Payer Backlash May Slow Unnecessary Spinal Fusion Surgeries

Christopher Cheney, May 23, 2014

A surge in spinal fusion procedures has brought mounting scrutiny on providers. Now payers appear poised to crack down on needless procedures by applying coverage pressure on physicians.

Annual US spine fusion surgeries have skyrocketed over the last decade, rising from about 260,000 in 2002 to about 460,000 in 2011, according to federal data. And recent media reports have raised alarms over the proliferation and overuse of spine fusion procedures.

Now CMS officials are cracking down and leading a backlash against unnecessary spine fusion procedures, according to Joseph Gregory, a surgical devices analyst at London-based GlobalData.

"The financial incentives really need to be in there to stop unnecessary procedures," says Gregory, who is the lead author on a spine fusion report GlobalData is set to release soon.

CMS has gotten involved because of "money going to procedures that shouldn't have been done in the first place," he says.

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To receive Medicare payment for spine fusion procedures, physicians are facing several requirements, such as providing imaging results to regulators and documenting three to six months of consecutive therapy before surgery is performed, Gregory said. "If they don't have the documentation, they basically won't be paid by the payer."

Christopher Cheney

Christopher Cheney is the senior finance editor at HealthLeaders Media.


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