CHAPTER 8

The Future of the Use of Spine Surgery

Joseph S. Cheng, MD, Kern P. Vohra, Cyrus C. Wong, MD, and Matthew J. McGirt, MD

ational spending on health care was estimated to have reached $2.7 trillion in 2011 by the Ofce of the Actuary in the Centers for Medicare & Medicaid Services, representing an estimated 17.9 % of our nations Gross Domestic Product.1 This growth in healthcare spending is compounded by our aging American population. Disabling low back pain associated with degenerative spinal disorders particularly affects the rapidly growing population of those . 65 years of age and is one of the most frequent indications for surgery in this age group.1-5 This rise in healthcare costs not only is dramatic but also could be classied as unsustainable. The cumulative growth in healthcare costs is projected to increase by almost 16% by 2018; in contrast, the US Gross Domestic Product is projected to increase by only 4% in the same time period. Many critics point to spinal surgery costs as a major contributor to the rise in overall healthcare costs during this time period. Deyo et al6 note in their study of Medicare patients that more complex spinal surgeries are on the rise, along with spinal surgery costs, and are frequently performed unnecessarily. Favorable surgeon and hospital reimbursements have been cited to explain this rapid growth of complex spinal surgery such as anterior and posterior lumbar interbody fusions over nonsurgical care or simple decompressive surgery in the Medicare population. With the assumption that there is a stable incidence of spinal disease in the Medicare population that has not changed, it would be logical to conclude that there is too much inappropriate medical and surgical care being delivered. However, according to the 2010 Census, although the percentage of younger people in the United Stated (25-44 years of age) declined by 3.4%, the older population of those in the retirement age bracket, $ 62 years of age, grew by 21.2%. Overall, those of Medicare age (65 years) represent 39% of our total population and represented the fastest-growing age group in the United States.7-10 The number of people in the United States who are $ 90 years of age has tripled over the past 3 decades, reaching 1.9 million in 2010, and is expected to quadruple over the next 4 decades thanks to advances in medicine and health care. As the number of our senior citizens increases, so will the need for age-appropriate medical care such as treating the disability associated with degenerative spine disease.

The growth of spinal surgery reported in the Medicare population may be a factor of our changing aging patient demographics, but because spinal surgery is only one of the treatment options for disabling back and leg pain, we reviewed the Medicare data from the American Medical Associations Relative Value Scale Update Committee database to assess the relative growth of high-cost, complex surgical procedures compared with that of noninvasive or nonsurgical care.

COMPLEX SPINAL SURGERY

An analysis of the Medicare data over the period of 1999 to 2009 would seem to support the signicant increase in the number of complex spinal surgeries as described by other authors such as anterior (ALIF), posterior (PLIF), and transforaminal (TLIF) lumbar interbody fusions, with their associated overall Medicare professional payments to surgeons as represented by the American Medical Association Current Procedural Terminology (CPT) code for ALIF (CPT 22558) and PLIF/TLIF (CPT 22630; Figure 1). The number of ALIFs increased by 127% from 2951 surgeries performed in 1999 to 6697 in 2009, and PLIF/TLIFs increased by 490% from 4181 performed in 1999 to 24 667 in 2009. The amount of money paid by Medicare to surgeons to perform these complex procedures in 2009 alone was estimated to exceed $35 million, with $5.5 million paid for performing ALIF surgeries and $30 million for PLIF/TLIF surgeries. From those numbers alone, it would seem that the extreme growth and cost rise are beyond those expected for the growth rate of the aging population and may be due to an unnecessary amount of complex spinal surgeries performed. That is exactly the accusation of many in the mainstream with allegations of aggressive marketing of spinal implants and lectures by surgeons on the payroll of device manufacturers, along with allegations of kickbacks to spine surgeons for using products with questionable nancial arrangements as consultants.11 Although there will always be cases of nancial fraud and ethical abuses, there is an insinuation that the majority of the growth of spinal surgeries is related to this. Because spinal surgery is not the only treatment option for those with back and leg pain caused by lumbar spondylosis and stenosis, these data on complex spinal surgery can be reviewed relative to the corresponding data for noninvasive management and simpler procedures. If it is economic incentives that drive the growth of spinal surgery at the expense of nonsurgical options,
Clinical Neurosurgery  Volume 60, 2013

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Use of Spine Surgery

FIGURE 1. Medicare data from 1999 to 2009 by Current Procedural Terminology code comparing relative growth of anterior (ALIF) and posterior (PLIF) lumbar interbody fusions.

then the future of the use of spine surgery would be one of rapid decline as we reign in unneeded surgeries.

