Surgeons and medical device makers find insurers are resisting costly back fusions and requiring proof that less risky therapy for pain has been given a chance.
Updated: 01/29/2011 11:35:39 PM CST
There's nothing like back pain.
Just ask Dan Hoxworth, 50, of Mahtomedi. Beyond watching his father and brothers suffer from disc problems over the years, Hoxworth has felt the pain personally with herniated discs in each of the past three decades. The sensation at times is a bit like sticking your finger in an electrical outlet — and not pulling it out, he says.
Still, there are two key reasons Hoxworth considers himself lucky in his spinal struggles.
First, the interval of time between each of his three episodes of back troubles grew. His first two herniated discs were separated by a span of just six years, while it was another 13 years before he suffered from a third disc problem in 2008. So, Hoxworth jokes that his back now should be good for another 20-plus years or so.
The second bit of luck is no joke.
'I've had success in avoiding surgery,' Hoxworth said. 'The doctors I've had always said that surgery is the last option.'
Pushing back on spine surgery is becoming a battle cry for health plans these days, too. Faced with skyrocketing health costs due to surgeries known as spinal fusions, health plans in Minnesota and across the U.S. are intensifying scrutiny of the procedures.
Spine surgeons are feeling the impact. So are companies like Fridley-based Medtronic, which is the largest manufacturer of medical devices used in spine surgery.
'Payers are also implementing new fusion procedure guidelines, which are lengthening the time required to give pre-approvals,' said Gary Ellis, the chief financial officer at Medtronic, during a conference call with investors last year.
Bloomington-based HealthPartners was one of the first health plans in Minnesota to start scrutinizing spine surgery costs. In February 2009, the insurer started requiring
patients to receive approved decision guides such as booklets or videos to help them learn more about alternatives to surgery before they could receive a common but expensive procedure called 'lumbar fusion.'
Health plans and a growing number of doctors say that too many patients have been getting lumbar fusions without first trying treatment options including physical therapy, exercise and even epidural steroid injections to deal with pain.
As part of its efforts to control spine surgery costs, HealthPartners asked surgeons to document that patients had attempted rehabilitation before surgery and had nonetheless failed to see a significant improvement in their pain levels and back function.
Two years later, what impact has the program had?
"Little to none," acknowledged Dr. Tom Marr, a medical director at HealthPartners. "The number of fusions continues to go up."
HealthPartners paid for 305 lumbar fusions in 2006. The number more than doubled to 684 in 2008. Then, during the first year of the shared decision-making program, the number of lumbar fusions increased to 823. The health plan pays an average of about $54,000 for all the care that goes into a lumbar fusion procedure.
Just ask Dan Hoxworth, 50, of Mahtomedi. Beyond watching his father and brothers suffer from disc problems over the years, Hoxworth has felt the pain personally with herniated discs in each of the past three decades. The sensation at times is a bit like sticking your finger in an electrical outlet — and not pulling it out, he says.
Still, there are two key reasons Hoxworth considers himself lucky in his spinal struggles.
First, the interval of time between each of his three episodes of back troubles grew. His first two herniated discs were separated by a span of just six years, while it was another 13 years before he suffered from a third disc problem in 2008. So, Hoxworth jokes that his back now should be good for another 20-plus years or so.
The second bit of luck is no joke.
'I've had success in avoiding surgery,' Hoxworth said. 'The doctors I've had always said that surgery is the last option.'
Pushing back on spine surgery is becoming a battle cry for health plans these days, too. Faced with skyrocketing health costs due to surgeries known as spinal fusions, health plans in Minnesota and across the U.S. are intensifying scrutiny of the procedures.
Spine surgeons are feeling the impact. So are companies like Fridley-based Medtronic, which is the largest manufacturer of medical devices used in spine surgery.
'Payers are also implementing new fusion procedure guidelines, which are lengthening the time required to give pre-approvals,' said Gary Ellis, the chief financial officer at Medtronic, during a conference call with investors last year.
Bloomington-based HealthPartners was one of the first health plans in Minnesota to start scrutinizing spine surgery costs. In February 2009, the insurer started requiring
patients to receive approved decision guides such as booklets or videos to help them learn more about alternatives to surgery before they could receive a common but expensive procedure called 'lumbar fusion.'
