Changes in commercial insurance policies in North Carolina to restrict lumbar fusion surgeries for certain indications resulted in a sharp reduction of elective lumbar fusion surgeries in that state.
Insurer Causes Fusion Surgery Decline in North Carolina
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That’s the conclusion of a recent study published in Spine (June 2016 – Volume 41 – Issue 11 – p. 647–655).
North Carolina has been ground zero in some ways over the denial of coverage for certain spine surgeries due to, specifically, coverage decisions by Blue Cross/Blue Cross of North Carolina. Admittedly we have not been unbiased in our coverage referring to the insurer as the “Flat Earth Society.”
The study, titled, Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption, (Martin, Brook I. Ph.D., M.P.H.; Deyo, Richard A. M.D., M.P.H.; Lurie, Jon D. M.D., MSc; Carey, Timothy S. M.D., M.P.H.; Tosteson, Anna N. A. ScD; Mirza, Sohail K. M.D., M.P.H.), said the commercial insurance policy changes “had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in spine surgery.”
The aim of the study was to examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications and to forecast the potential impact if the policy were adopted nationally.
The authors included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. They aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1, 2011.
The results of the study showed there was a “substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100, 000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100, 000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis, or revision procedures, but there was a coincident increase in decompression without fusion.”
The authors conclude that broader adoption of the policy could “significantly reduce the national rates of fusion operations and associated costs.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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