Plan to limit unnecessary spine surgeries

Goal is to reduce costs, improve quality

Reliance National Insurance Company of New York City and the Marietta, GA-based National Spine Network (NSN) have joined forces to launch a pilot program aimed at helping employees make more informed decisions about possible spine surgery. Their goal: Reduce spine surgery costs by 20% to 40% annually, while improving quality of care.

The NSN is composed of 24 "Centers of Excellence" for spine care and member physicians — orthopedists, neurosurgeons, and physiatrists (physical medicine/ rehab) — located across the country. NSN Centers of Excellence include Atlanta’s Emory Spine Center; University Hospitals of Cleveland (OH)/Case Western Reserve; Thomas Jefferson University in Philadelphia; and Georgetown University Hospital in Washington, DC.

"We are focused on treating the patient from a non-operative perspective," explains Alana Brody, MBA, director of network development for NSN. "Patients are evaluated for appropriate nonoperative treatment including the use of active modalities like physical therapy, as well as nonsteroidal anti-inflammatory medications and steroidal injections administered under X-ray."

Partnering with NSN was a logical move for Reliance, says Richard Eskow, vice president of managed care. "We wanted to do this program with true centers of excellence. We want to help the [managed care] industry go from discount medicine to high-quality medicine, which will have a better impact in the long run," he explains.

Neither Eskow or Brody denies that part of what makes the program so attractive is that it can help save significant amounts of money for clients and patients. "Workers’ comp patients are typically the individuals who will use the program," notes Brody. "It can help them to get back to work more quickly in addition to reducing direct medical expenses, which represent 25% to 35% of all workers’ comp costs. The rest of the costs come from litigation and disability claims."

"We feel that back injury is such a large percentage of both workers’ comp medical and indemnity costs, and there’s so much research to indicate that there are unnecessary surgeries being performed that have negative outcomes for patients and the system," adds Eskow.

Brody is confident the program will work. In fact, she says, while this is the first such program launched by the entire network, members at both Georgetown and Emory have had great success with independent programs. "We have found that in many cases, patients who are recommended for surgery don’t have a full understanding of what that purpose is intended to be. The combined experience of our network physicians indicates that when they truly do understand, 20% to 40% of the time they will choose not to have surgery," she says.

Brody provides this real-life example of how the program works. A woman she calls Patient "X," a 22-year-old female with a pre-existing spinal condition who works in a nursing home, aggravated the problem while on the job. She went to a physician in her community, and after the first visit, he told her she did not require surgery. Then, she met with a lawyer to explore her options under workers’ compensation. When the surgeon found out she had seen a lawyer, he decided to proceed with the surgery to avoid possible litigation later on. She was subsequently evaluated at an NSN center and told that surgery could cause her to have pain for the rest of her life. She returned to work within a week and is receiving physical therapy. After a conference between her physician and the case manager, she has been put on light duty.

"We call this ‘informed patient decision- making,’" says Brody. "We give the patient as much information as possible, so they can more fully understand their condition and treatment options. We’ve found that patients have better outcomes when they make the choice, when they are part of the process."

"This process fits with what we are trying to do," adds Eskow. "We want to make sure the injured worker has someone they can communicate with at all times during the process. We assign our own case managers, and then when the employee enters the program, a back specialist case manager is added to the team, which provides all-important continuity."

Following this initial pilot program, Reliance plans to offer spine surgery evaluation to all of its insureds as part of its overall health care coverage. "We know we will save money and have better outcomes; the NSN will work with us to quantify and measure the savings, and eventually, they will be passed back to the members," says Eskow. The baseline data is already lined up, he says, and he believes that "within a quarter" he will be able to quantify real savings.

He also sees additional employee health benefits. "This program makes clear to the employees that they are getting top quality service, which will improve morale — and state of mind as we know is a big part of the curative process, especially where back pain is concerned," he observes. "And a high quality of care will get people healthier more quickly, which will result in cost savings. A lot of managed care companies are pennywise and pound foolish; you need to get an injured worker to the best person possible as quickly as possible."

[Editor’s Note: For more information, contact: Alana Brody, National Spine Network, 1 Concourse Parkway, Suite 750, Atlanta, GA 30328. Telephone: (770) 509-5341. Fax: (770) 804-5852.]