3,593: number of spinal fusion surgeries Blue Cross and Blue Shield of North Carolina covered last year, up 22 percent from 2007. $105 million: amount the insurer paid in claims for the procedures last year, up 44 percent from 2007. Nine: number of medical associations that signed a Dec. 15 letter to Blue Cross, urging changes to its new policies, which take effect Jan. 1. 3.7 million: Blue Cross members statewide.
The state's largest health insurer is coming under fire from surgeons across the country for implementing tougher restrictions on an increasingly common type of spinal surgery.
Blue Cross and Blue Shield of North Carolina's new rules, which take effect Jan. 1, are designed to reduce overuse of spinal-fusion surgery, a costly and controversial procedure to ease patients' lower back pain . The Chapel Hill-based insurer says it wants to ensure the surgeries are approved based on the latest medical evidence.
"We are not going to stop coverage, but we do want to make sure the ones being done are appropriate," said Dr. Don Bradley, Blue Cross' chief medical officer. "In some cases, we're seeing technology being used when more conservative measures might be more appropriate."
But some spine surgeons worry that the restrictions will limit care for thousands of patients and could set a new coverage standard among other insurers.
A coalition of surgeons representing nine medical associations, including the American Association of Neurological Surgeons and the North American Spine Society, wrote to Blue Cross this month, urging the company to reconsider.
The group also suggested various changes that would ease the new restrictions.
"If this intrusion into the physician-patient relationship goes unchallenged, other insurers will follow suit," said Dr. John Wilson, a neurosurgeon at Wake Forest University Baptist Medical Center who is president of the N.C. Neurological Society and one of nine physicians who signed the letter to Blue Cross.
"It will be a progression of ever-more restrictive policies that will handcuff us as we try to treat patients," Wilson said.
The surgeon groups requested a meeting with Blue Cross executives before the rules kick in one week from today to discuss the new policy. But the insurer responded in an e-mail message that because of the holidays, a meeting could not be scheduled until the third week of January.
Wilson estimates that he performs about 100 spinal-fusion surgeries a year. Only a small percentage of his practice's patients would be ineligible for coverage under the new Blue Cross rules.
"Even if it's just a few patients, if we're limited in how we can help them, it doesn't sit right with us," he added.
The new spine-surgery rules come as Blue Cross faces increasing pressure to keep costs down and control premiums. The company announced plans in July to slash administrative costs up to 20 percent by 2014.
"The tendency is to label us as the big, bad insurance company," Bradley said. "We understand folks rely on us to cover the things that should be covered. They also assume that we're making decisions about appropriate care" to keep premiums affordable.
Blue Cross reports that it covered 3,593 spinal fusion surgeries last year, up 22 percent from 2007. The insurer paid $105 million in claims for the procedures last year, up 44 percent from 2007. The procedures require longer hospital stays and cost more than three times the amount of a simpler surgery, according to the Journal of the American Medical Association.
The new rules will require patients and physicians to get approval before spinal-fusion surgery. The insurer still will cover the surgery for some ailments, such as scoliosis, injury and tumors.
But Blue Cross won't cover the surgery for degenerative disk disease. The condition is caused by aging disks and can cause debilitating back pain.
"We feel that to completely omit this as a covered procedure under any circumstance is overly restrictive," the national group of surgeons wrote in their letter to Blue Cross.
The surgeries involve implanting rods and screws to repair vertebrae. JAMA reports that patients who had a complex fusion procedure were nearly three times as likely to develop a life-threatening complication and that the surgeries didn't result in dramatically better outcomes.
But spinal implants have become a booming business for surgeons and medical-device companies since winning Food and Drug Administration approval in 1995. Minneapolis-based Medtronic is the biggest maker of spinal implants, accounting for about half of the $7 billion market last year, The Wall Street Journal reported.
Critics in Congress and elsewhere are calling for a review of Medicare's coverage of the procedures. Spinal-fusion claims cost Medicare $2.24 billion in 2008, up nearly 400 percent since 1997 after adjusting for inflation, The Wall Street Journal reported.
Blue Cross has tried to work with physicians for several years to develop guidelines on the procedures, but it hasn't stemmed the surge in the number performed, Bradley said.
"We have tried the kinder, gentler approach," he said. "It's unfortunate that it takes looking at each case each time, but other approaches haven't really worked."
A Blue Cross patient or surgeon could appeal any denial of coverage, and the process would include at least one review by a physician who isn't employed by the insurer, Bradley said.
In late September, the company notified spine surgery practices across the state about the new rules. Before issuing the new policy, officials met with several spine surgeons in the Chapel Hill area and incorporated their input into the new rules.
In some cases, where doctors have tried physical therapy and other types of treatment, the only other option may be surgery, Wake Forest's Wilson said. "To say you're not going to cover them at all, you're hurting some patients," he added. "We don't want there to be patients left suffering."
Blue Cross continually reviews its coverage policies and makes adjustments based on the latest medical guidelines, Bradley said. But the new rules will take effect Jan. 1, despite the outcry from surgeons.
"We always listen to providers," he said. "It's unlikely we would not implement this. But if there's new data that says our criteria are incorrect, we'll be open to that."