation requested) appropriate for the claimed injury?4. Are there other more appropriate services (alternative operations or pain

management strategies) which would be applicable for the claimed injury?

Report to Insurer and G.P. (→ a “useful” process).


3. MD IME

Total 24 (from 17.7.2017)

Direct approve 12

Direct deny 12

→ 7 GP follow alternative suggestions5 ? Too early to tell/no action at this stage

None so far to Conciliation/Medical Panels Vic

Patient survey - > 80% approval rating!


CONCLUSIONS

1. Await MBS Review – all State compensation systems tied to CMBS.BUT Evolutionary not Revolutionary

2. WSV - early days but producing beneficial innovations

- for patients ?- for treaters X!- for employer ? ↓ $$$!

3. AOA, RACS and other bodies on board – recognition of threat to status as autonomous professional bodies.








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The Rise & Rise of Spinal Fusion Surgery · The Rise & Rise of Spinal Fusion Surgery Never ask a barber if you need a haircut! (W Buffet) Brisbane, October 2017. ... Spine fusion