PAIN MANAGEMENT AND SPINAL INJECTIONS

One option for patients with symptomatic degenerative spinal disorders who wish to avoid surgery is the use of spinal injection procedures such as lumbar epidural steroid injections (ESIs) performed either via an interlaminar injection (CPT 62311) or via a transforaminal approach (CPT 64483) for injection. Lumbar ESIs have grown by 325 860 procedures since 2001 (Data before this time are unavailable because the code changed that year to differentiate this procedure from lumbar transforaminal ESIs). Transforaminal ESIs had an increase of 678% in 2009 compared with 1999; lumbar and transforaminal ESIs together represent an increase of 896 025 procedures since 2001 at an estimated cost of $328.7 million in Medicare payments to physicians in 2009 (Figure 2). From this information, it would appear that the use of spinal procedures such as injections had a larger increase than the complex spinal surgeries noted previously, in addition to a much larger increase in physician professional costs. But perhaps there is a propensity to reward physicians performing procedures and surgery, not those who manage patients with medications and noninvasive modalities. Martin et al12 performed a thorough review of estimated inpatient, outpatient, emergency department, and pharmacy expenditures related to back and neck problems in the United States from 1997 through 2005 and noted that $85.9 billion were spent on the treatment of low back pain in 2005. Of this amount, expenditures for pain medicines had increased 423% from 1997 to 2005 and accounted for the greatest relative increase among expenditure categories. On the basis of this yearly value of $85.9 billion, surgeon fees for all lumbar spine surgery were estimated to represent only less
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than one-half of 1% (0.46%) of the total dollars spent on low back pain in 2005. Currently, the primary treatment for most individuals with low back pain related to lumbar degenerative disease is nonoperative management. Because the population of patients treated with surgery is selected from those who have already failed extensive nonoperative management, it would be reasonable to expect an increase in spinal surgery to mirror the growing use of medical management. Surgical and nonsurgical therapies are complementary, and surgery is typically not performed unless nonoperative modalities have already failed and have already been demonstrated not to improve patient outcomes.

EXERCISE THERAPY AND SPINAL MANIPULATIONS

Has there been such an increase in patients needing care, or are physicians just medical opportunists looking to perform procedures or to medicate unsuspecting patients? Many insurance carriers require proof that a patient has been through physical therapy with core stabilization exercises and passive and active treatment modalities before approving any invasive procedure.13 Because CPT coding for physical therapy (PT) follows that of clinic visits, with new vs return patient visits, we can look at new PT patient visits to assess use not confounded by different frequencies of treatment visits based on a patients needs. Based on CPT 97001 for new PT visits, PT and their exercise programs are being used more for spinal disorders, with International Classication of Disease, Ninth Revision, code 724 (other and unspecied disorders of the back [spine]) leading the list of top 5 diagnoses for an initial PT visit, along with code 723 (other disorders of cervical region [spine]). Initial PT evaluations have risen by 1.4 million patients in 2009 compared with 1999, with Medicare payments of $121.7 million in 2009 (Figure 3). Another

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FIGURE 2. Medicare data from 1999 to 2009 by Current Procedural Terminology code comparing relative growth of physical therapy (PT) and epidural spinal injections (ESIs) with spinal fusions. PLIF, posterior lumbar interbody fusion; tESI, transforaminal epidural spinal injection.

way of looking at this is that in 1999, of all the patients who underwent a new PT visit, 1.3% of patients had a lumbar fusion with a PLIF/TLIF. Given the explosive growth of PT management for patients with spinal disorders, that ratio of new PT patients to PLIF/TLIF did not change much in 2009 at 1.4% (Table 1). The value of $85.9 billion spent on the treatment of low back pain in 2005 was not just for medical management but also included the costs of alternative medicine and chiropractic care. Many out-of-pocket payments are not captured in the growth of patients with spinal problems, with Medicare data reimbursing for only a few chiropractic procedures and codes. Looking at just one of the chiropractic CPT codes such as manipulative treatment of 3 to 4 regions of the spine, represented by CPT 98941, we see an increase of 8.3 million encounters since 1999 with 2009

estimated payments to chiropractors exceeding $471.5 million for this 1 procedure CPT code alone (Figure 3). In comparison, Medicares physician payments for the entire eld of neurosurgery was $570 million in 2007, which includes all cranial, pediatric, vascular, functional, stereotactic, pain, peripheral nerve, and other procedures our neurosurgical colleagues perform.14 It has been estimated that Medicare enrolls . 10 000 new Americans per day. This is reected in the number of new level 4 outpatient clinic visits (CPT 99244), which has risen by . 3 million patients in 2009 compared with 1999 (Table 1). Because the growing numbers of Medicare patients are using nonsurgical treatment options more than spinal surgery, it would appear that surgery may be underused on the basis of these trends. However, the criticisms and concerns about the unsustainable rise in healthcare costs are not about the patient use of surgery but

