Spine Health:A Payer’s Perspective

Janet R Maurer, MD, MBAAssociate CMOVP, Quality & ComplianceNIA Magellan HealthMember, Board of Directors NASF

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Who Are the Payers?

• Private Sector• Commercial Insurance Companies (Private Sector Employers)• Individuals

• Public Sector• Medicare (Original and through Commercial Insurers)• Medicaid (Mostly through Commercial Insurers)

• Private and Public Sectors• Worker’s Compensation Insurance

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Why Do Payers and Individuals Care About Spine Health?

$$$Comorbid:

anxiety, depression, obesity, other

chronic conditions, etc

Medical/DME:

imaging, interventional pain

management, surgery,

conservative care modalities,

assistive devices

Pharmacy: opioids, non-

opioids, relaxants, anxiolytics, etc.

Disability Insurance Costs

Productivity/Absenteeism

Worker’s Compensation

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Costs of Back and Neck Problems Through 2012

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From Variation in the Care of Surgical Conditions, Dartmouth Atlas Project, Sept 2014 http://www.dartmouthatlas.org/pages/variation_surgery_2

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What is Causing the Payer Concern?

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Back pain health care costs are increasing*

Disability rates, other outcomes do not seem to be improving

*

Top cause of Global Disability 1990 and 2013 from Global Burden of Disease Study 2013 Collaborators, published online by The Lancet, June 8, 2015. http://dx.doi.org/10.1016/S0140-6736(15)60692-4

Payer, Employer, Back Pain Patient, Provider

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How Does the Payer Think About Health Care Outcomes and Costs?

• Payer’s (Private and Public) Goal is best Value for the health care purchased• Value = Outcomes/$$ spent• Focus is on achieving best outcomes (best achievable health state) at reasonable cost• Ensure use of evidence-based guidelines (standard of care)• Avoid unnecessary duplication in diagnostic tests• Ensure least invasive approach used when results similar• Ensure qualified providers deliver care (networks)• High cost, clearly defined areas payers address, e.g. spine health• Spine MRI, Interventional Pain Management, Spine surgery• Other potentially high cost care: PT, chiropractic, Devices

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Payer Approaches to Improving Value in Spine-related Health Care• Prior Authorization of Requested Tests/Procedures/Devices, etc.• Pre-approval by medical management of insurer• Insurer medical personnel: nurses, physicians using evidence-based guidelines

• Creation of Networks • Contract with providers (physician, PT, etc) that are moderate cost; have high

quality ratings• Contract with accredited, moderate cost rendering facilities or imaging centers

(spine MRI cost can vary from <$500 to >$1500 even in same city)

• Case Management• Identify high cost/risk patients and help ensure appropriate management plan

• Integrated Care• Identify spine patients early and ensure transparency in all aspects of care from

pharmacy, behavioral health, imaging, interventions, devices, etc.

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Spine MRIs

8

Source: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health expenditure and financing: Health expenditure indicators", OECD Health Statistics (database). doi: 10.1787/health-data-en (Accessed on September 10, 2014).

Why Focus on MRIs? The Rise of MRIs and MRI USE in the USA

1995 2000 2005 2010 20150.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

12.3

35.46

4.5

10.2

United States

Comparable Country Average

Magnetic Resonance Imaging (MRI) units per million population

Australia

United Kingdom

Netherlands

Austria

Comparable Country Average

Canada

France

United States

0 20 40 60 80 100 120

26

41

50

50

51

54

82

105

More availability of medical technology does not always equate to higher utilization; But in the USA It Does

United Kingdom

France

Canada

Netherlands

Comparable Country Average

Australia

Austria

United States

0 5 10 15 20 25 30 35 40

7

9

9

12

12

15

19

34

Number of MRI units available per million population (2012) Number of MRI exams performed per 1,000 population (2012)

Sources: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health care resources", OECD Health Statistics (database). doi: 10.1787/health-data-en (Accessed on September 10, 2014). Notes: In cases where 2011 data were unavailable, data from the countries' last available year are shown. Some countries, such as Japan, are omitted because data are not available for both indicators.

•Requests undergoing clinical review that do not meet medical necessity guidelines:*

Focus on Cervical and Lumbar Spine MRIs:NIA Magellan Snapshot• NIA Provides Spine MRI Prior Authorization for:• 76 Customers • 34 states• 25.7 million lives• Mix of Commercial, Medicare, Medicaid

• Spine MRI Requests• >30K lumbar/mo; > 17K cervical/mo• > 564K/yr = 21.9/1000 request rate

• Of the 564K, 9% approve immediately• Tumor, infection, trauma post-op,

progressive neurological deficit, immunosuppression, etc.