Health plans and a growing number of doctors say that too many patients have been getting lumbar fusions without first trying treatment options including physical therapy, exercise and even epidural steroid injections to deal with pain.
As part of its efforts to control spine surgery costs, HealthPartners asked surgeons to document that patients had attempted rehabilitation before surgery and had nonetheless failed to see a significant improvement in their pain levels and back function.
Two years later, what impact has the program had?
"Little to none," acknowledged Dr. Tom Marr, a medical director at HealthPartners. "The number of fusions continues to go up."
HealthPartners paid for 305 lumbar fusions in 2006. The number more than doubled to 684 in 2008. Then, during the first year of the shared decision-making program, the number of lumbar fusions increased to 823. The health plan pays an average of about $54,000 for all the care that goes into a lumbar fusion procedure.
"That cost is an issue, but it's not the main issue," he said. "The main issue is: Are patients getting maximum benefit from this."
The answer at HealthPartners appears to be no, and that's why the health plan is "re-energizing" its policies for scrutinizing lumbar fusion surgeries. Others are doing the same.
A year ago, Minneapolis-based UCare started requiring members to consider other options to spine surgery, said Dr. Craig Christianson, an associate medical director.
Some spine surgeons bristled at the requirement, he said, until the health plan started showing examples of how some Medicare patients in their 80s and 90s were undergoing spinal fusion procedures — an aggressive treatment choice at that age, Christianson said.
Some patients are drawn to the more immediate impact that spine surgery can offer for back pain compared with conservative approaches, Christianson acknowledged. But long-term outcomes are fairly similar for the two groups, he said, at which point spine surgery patients have fewer options.
"The advantage to conservative care is that there are no bridges being burned," Christianson said.
Last month, Blue Cross Blue Shield of North Carolina issued rules that lumbar spinal fusion surgeries required prior review and certification by the insurance company to be covered. Some doctors who have been critical of the growth in spine surgeries for back pain cheered the move.
"The major national concern has to do with the performance of multilevel instrumented fusions to treat low back pain in patients with lumbar degenerative disc disease who are neurologically intact, who do not have spinal deformity and in whom all appropriate conservative treatment measures have not been performed," said Dr. Charles Burton, a surgeon in St. Paul. "Study after study after study has shown that in this population of patients, physical therapy is as good if not better — and there are no complications."
But a group of national spine surgery societies criticized the North Carolina rules as too broad, and cautioned in a December letter that they could block surgeries for patients "who have a high probability of clinical success with fusion."
The concern is echoed locally by Dr. Paul Hartleben, a spine surgeon with Summit Orthopedics in Woodbury.
Spinal fusions were developed as a treatment for a deformity called scoliosis and the surgery can successfully halt the progression of that condition, Hartleben said. In a fusion, surgeons use rods, screws and plates to stabilize otherwise mobile spine segments.
Over the years, doctors started using the tools for other spine problems, including intractable back pain. That's where the controversy comes in — not just with health plans, but even among spine surgeons, said Hartleben.
"There's always a group of surgeons that believes that any fusion done for degenerative disc disease and back pain is inappropriate," he said. "Then there are those that say: What do you do for the patient who is incapacitated and has tried everything else?"
In some cases, the procedure has been "overdone," Hartleben said. But physicians aren't doing it for personal gain, he said, and are willing to work with health plans to improve care — even though navigating pre-authorization rules can take as much time as the spine surgery itself.
"There are many diagnoses where spinal fusion is worth it," Hartleben said. Noting that the federal Medicare program and Blue Cross Blue Shield of Minnesota also are paying more attention to spinal fusion costs, the surgeon added: "They want to make sure it's the right decision for their patients."
Hartleben says that doctors also are working more closely with hospitals, which also have concerns about increasing costs of spine surgery. The St. Paul-based HealthEast system, for example, recently hired Dr. Adam Locketz to promote the use of spine care options that go beyond surgery and are grounded in stronger medical evidence.
"It's not that lumbar fusions are never appropriate," Locketz said, "but they're being utilized too early in the process."