FIGURE 3. Medicare data from 1999 to 2009 by Current Procedural Terminology code comparing relative growth of chiropractic (Chiro) manipulation (3-4 regions) with physical therapy (PT), epidural spinal injections, and fusions. PLIF, posterior lumbar interbody fusion; tESI, transforaminal epidural spinal injection.

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TABLE 1. Medicare Data by CPT Code Comparing Relative Growth From 1999 to 2009a
CPT Code ALIF PLIF Posterior fusion Lumbar laminectomy Lumbar ESIb Lumbar TF ESIb Chiropractic manipulation of 3-4 regions New patient visit Initial PT evaluation 22558 22630 22612 63047 62311 64483 98941 99244 97001 1999 2951 4181 18 092 51 048 579 277 84 076 5 550 185 3 138 928 326 660 2009 6697 24 667 56 075 76 458 905 137 654 241 13 888 398 6 182 316 1 720 315 1999-2009 Increase 3746 20 486 37 983 25 410 325 860 570 165 8 338 213 3 043 388 1 393 655 CMS Fee, $ 1465.76 1457.46 1514.83 1 035 63 181.14 251.87 33.95 185.47 70.73 Estimated 2009 CMS Payments, $ 9 816 195 35 951 166 84 944 092 79 182 199 163 956 516 164 783 681 471 511 112 1 146 634 149 121 677 880

a ALIF, anterior lumbar interbody fusion; CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; ESI, epidural steroid injection; PLIF, posterior lumbar interbody fusion; PT, physical therapy; TF, transforaminal. b Data since 2001 owing to CPT code changes.

rather the overall high costs of spinal surgery relative to the other nonsurgical modalities available.

WE ARE CONCERNED ABOUT COSTS, NOT USE

Given the exponentially higher growth and use of nonsurgical treatments over spinal surgery, we have to question why there is so much more scrutiny of surgical treatments. Although the general public has the perception that physicians are overpaid and are the main drivers of healthcare costs, , 5% of the healthcare dollar actually goes to pay physicians for their services. However, the downstream revenue of surgery to others in the healthcare system is immense. Spinal fusion surgery has been a principal driver of the rapid increase in inpatient stays per population among the elderly.15 Of the $207.6 billion in nonelderly patient aggregate hospital costs for inpatient stays in 2009, spinal fusion surgeries alone accounted for hospital payments of $7.9 billion, or almost 4% of the costs. In the nonelderly, this represented a 14.9% average annual growth, whereas in the elderly, this was a 19% average annual growth in inpatient hospital costs.15 So although it may not be correct that spinal surgery is being overused, spinal surgery costs are increasing signicantly, and our concern about use is really related to the costs. Healthcare costs are increasing, and according to Centers for Medicare & Medicaid Services, the average costs per beneciary in 1960 was $151, grew to $605 per beneciary by 1975, rose to $4781 per beneciary by 2000, and now exceeds $8000 per beneciary. However, this increase was driven by price in per capita spending, not by increased use by a growing number of patients. An analysis by the Health Care Cost Institute looked at aggregate data from payers and noted that increases in per capita healthcare expenditures from 2009 to 2010 were driven primarily by higher prices, not by the use or intensity (mix) of services.16 However, costs per beneciary of physician services are declining. That is, physicians are being paid less over time to provide the same services to patients, thus becoming more cost-effective. On the basis of CPT codes from 1997 to 2009, the professional payment to surgeons for spinal
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surgery has been declining (Table 2). Surgeons in 2009 were actually being paid less per patient than they were in 1997, and any increase in physician compensation is related to increased use with lower cost/payment per patient. For example, a surgeon performing a PLIF and coding this procedure with CPT 22630 would be paid $1705 in 1997 and only $1433 for the same procedure in 2009, with these values not adjusted for ination. The increases seen in physician compensation have been tied to an increased number of patients and their use of health care. Physicians are not being overpaid but rather overworked and underpaid for their work compared with the past.

