Current Concepts | Value in Spine Care
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injection procedures may also be affected by the publication,
as private insurers often use CMS policies as benchmarks for
In a 2016 editorial in JAMA, Don Berwick outlined three
eras in medicine: “protectionist, reductionist and a future,
third era more reliant on ethics than the first two.” 2 The
question of the value of injections in spine care can be seen
along this paradigm. As isolated silos providing spine care,
proceduralists protected their own interests and the number
of injections exploded over the last 20 years. Payers and policy
makers have tried to rein in overutilization and variability,
using data as a surrogate for accountability. While the intent
may not have been unreasonable, these policies have led to
our current environment of reductionism. Decisions between
physicians and patients are judged on algorithms, with little
accommodation for individual nuance.
The AHRQ report and similar reviews are helpful on a
population level, but the conclusions do not reduce well to
individual patient care. Population-level evidence on resource
utilization by spine patients and the lack of corresponding
improvement in outcomes is compelling. Payers and policy
makers have been responding to what they perceive as low
value interventions by driving change out of the protectionist era and into the current reductionist environment. One
of the most negative consequences of this movement has
been case-by-case utilization review. While unfettered cost-based reimbursement proved unsustainable, the current
control mechanisms are not the answer. Prior authorization
processes mostly act to reduce care instead of lowering cost,
as savings from reduced labor costs per patient are spent on
administrative functions. 3-5 Patient experience suffers under
current utilization review practices. 6
Expecting accountability for what spine providers do is
reasonable. Once reliable, risk-adjusted data systems are
available, a possible solution may be to conduct audits of
practices and share them transparently to allow benchmark-
ing. With hope, Mr. Goodman’s treatment team will enable
him to participate in shared decision-making that respects
his preferences and the context of his presentation, rather
than being exposed to the incentives of providers protecting
their own silos and payers reducing decisions to numbers
calculated from incomplete data.
In summary, the AHRQ Technological Assessment and the
Novitas Solutions LCD documents highlight the challenges
facing spine providers in delivering judicious care to individual patients. Doing injections on everybody is not reasonable but systems prohibiting injections on anybody with axial
back pain are not helpful. As Dr. Berwick suggests, there may
still be hope for a future where, if Mr. Goodman and his doctor determine that an injection is the right option at the right
time, it can be provided.
1. Groopman J, Hartzband P. Your Medical Mind: How to Decide What
Is Right for You. New York, NY: Penguin Publishing Group; 2011.
2. Berwick DM. Era 3 for medicine and health care. JAMA.
3. Casalino LP, Nicholson S, Gans DN, et al. What does it cost
physician practices to interact with health insurance plans?
Health Affairs (Project Hope). 2009;28:w533-43.
4. American Medical Association. 2016 AMA Prior Authorization
Physician Survey. Available at: https://www.ama-assn.org/
5. Wegner SE, Trygstad TK, Dobson Jr LA, Lawrence Jr WW, Steiner
BD. A physician-friendly alternative to prior authorization for
prescription drugs. Am J Managed Care. 2009;15:e115-22.
6. Burton SL, Randel L, Titlow K, Emanuel EJ. The ethics of
pharmaceutical benefit management. Health Affairs (Project
MJ Smith: nothing to disclose.