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 • done consulting work for: • given paid presentations for: Nil • received institutional support from: Nil • AOA Director, 2006-2012 • Past President, Spine Society of Australia 2006-2008 Signed: Brisbane, October 2017

High Value Spine Surgeries Lumbar Spinal Canal Stenosis (N.I.C.E) (THJR, Cataracts, Coronary Graft) Specific Pathologies - Deformity - Infection - Trauma - Neoplasm - Spondylolisthesis - ‘lytic - degenerative Spine fusion for non-specific low back pain - Indications vague - Techniques various - Results unpredictable Do higher costs produce higher value? Brisbane, October 2017

Practice Variations Low Cost to High Cost - ? increased value Minimally Invasive Spinal Surgery (MISS) eg L4-5 Decompression + Fusion for Degenerative Spondylolisthesis. “Old” “New” ( including M.I.S.S.) 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 - $1300 x 4 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

Practice Variations Spine Operations - Numbers and Costs ALL Spine Operations – (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

Practice Variations Interbody Fusion Ops (48654-48675) Numbers and Costs (N = 27,000) 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

Evidence – Practice Disconnect. 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

BILLING VARIATIONS 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

BILLING VARIATIONS – Fusion in Degen. Dis. 48639 – Vertebral Body, total or subtotal excision of… 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 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 48639 contraindicated in ~ all ACDF and ALIF variants due to likely cage subsidence. AMA MT 140 : $5120. MBS : $1365 Brisbane, October 2017

Is Funding for Spinal Surgery Sustainable? Aust Govt Dept of Health 4/2014 CMBS Review “Spinal Fusion for Back pain” → ALL Spinal Surgery Is Medicare Sustainable? “A Healthier Medicare” 22 April 2015 Whole of Medicare/CMBS Review – Prof Bruce Robinson Brisbane, October 2017

Spine Surgery Outcomes in a Workers’ Compensation Cohort. 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 - Payments ≥ $2000/month – Medical/Hospital Brisbane, October 2017

Appointment of Surgical Advisory Panel (S.A.P.) early 2016. Lisa Boyd • 2 Orthopaedic spine surgeons Director, • 5 Neurosurgeons Worker Support & Health 1. Retrospective data review → Items/Payments → Enforcement (repayments) 2. Prospective requested Item Number review ≥ 29/6/2016. 3. Introduce MultiDisciplinary IME (MD IME) - Surgeon and Pain Physician - Review Request for Surgery - Suggest alternatives - Communicate to Insurer and Treaters 4. Future - Reaccreditation of IMEs – emphasis on expertise. - Other reviews e.g. I.P.M./Orthopaedic etc. Brisbane, October 2017

Big Data (2015-6) 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

1. Review 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

2. Item Number Requests (All Spine) 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 L. Laminectomy 27 Various Lumbar Fusions 212 Brisbane, October 2017

2.Item Number Requests (All Spine) 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

2. Item Number Reviews 80 70 July 2016 to 60 TOTAL number of requests WITH a billing review July June 2017 2016 to June 2017 50 Number of 40 Elective Spinal 30 Surgery Requests 20 made to 10 0 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 Brisbane, October 2017

2. Item Number Reviews Future Actions 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