PHYSICIAN DECISIONS DRIVE HEALTHCARE COSTS

Although payments to physicians performing spinal surgery are not themselves the increased cost per capita spending in health care, decisions made by surgeons play a key role in our rising healthcare costs. The massive cost increase comes from choices of surgeons regarding surgical equipment and drugs, radiology imaging, and hospital charges during the coordination of patient care. In spinal fusion surgery,

TABLE 2. Decrease in Medicare Payment for Spinal Surgery From 1997 to 2009a
CPT Code 22554 22612 22630 22842 22845 22851 63030
a

Procedure Description Anterior cervical fusion Lumbar posterior lateral fusion PLIF Lumbar pedicle screws Anterior cervical plating Spinal biomechanical device Lumbar diskectomy

1997 Payment, $ 1662 1801 1705 842 761 580 1205

2009 Payment, $ 1200 1485 1433 750 719 399 892

CPT, Current Procedural Terminology; PLIF, posterior lumbar interbody fusion.

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the economic incentives for more complex surgeries lie not with the surgeon but with the company that manufactures the spinal implants catering to the surgeons preferences. For example, when a surgeon performs a single-level posterior lumbar instrumentation such as at L4-L5 with placement of 4 pedicle screws, the surgeon can expect compensation by Medicare of $746.95 based on 2010 reimbursements for CPT code 22840, with the spinal implant manufacturer expecting an estimated average of $6728 for the cost of the implants based on 2010 prices. If the surgeon decides to perform a complex spinal fusion such as placing spinal hardware at 6 levels (T12-L5) instead of just 2 levels, the surgeon can expect an additional $1.08 for putting in an additional 8 pedicle screws. Because the average reported additional time to do this based on CPT code 22842 was 105 minutes, the surgeon is being paid an additional 62 cents per hour, or 14 cents per additional screw, for his or her effort compared with just doing a single-level instrumentation. This would not be considered an economic incentive to implant spinal hardware unnecessarily. In graphic contrast to this, the manufacturer of the screws is compensated an additional $13 456 for the additional 8 pedicle screws and set screws used. If a surgeon performs even more complex spinal fusions such as placing spinal hardware at 12 levels (T6-S1) instead of just at L4-L5, the surgical fee increases by $2.27 for CPT 22843 vs CPT 22840, whereas the implant manufacturer will see additional average payments of $33 640 for the additional 20 screws used. This disparity in healthcare costs is also seen in other aspects in the United States compared with other developed countries. Although physician compensation per patient treated is not signicantly different in the United States compared with other developed countries, this is not the same for the costs of drugs, devices, hospital charges, and other charges, which lead to the large differences in healthcare spending per Gross Domestic Product. The United States has much higher prescription drug prices than other countries around the world. An

example can be seen in the name-brand drug Lipitor used to treat high cholesterol or radiology studies such as computed tomographic scans of the head (Figure 4). Choices made by the physician to write a prescription or to order a scan have significant implications in contributing to the costs of health care. Although development costs of drugs and new technology have been cited as contributors to their high costs in the United States, this does not apply to daily hospital charges, which are also signicantly higher in the United States than in other developed countries (Figure 4). This speaks to the complexity of the US healthcare system and the highly regulated environment in which we practice, with the higher associated costs. This has led to an explosive growth in hospital administration, with Cowan17 in 2009 noting that from 1970 to 2004, there was a 2753% increase in the number of hospital administrators compared with a 156% increase in the number of physicians (Figure 5). The costs for hospital administrators alone account for 7% of the more than $2 trillion spent for health care and rivaled the amount spent in the United States on pharmaceutical drugs.18 All of the aforementioned factors are important contributors to the noticeable increase in healthcare costs, and from the evidence, it is safe to say that these price increases have had larger impacts on US healthcare costs than the use of complex spinal surgeries to help patients. However, because only physicians can practice medicine and write prescriptions and perform surgery, there is intense scrutiny of the choices we make to control the future use of spinal surgery and the costs associated with it.

The signicant costs associated with the use of spinal surgery to treat prevalent conditions such as lumbar spondylosis have led to the development of payer policies to temper the rise in healthcare use that appear to conict with local

LONG TERM: COST VS BENEFIT

FIGURE 4. Comparative prices of Lipitor, head computed tomography (CT), and hospital (Hosp) day in Canada, France, and Germany as a percentage relative to the United States.