The scrutiny is affecting the bottom line for manufacturers such as Medtronic.
Medtronic is the world's largest manufacturer of medical devices used in spinal surgery, with more than one-third of the $7 billion worldwide market, according to Joanne Wuensch, an analyst with BMO Capital Markets. Still, Wuensch estimated in a recent report that Medtronic's revenue from spine devices will be down slightly for 2010 at about $2.6 billion.
The program at Blue Cross of North Carolina is an example of the challenges facing the industry, Wuensch wrote.
Marybeth Thorsgaard, a spokeswoman at Medtronic, contended the North Carolina policy actually would apply to only "a small percentage of our cases." Still, the manufacturer is responding to pressure from health plans through "the creation of new clinical and economic evidence to support new technologies and therapies," Thorsgaard said.
The scrutiny of spine surgery has come at a time when financial ties between medical device companies and doctors have become more visible.
Last year, Medtronic started disclosing how much it pays doctors in product royalties and consulting fees in three categories: training other doctors in the use of Medtronic products; offering advisory services to the company; and contributing to research and development.
Through the first three quarters of 2010, Medtronic paid between $2 million and $2.2 million to about 20 doctors in Minnesota. The vast majority of the money went to nine spine surgeons for royalties on Medtronic products that the physicians helped design.
Royalty payments to spine surgeons "are what they are," said Marr, the medical director of HealthPartners. But the health plan has more concerns about other financial relationships between doctors and manufacturers — particularly when a doctor is being paid by a manufacturer to lobby HealthPartners to cover a spinal procedure.
"They don't tell us they're being paid," Marr said. Noting other potential conflicts of interest, he adds: "You start to say, 'You might be as pure as the driven snow, but after the plows come through, you're not so pure.' "
Snow removal wasn't the chore that led to Dan Hoxworth's most recent back troubles. He was helping a neighbor in Mahtomedi chop down trees and went too far.
After pain in his back would not go away, he spent weeks in physical therapy before finally being referred to a back specialist for a cortisone injection. The shot knocked down the pain more quickly than it did with his previous herniated discs — imaging technology has improved, he said, so that doctors can more accurately deliver the injection.
Hoxworth also went through a back-strengthening program at Physicians Neck & Back, a practice that's owned by HealthPartners and promotes exercise as a way to prevent back woes. Hoxworth completed the program about two years ago, but still regularly performs back-strengthening exercises he learned from the medical group.
"I like to chop wood, and I'm fine at doing that again," Hoxworth said. "I just don't do it until exhaustion, which is when you tend to get a back problem."
Christopher Snowbeck can be reached at 651-228-5479.
The answer at HealthPartners appears to be no, and that's why the health plan is "re-energizing" its policies for scrutinizing lumbar fusion surgeries. Others are doing the same.
A year ago, Minneapolis-based UCare started requiring members to consider other options to spine surgery, said Dr. Craig Christianson, an associate medical director.
Some spine surgeons bristled at the requirement, he said, until the health plan started showing examples of how some Medicare patients in their 80s and 90s were undergoing spinal fusion procedures — an aggressive treatment choice at that age, Christianson said.
Some patients are drawn to the more immediate impact that spine surgery can offer for back pain compared with conservative approaches, Christianson acknowledged. But long-term outcomes are fairly similar for the two groups, he said, at which point spine surgery patients have fewer options.
"The advantage to conservative care is that there are no bridges being burned," Christianson said.
Last month, Blue Cross Blue Shield of North Carolina issued rules that lumbar spinal fusion surgeries required prior review and certification by the insurance company to be covered. Some doctors who have been critical of the growth in spine surgeries for back pain cheered the move.
"The major national concern has to do with the performance of multilevel instrumented fusions to treat low back pain in patients with lumbar degenerative disc disease who are neurologically intact, who do not have spinal deformity and in whom all appropriate conservative treatment measures have not been performed," said Dr. Charles Burton, a surgeon in St. Paul. "Study after study after study has shown that in this population of patients, physical therapy is as good if not better — and there are no complications."
But a group of national spine surgery societies criticized the North Carolina rules as too broad, and cautioned in a December letter that they could block surgeries for patients "who have a high probability of clinical success with fusion."
