The Rise & Rise of Spinal Fusion Surgery Never ask a barber if - - PowerPoint PPT Presentation
The Rise & Rise of Spinal Fusion Surgery Never ask a barber if you need a haircut! (W Buffet) Brisbane, October 2017 INTERESTS I declare that in the past three years I have: held shares in: Nil received royalties from: Nil
Brisbane, October 2017
I declare that in the past three years I have:
Signed:
Brisbane, October 2017
(THJR, Cataracts, Coronary Graft)
Spine fusion for non-specific low back pain
Do higher costs produce higher value?
Brisbane, October 2017
eg L4-5 Decompression + Fusion for Degenerative Spondylolisthesis.
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 - $3600 Others ? Bed
Patient goes home! Implants - $10000++ O’biologics - $6400 Consumables (MISS) - $1000+ Others - ? Patient goes to 1-2 weeks Rehab. If “STAGED” – costs obviously↑↑↑ $10K approx. $40K approx.
Brisbane, October 2017
(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 11 Mean No Items 3.04 3.22 0 (1->10) Hospital Cost (excl. prostheses) $ 53m $ 71m 35 Prosthesis Cost (incl. BMPs etc) $ 44m $ 53m 20 I.C.U. $ 2.9m $ 5.2m 73 Medical Cost (Medicare/Pte Ins) $ 32m $ 41m 28
NB Hospital & Prosthesis Costs >> Medical Costs
Brisbane, October 2017
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 45 Prosthesis cost $ 27m $ 34m 29 I.C.U. cost $ 1.5m $ 2.8m 84 Medical Cost (Medicare/Pte Ins) $ 11.2m $ 15.4m 37 *28% of all ops include an Interbody Fusion.
Brisbane, October 2017
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!
Brisbane, October 2017
OK Lumbar Discectomy (40300 OR 40301 - each a CMS) NOT OK 40300 AND 40301
Australia wide 2008-9 2014-5 17% 44% ACT NSW NT QLD SA TAS VIC WA FY08-09 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.
Brisbane, October 2017
July 2015-June 2016 State Total NSW VIC QLD SA WA TAS ACT NT Services Services Services Services Services Services Services Services Services 48639 239 1,283 56 45 57 16 2 5 1,703 July 2010-June 2011 State Total NSW VIC QLD SA WA TAS ACT NT Services Services Services Services Services Services Services Services Services 48639 214 406 23 28 13 19 3 5 711
48639 contraindicated in ~ all ACDF and ALIF variants due to likely cage subsidence. AMA MT 140 : $5120. MBS : $1365
Brisbane, October 2017
Aust Govt Dept of Health 4/2014 CMBS Review “Spinal Fusion for Back pain” → ALL Spinal Surgery
“A Healthier Medicare” 22 April 2015
Brisbane, October 2017
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
Brisbane, October 2017
Appointment of Surgical Advisory Panel (S.A.P.) early 2016. Lisa Boyd
Health 1. Retrospective data review → Items/Payments → Enforcement (repayments) 2. Prospective requested Item Number review ≥ 29/6/2016. 3. Introduce MultiDisciplinary IME (MD IME)
4. Future - Reaccreditation of IMEs – emphasis on expertise.
Brisbane, October 2017
Population Victoria 6.25M Workers 3.05M WSV 2.39M (5 Insurers) Total WSV Claims 72,841 Payments $284M Total Back Claims * 9300 * Med & Hosp ~ $19M Post-Op Rehab 26% fusion 8% non-fusion Cost Rehab $740,000 What is VALUE and how do we assess it? Different for patients, treaters and Insurers!
Brisbane, October 2017
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 results N ≈ 40 None of the above (?? Is operation appropriate?) Awaiting further analysis…….
Brisbane, October 2017
Item number parameters set by S.A.P. → Prospective S.A.P. assessment of requested MBS Item Numbers Period 29 June 2016 → 30 June 2017 Patient Numbers Total request for Operation 923 Denied at agent level 239 Unresolved 38 Approved 646 On parameters referred to S.A.P. 300 (46%!!) Neck (ACDF) 61
Various Lumbar Fusions 212
Brisbane, October 2017
N = 300 Operations/Reviews Requested 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]
Brisbane, October 2017
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 July 2016 to June 2017
July 2016 to June 2017 Number of Elective Spinal Surgery Requests made to
Brisbane, October 2017
1. 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
Brisbane, October 2017
Early days – 1st on (17.7.2017) Panel appointees 6 Spine Surgeons 6 Pain Physicians Each MD IME 1 Surgeon and 1 Pain Physician 2 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
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).
Brisbane, October 2017
Total 24 (from 17.7.2017) Direct approve 12 Direct deny 12 → 7 GP follow alternative suggestions 5 ? Too early to tell/no action at this stage None so far to Conciliation/Medical Panels Vic Patient survey - > 80% approval rating!
Brisbane, October 2017
compensation systems tied to CMBS. BUT Evolutionary not Revolutionary
beneficial innovations
board – recognition of threat to status as autonomous professional bodies.
Brisbane, October 2017
Brisbane, October 2017
Brisbane, October 2017