Landmark Study: Spine Care Prior-Authorizations May Not Reduce Surgeries or Costs

In the ongoing effort to measure the value of health plan prior authorizations regarding low-back pain patient care, new research shows that prior authorizations meant to ensure the use of non-surgical services first do not ultimately result in patients avoiding surgery and can result in increased non-operative care costs for insurers.

Paul Park, M.D., associate professor of Neurosurgery at the University of Michigan, coauthored a research paper titled, “The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain, ” and presented the findings at the April International Society for the Advancement of Spine Surgery (ISASS) conference. The paper will be published in the May 2016 issue of Spine.

Park and his colleagues, Robert Goodman, D.O., M.H.S.A., a Medical Director at Blue Care Network of Michigan (primary author), and Corey C. Powell, Ph.D., conducted a retrospective study of health plan administrative data for 501 patients who underwent lumbar fusion surgeries before and after implementation of spine care related prior authorization programs during a six-year period (January 2008-December 2013). Patients were commercial enrollees in a 500, 000+ member HMO plan. The prior authorization programs examined included a mandatory physiatrist visit before a spine surgeon evaluation was allowed.

Prior Authorization Increased Costs!

The study results show that mandating referral to a physiatrist prior to surgical evaluation did not result in the intended outcome of reducing lumbar fusion surgeries. Instead, prior authorization programs had the unintended consequence of increasing costs from more non-operative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both prior authorization programs.

Park and Goodman believe this research is timely and important for several reasons. As cited in their paper, total lumber fusions increased 356% from 1993-2001. In addition, the effectiveness of lumbar fusion surgeries has continued to be researched with inconclusive results. These research findings have led to health plan implementation of prior authorization programs addressing the care of low-back pain patients.

“The general premise that gets promulgated is that there’s overuse of surgery and that surgeons are anxious to do surgery, because after all they’re surgeons, and patients are also eager to have surgery as an initial treatment option, ” said Goodman. “That’s the premise these [prior authorization programs] operate under, and that if there was only greater adherence to using a more conservative, less invasive treatment paradigm before you get to surgery that would reduce the number of surgeries. People would feel better, they’d have physical therapy and injections, and wouldn’t go on to have surgery, and that [the conservative, less invasive] approach isn’t used as robustly as it could be. ”

Spine Fusions Decreased Initially Then Rebounded

However Goodman and Park found the opposite to be true. In the patient data set they examined, patients were already receiving non-operative services like physical therapy, spinal injections and other types of pain management services prior to having lumbar fusion surgery.

“After prior authorization was put into effect, it mandated more conservative therapy that showed that all you did was essentially spend more money on more of those sorts of services, but at the end of the day, the surgical rate didn’t really change, ” Goodman said. “There was a temporary dip [in rate of surgeries] because these [prior authorization] programs instituted a delay, so there was a temporary decline in operative cases, but then there was a rebound after this delay that was caused by these programs being present to begin with.”

According to the research findings, after initiation of the physiatrist prior authorization requirement in December 2010, lumbar fusions decreased from 76 out of 100, 000 in 2010 to 63 out of 100, 000 in 2011 with subsequent increases to 64 out of 100, 000 and 74 out of 100, 000 in years 2012 and 2013. For members who had lumbar fusion, per-member, pre-surgical costs increased by $2, 233 with the physiatrist prior authorization and an additional $1, 370 with implementation of the low-back pain surgery prior authorization (March 2013).

Spinal Injections and Admissions Pushed Costs Higher

Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs. The physiatrist and low-back pain surgery prior authorization programs were also associated with lengthening of low-back pain episodes ending in surgery by 309 and 198 days, respectively.

Park and Goodman said they were interested in doing this research as a follow-up to research published in 2013 that looked at a spine care prior authorization in regards to Priority Health, a West Michigan-based health plan. That research received coverage in Spine and likely was used to legitimize the implementation of prior authorizations by a large commercial insurer that is the subject of Goodman and Park’s research. However, there are differences between the outcomes of the two insurers.

“In that [Priority Health] study, they showed that physiatrist visits went up about 70 percent, which is not surprising because it was a mandatory referral, ” Park explained. “The number of surgical evaluations went down about 48 percent. The number of actual spine surgeries went down about 25 percent. This led others to look at it—journal readers and insurers—and think it was an effective prior authorization in terms of decreasing the number of surgeries.”

Although the initial research results had the intended effect of reducing surgeries and costs, Park said the study was only a short-term snap shot, and he had other questions. “I wanted to look at the long-term impact. If these patients weren’t getting surgeries, how were they being treated, what was the cost associated with it?”

Goodman and Park chose a data set that included people who were with the large health plan before and after the prior authorizations went into effect, so they could see the utilization of services pre and post implementation. They also looked at overall trends of lumbar fusion with the health plan using their population, the rates of all spine surgeries, and whether the prior authorization program had an impact. They compared the rates of surgery in the health plan to surgery rates reported across the country using the National Committee on Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS). In the end, their study concluded that patients were utilizing non-operative services before the prior authorizations went into effect and that surgical rates remained largely the same.

Goodman and Park think the Priority Health research results were based on the uniqueness of their situation. “They had higher surgical rates, if you look at the reported HEDIS rate, ” Park said. “They were kind of an extreme case, so they got better and then they sort of came down to a level that matched the health plan that was studied and then they had similar results after that and basically mimicked each other’s rates.”

Not All Prior Authorization Programs Work as Intended

Goodman said this shows that one prior authorization program’s effectiveness is not generalizable. “You have to look at your own situation to make an assessment about whether it will be effective in your environment.”

“The premise for these programs is that one it’s a safety issue and the other is to minimize costs, but still provide effective care, ” Park added. “It’s a premise. I think one thing you could get out of this research is that not all prior authorizations work as they should or are thought to work. Prior authorizations are getting so prevalent, and they are a big aspect administratively. I think going forward you are going to see more research on this.”