Panel: Insurers favor more costly back pain treatments

CMS doubles rate for less invasive procedure

Insurance companies favor fusion surgery over back pain management therapies, according to a recent panel of orthopedic surgeons, interventional radiologists, physiatrists, and pain management specialists from academic centers. Yet fusion surgery often is more than 10 times costlier than other methods of managing chronic discogenic lower back pain.

The panel discussed and examined pain management strategies from medical specialties that routinely work with patients suffering from chronic lower back pain. Participants in the panel discussion included pain management specialists, spine surgeons, interventional radiologists and physiatrists from various institutions such as the Albany (NY) Medical College, the Cleveland Clinic, Columbia University in New York City, Johns Hopkins Hospital in Baltimore, Rush Presbyterian-St. Luke’s Medical Center in Chicago, Mayo Clinic in Jacksonville, FL, Cedars-Sinai Institute for Spinal Disorders in Los Angeles, and Stanford University Medical Center in Palo Alto, CA.The panel was conducted by MedPanel in Cambridge, MA, an on-line medical market research company.

The discussion was sponsored by the American Society of Interventional Pain Physicians (ASIPP) and Smith & Nephew Endoscopy.

In discussing their treatment options for patients with chronic discogenic lower back pain, panelists agreed that the first course of treatment always should be physical therapy and/or chiropractic, muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs). If the patient doesn’t respond to these treatments in four to six weeks, most of the panelists agreed that minimally invasive procedures should be considered. Panelists also agree that the last treatment to consider is fusion surgery, which fuses two or more damaged discs together to reduce or eliminate pain. But this also can cause potential complications such as nerve damage and treatment failure.

The panel of physicians concluded that there is a bias toward the higher-cost fusion surgery option. This bias is the result of several factors — in particular, insurance companies opting to pay for more invasive treatments, rather than minimally invasive or pain management procedures, even though those pain management protocols and procedures are considerably less expensive and may be more clinically relevant.

Intradiscal electrothermal therapy (IDET) costs about $7,000, but only between 5,000 and 7,000 of these procedures are performed each year. IDET is sold by Smith & Nephew Endoscopy, but the procedure has not caught on though it is substantially less expensive, less invasive, and reversible, unlike a fusion surgery. The IDET procedure is for those who have failed a program of aggressive nonoperative therapy. During the procedure, controlled levels of thermal heat are applied to the affected disc to contract and thicken the collagen fibers within the disc wall, potentially closing the cracks and tears and cauterizing the tiny nerve endings that cause the pain.

One positive sign for IDET is the recent news that the Centers for Medicare & Medicaid Services (CMS) has increased reimbursement for the procedure, placing it in a more appropriate Ambulatory Payment Classification (APC). The new reimbursement classification appears in the final rule for the Medicare Hospital Outpatient Prospective Payment System for 2006. Under the reclassification, CMS will reimburse $1,424.50 for the procedure in 2006, in place of the 2005 payment level of $622.43. Medicare does not pay for this procedure in a surgery center, according to Smith & Nephew.

Huge financial incentive’ for fusion procedure

David Kloth, MD, president of ASIPP and an interventional pain physician at Danbury (CT) Hospital attributed some of the low numbers of IDET and other less invasive surgical procedures being performed to the fact that surgeons can make up to nearly $40,000 for a single-fusion operation. "There is a huge financial incentive for surgeons not to see [IDET] done on a routine basis," he said.

However, Kloth noted that surgeons also may be less likely to refer patients for IDET because they are not familiar with it, and he acknowledged that the minimally invasive procedure is not for everyone. "I will tell you that the patients I see who have disc problems, more times than not I have to turn them away from these minimally invasive surgeries because they’re not a candidate because of their specific anatomy."

Kloth said initially, perhaps some minimally invasive techniques such as IDET were first done on patients who perhaps were not good candidates for the procedures, but over the last six or seven years, "we’ve certainly refined [the population], and it’s much better." He defined a "good" candidate for IDET as someone with good disc height (70% or greater), no instability, no significant modic endplate changes, and no sizeable disc herniations.

Obviously, the cost of an IDET procedure vs. a lumbar fusion also is an issue that needs to be debated, and Kloth said he remains puzzled as to why more insurance carriers aren’t covering a procedure that costs nearly 10 times less than its more radical surgical cousin.

"Even if you take some of the worst [IDET] studies," he said, "it’s still got a 50% success rate, so if 50% of the people get better without needing a $50,000 operation, it’s not hard to run those statistics and say, Wait a minute, you would save millions of dollars if you did this on a cohort of patients.’" Kloth pointed out that "even if you fail at IDET, you can always go to fusion; [whereas,] if you fail a fusion, you’re really up the creek," which typically means having to do another fusion procedure at another level of the spine or having a spinal stimulation device implanted.

Kloth said he believes that patients should definitely get a second opinion before having a fusion done, and adds that he thinks insurance companies, who are known for their desire to keep costs to a minimum, will come around to the notion that trying out the less costly alternative first might be better for the bottom line.

"I think what you’re going to see five years from now are that the insurance companies are actually going to mandate a pain-management evaluation before you have a lumbar fusion," he predicted.

While some have argued that the IDET’s success rate is not very good and has not been borne out long-term in studies, Kloth said from personal experience he believes that the right candidates can benefit from it. He pointed out that while some private insurers still will not pay for it, workers’ compensation in Connecticut, where he practices, routinely pays for these surgeries because "they know my return-to-work rate with the treatments that I do with these aggressive minimally invasive surgeries is 75%. Historically, fusion success return to work is 25%."