The concern is echoed locally by Dr. Paul Hartleben, a spine surgeon with Summit Orthopedics in Woodbury.
Spinal fusions were developed as a treatment for a deformity called scoliosis and the surgery can successfully halt the progression of that condition, Hartleben said. In a fusion, surgeons use rods, screws and plates to stabilize otherwise mobile spine segments.
Over the years, doctors started using the tools for other spine problems, including intractable back pain. That's where the controversy comes in — not just with health plans, but even among spine surgeons, said Hartleben.
"There's always a group of surgeons that believes that any fusion done for degenerative disc disease and back pain is inappropriate," he said. "Then there are those that say: What do you do for the patient who is incapacitated and has tried everything else?"
In some cases, the procedure has been "overdone," Hartleben said. But physicians aren't doing it for personal gain, he said, and are willing to work with health plans to improve care — even though navigating pre-authorization rules can take as much time as the spine surgery itself.
"There are many diagnoses where spinal fusion is worth it," Hartleben said. Noting that the federal Medicare program and Blue Cross Blue Shield of Minnesota also are paying more attention to spinal fusion costs, the surgeon added: "They want to make sure it's the right decision for their patients."
Hartleben says that doctors also are working more closely with hospitals, which also have concerns about increasing costs of spine surgery. The St. Paul-based HealthEast system, for example, recently hired Dr. Adam Locketz to promote the use of spine care options that go beyond surgery and are grounded in stronger medical evidence.
"It's not that lumbar fusions are never appropriate," Locketz said, "but they're being utilized too early in the process."
The scrutiny is affecting the bottom line for manufacturers such as Medtronic.
Medtronic is the world's largest manufacturer of medical devices used in spinal surgery, with more than one-third of the $7 billion worldwide market, according to Joanne Wuensch, an analyst with BMO Capital Markets. Still, Wuensch estimated in a recent report that Medtronic's revenue from spine devices will be down slightly for 2010 at about $2.6 billion.
The program at Blue Cross of North Carolina is an example of the challenges facing the industry, Wuensch wrote.
Marybeth Thorsgaard, a spokeswoman at Medtronic, contended the North Carolina policy actually would apply to only "a small percentage of our cases." Still, the manufacturer is responding to pressure from health plans through "the creation of new clinical and economic evidence to support new technologies and therapies," Thorsgaard said.
The scrutiny of spine surgery has come at a time when financial ties between medical device companies and doctors have become more visible.
Last year, Medtronic started disclosing how much it pays doctors in product royalties and consulting fees in three categories: training other doctors in the use of Medtronic products; offering advisory services to the company; and contributing to research and development.
Through the first three quarters of 2010, Medtronic paid between $2 million and $2.2 million to about 20 doctors in Minnesota. The vast majority of the money went to nine spine surgeons for royalties on Medtronic products that the physicians helped design.
Royalty payments to spine surgeons "are what they are," said Marr, the medical director of HealthPartners. But the health plan has more concerns about other financial relationships between doctors and manufacturers — particularly when a doctor is being paid by a manufacturer to lobby HealthPartners to cover a spinal procedure.
"They don't tell us they're being paid," Marr said. Noting other potential conflicts of interest, he adds: "You start to say, 'You might be as pure as the driven snow, but after the plows come through, you're not so pure.' "
Snow removal wasn't the chore that led to Dan Hoxworth's most recent back troubles. He was helping a neighbor in Mahtomedi chop down trees and went too far.
After pain in his back would not go away, he spent weeks in physical therapy before finally being referred to a back specialist for a cortisone injection. The shot knocked down the pain more quickly than it did with his previous herniated discs — imaging technology has improved, he said, so that doctors can more accurately deliver the injection.
Hoxworth also went through a back-strengthening program at Physicians Neck & Back, a practice that's owned by HealthPartners and promotes exercise as a way to prevent back woes. Hoxworth completed the program about two years ago, but still regularly performs back-strengthening exercises he learned from the medical group.
"I like to chop wood, and I'm fine at doing that again," Hoxworth said. "I just don't do it until exhaustion, which is when you tend to get a back problem."
Christopher Snowbeck can be reached at 651-228-5479.
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