Lumbar MRI Cervical MRI Average % Average %

Commercial 35 32Medicare 26 25Medicaid 44 38

*Office records documentation available

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Why the High Percent Not Meeting Medical Necessity Guidelines?• More than 90% of not medically necessary Spine MRI requests is related to lack of (or lack of documentation of) an adequate period of conservative care

Per NASS and multiple other societies and guidelines, conservative care is required prior to advanced imaging:NASS Choosing Wisely: ‘Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of ‘red flags’

• How many second requests for MRI for same patient are received between 6 weeks and 6 months after the initial non-approval (presumed failed conservative care)?• 9 % of initial ‘Does not meet medical necessity’ requests

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Interventional Pain Management

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Rapid Increase in Interventional Pain Management Procedures in Medicare Fee-For-Service

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Manchikanti L, et. al. Pain Physician 2015: 18: E115-27

Provider Variation is Observed in the Use of Repeat Facet Joint Injections (FJI) Each diamond below reflects a provider with 15 or more patients during the data period. Generally, NIA would expect the average patient to receive 1 to 2 Facet Joint Injections and rarely more than 3 in a

six month period. 15% of high volume FJI providers have more than one patient receiving in excess of 3 FJI in a six month period. Providers designated with orange diamonds represent care that is well outside the standard of care represented

by the clustering of IPM Providers whose patients receive 1-2 FJI and 0% of patients with more than 3 in a six month period.

IPM Provider VariationFacet Joint Injection Sample

Outlier Provider Care(orange diamonds)

Provider A is a mid volume provider with an average of 3.3 visits per patient. 54% of provider’s patients had 4 or more Facet Joint injections in a 6 month period. (highest %)

Provider B is the 4th highest volume provider for the plan with an average of 3.0 visits per patient. This provider had 29% of patients with 4 or more Facet Joint injections in a 6 month period.

15

0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.00%

10%

20%

30%

40%

50%

60%

Avg Facet Joint Visits per Patient

% P

atien

ts >

=4 in

6 m

onth

s

Provider A

Provider B

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How to Manage the Rapid Increase in Interventional Pain Procedures?

• Is the increase in IPM procedures justified? • Standard of care elusive; guidelines often vague and based on poor data• Many ‘medical necessity’ determinations made on expert consensus standards• Recent articles question overall impact of IPM and suggest need for better

studies/approaches‒ Pain Management Injection Therapies for Low Back Pain, AHRQ Technology

Assessment, pub. March 20, 2015 www.AHRQ.gov‒ Several studies question impact of steroids in spinal stenosis, e.g., NEJM 2014;

371:11•NIA Magellan initial experience with IPM (epidural, facet, sacroiliac)

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Requests/1000 ‘Not medically necessary’ Rate

12 30%

Lumbar Spine Surgery

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Lumbar Spine Surgery for Spinal Stenosis: Example of Issues that Concern Payers

•Medicare Fee-For-Service: rates of surgical decompressions• Increased 67% between 2001-2011 from 31.6 to 52.7/100,000• Variation in rates is huge across country

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From Variation in the Care of Surgical Conditions, Dartmouth Atlas Project, Sept 2014 http://www.dartmouthatlas.org/pages/variation_surgery_2

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Lumbar Spine Surgery for Spinal Stenosis: Example of Issues that Concern Payers

•Medicare Fee-For-Service: rates of surgical fusions• Rate of fusions between 2001-2011 was 41.1/100,000• Variation in rates is huge across country: from 9.2 to 127.5/100,000

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From Variation in the Care of Surgical Conditions, Dartmouth Atlas Project, Sept 2014 http://www.dartmouthatlas.org/pages/variation_surgery_2

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Lumbar Spine Surgery for Spinal Stenosis: Is The Treatment Worse Than The Disease?

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From Variation in the Care of Surgical Conditions, Dartmouth Atlas Project, Sept 2014 http://www.dartmouthatlas.org/pages/variation_surgery_2

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Summary: The Payer’s View

Payers are Confused:• Why is care so variable for these diseases across the country?• Where is the definitive research on outcomes to allow the creation of truly evidence-based

standards of care (guidelines)?• Why don’t many of the practitioners in this area follow the guidelines that are there?

What Payers Want:• Better comparative effectiveness studies that truly compare outcomes of different approaches

• Development of a holistic model of care‒ Including conservative management, pharmacy, weight loss approach, behavioral health, appropriate interventional management, culture change?‒ Able to be implemented by payers

• Overall better outcomes for patients

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IOM, 2011