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The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain.

Goodman RM, Powell CC, Park P - Spine (2016)

Bottom Line: Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs.The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days.Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions.

View Article: PubMed Central - PubMed

Affiliation: *Blue Care Network of Michigan, Southfield†Center for Statistical Consultation and Research‡Department of Neurosurgery, University of Michigan, Ann Arbor.

ABSTRACT

Study design: An observational study.

Objective: The aim of this study was to evaluate the impact of a health plan's prior authorization (PA) programs for low back pain (LBP) in a non-Medicare population by assessing changes in pre-surgical nonoperative care; lumbar fusion trends; and overall back surgery rates compared with another health plan with a similar program and national benchmarks. The PA programs require mandatory physiatrist consultation before surgical evaluation, with subsequent additional LBP surgery PA.

Summary of background data: LBP is prevalent and concern exists that spinal fusion is overutilized for LBP.

Methods: Annual rates of lumbar fusion trended over 6 years, and analysis of changes in standardized costs for LBP-related services among a 501-member subset who underwent lumbar fusion before and after program implementations, during the period January 1, 2008, through December 31, 2013, among commercial members aged 18 and 65 years enrolled in a health maintenance organization with commercial membership averaging >500,000 annually.

Results: After initiation of the physiatrist PA in December 2010, lumbar fusions decreased from 76.27/100,000 in 2010 to 62.63/100,000 in 2011 with subsequent increases to 64.24/100,000 and 73.84/100,000 in years 2012 and 2013. For members who had lumbar fusion, per-member, pre-surgical costs increased by $2,233 with the physiatrist PA and an additional $1,370 with implementation of the LBP surgery PA (March 2013). Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs. The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days.

Conclusion: Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions. Instead, these programs were associated with the unintended consequence of increased costs from more nonoperative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs.

Level of evidence: 3.

No MeSH data available.


Related in: MedlinePlus

SHP commercial lumbar fusion surgeries per 100,000, ages 18 to 65 years, regions 1 and 2 only. SHP program start dates: SCR PA December 1, 2010, lumbar surgery PA March 1, 2013.
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Figure 1: SHP commercial lumbar fusion surgeries per 100,000, ages 18 to 65 years, regions 1 and 2 only. SHP program start dates: SCR PA December 1, 2010, lumbar surgery PA March 1, 2013.

Mentions: Figure 1 shows the SHP rate of lumbar fusion surgeries, as defined for this study, for SHP Regions 1 and 2 (see Supplement). The SHP SCR-PA started December 1, 2010 in these two regions, with all of 2008 to 2010 considered as substantively the pre-SCR-PA program period. The rate increased from 2008 to 2009 but by a lesser degree from 2009 to 2010, with annual changes of 7.55 (11%) and 0.67 (<1%) lumbar fusions/100,000 members. The fusion rate decreased the first year after implementation of the SCR-PA from 76.27/100,000 in 2010 to 62.63/100,000 in 2011. Subsequent years demonstrate an increase, with the 2013 rate approaching the pre-SCR-PA rate. The 2013 post-SCR-PA rate, while slightly lower than 2010, should be considered in the context of the LBS-PA implementation beginning March 1, 2013, as both programs associated with substantive episode lengthening and additional nonoperative management.


The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain.

Goodman RM, Powell CC, Park P - Spine (2016)

SHP commercial lumbar fusion surgeries per 100,000, ages 18 to 65 years, regions 1 and 2 only. SHP program start dates: SCR PA December 1, 2010, lumbar surgery PA March 1, 2013.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4834807&req=5

Figure 1: SHP commercial lumbar fusion surgeries per 100,000, ages 18 to 65 years, regions 1 and 2 only. SHP program start dates: SCR PA December 1, 2010, lumbar surgery PA March 1, 2013.
Mentions: Figure 1 shows the SHP rate of lumbar fusion surgeries, as defined for this study, for SHP Regions 1 and 2 (see Supplement). The SHP SCR-PA started December 1, 2010 in these two regions, with all of 2008 to 2010 considered as substantively the pre-SCR-PA program period. The rate increased from 2008 to 2009 but by a lesser degree from 2009 to 2010, with annual changes of 7.55 (11%) and 0.67 (<1%) lumbar fusions/100,000 members. The fusion rate decreased the first year after implementation of the SCR-PA from 76.27/100,000 in 2010 to 62.63/100,000 in 2011. Subsequent years demonstrate an increase, with the 2013 rate approaching the pre-SCR-PA rate. The 2013 post-SCR-PA rate, while slightly lower than 2010, should be considered in the context of the LBS-PA implementation beginning March 1, 2013, as both programs associated with substantive episode lengthening and additional nonoperative management.

Bottom Line: Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs.The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days.Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions.

View Article: PubMed Central - PubMed

Affiliation: *Blue Care Network of Michigan, Southfield†Center for Statistical Consultation and Research‡Department of Neurosurgery, University of Michigan, Ann Arbor.

ABSTRACT

Study design: An observational study.

Objective: The aim of this study was to evaluate the impact of a health plan's prior authorization (PA) programs for low back pain (LBP) in a non-Medicare population by assessing changes in pre-surgical nonoperative care; lumbar fusion trends; and overall back surgery rates compared with another health plan with a similar program and national benchmarks. The PA programs require mandatory physiatrist consultation before surgical evaluation, with subsequent additional LBP surgery PA.

Summary of background data: LBP is prevalent and concern exists that spinal fusion is overutilized for LBP.

Methods: Annual rates of lumbar fusion trended over 6 years, and analysis of changes in standardized costs for LBP-related services among a 501-member subset who underwent lumbar fusion before and after program implementations, during the period January 1, 2008, through December 31, 2013, among commercial members aged 18 and 65 years enrolled in a health maintenance organization with commercial membership averaging >500,000 annually.

Results: After initiation of the physiatrist PA in December 2010, lumbar fusions decreased from 76.27/100,000 in 2010 to 62.63/100,000 in 2011 with subsequent increases to 64.24/100,000 and 73.84/100,000 in years 2012 and 2013. For members who had lumbar fusion, per-member, pre-surgical costs increased by $2,233 with the physiatrist PA and an additional $1,370 with implementation of the LBP surgery PA (March 2013). Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs. The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days.

Conclusion: Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions. Instead, these programs were associated with the unintended consequence of increased costs from more nonoperative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs.

Level of evidence: 3.

No MeSH data available.


Related in: MedlinePlus