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Use of Spine Surgery

pure costs alone, we would assume that medical management was better than surgery because the direct 1-year cost of medical management of lumbar stenosis is $9350 and the same cost for a lumbar laminectomy is $24 716. However, although the cost of surgery is approximately 2.5 times higher than that of medical management, surgery was 5 times more effective than medical management at effectively treating patients with lumbar stenosis.21 On the basis of the benet to the patient, as measured in quality-added life-years gained, medical management per qualityadded life-year was much more costly at $95 500 vs surgery with a lumbar laminectomy at $33 700. In other words, spinal surgery is almost 3 times more valuable overall compared with medical management techniques used to treat lumbar stenosis.

CONCLUSION
Although certain individuals may believe that it is the economic incentives to the surgeon to perform more complex spinal surgeries that are driving the increases in spinal care costs, and potentially even healthcare costs as a whole, this is simply not the case. Procedures such as ESIs, PT, and chiropractic care have had far greater increases in the overall use in spinal care in recent years, and on the basis of the fee-for-service system of CPT coding notes, physicians are actually receiving lower compensation per patient now than they were for performing the same procedures in 1997. The increase in costs can be attributed to the increases in the prices of medical equipment, drugs, and tests such as scanning and imaging and in our regulatory burden and growing administrative costs. However, surgeons play a key role and must be competent in system-based practice as we continue our role as advocates for our patients. This includes being proactive and participating in our American Association of Neurological Surgeons/Congress of Neurological Surgeons neurosurgery registries to address misperceptions such as focusing on the higher cost of surgery for lumbar stenosis without noting the greater benets compared with medical management techniques. Surgery is not something malignant in spinal care; in fact, it may just be the best practice at the moment. We need to participate in data collection efforts and to support our national society leaders to help maintain access to benecial surgical care for our patients, and we must help protect the future use of effective spine surgery for the benet of our patients. For related video content, please access the Supplemental Digital Content: http://www.youtube.com/watch?v=d0TeOzhtf4c

FIGURE 5. The percentage increase of hospital administrators and physicians tracked by the US Bureau of Statistics from 1970 to 2004. From Cowan BD. Womens health care vital signs: stable or not? Paper presented at: 75th Annual Meeting of the Central Association of Obstetricians and Gynecologists; October 22-25, 2008; New Orleans, LA.17

standard of care and clinical guidelines.19 Thus, as neurosurgeons, we nd ourselves challenged to provide our patients with what we believe to be the most appropriate and benecial care in an increasingly difcult nancial environment with decisions increasingly inuenced by the conicting interests of government, hospitals, and insurers. These conicts are debated with evidence-based medicine, which has superseded the prior concepts of standard of care and the respectable minority practicing the art of medicine. The data extracted from the literature are frequently the key in assessing the delivery of health care in hospitals and community settings, and compliance with guidelines is now a surrogate analysis of a physicians effectiveness in providing treatment.19 However, a review of evidence-based guidelines on the use of spinal surgery such as fusion for the treatment of chronic low back pain noted inconsistencies across guidelines and policies that were government sponsored or developed by specialty societies.19 This heterogeneity in the assessment of the literature was more pervasive in the medical payer policies owing to variations in the literature cited and transparency of the development process.19 Unfortunately, concerns for healthcare costs have also affected the resources available for clinical research, leading to a decline in high-quality studies used for the development of policies and guidelines.20 Because large-scale randomized controlled studies to analyze all aspects of the utility of spinal surgery are not practical, efforts have been made by our national leaders in neurosurgery such as registry development through the NeuroPoint Alliance. Early work on lumbar stenosis showed that the long-term value of spinal surgery far outweighs its cost and highlights the improved cost-to-benet ratio of surgery compared with medical management.21 In lumbar stenosis, if we look at
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Disclosure

The authors have no personal nancial or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES
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patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine (Phila Pa 1976). 2007;32(2):230-235. Deyo RA, Martin BI, Kreuter W, Jarvik JG, Angier H, Mirza SK. Revision surgery following operations for lumbar stenosis. J Bone Joint Surg Am. 2011;93(21):1979-1986. Deyo RA, Mirza SK, Martin BI. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2011;306(10):1088. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG: Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13): 1259-1265. Howden LM, Meyer JA. Age and sex composition: 2010-2010 Census briefs, May 2011. http://www.census.gov/prod/cen2010/briefs/c2010br-03. pdf.Accessed January 1, 2013. He W, Muenchrath MN. 90+ in the United States: 2006-2008: American Community Survey Reports, November 2011. http://www.census.gov/ prod/2011pubs/acs-17.pdf.Accessed January 1, 2013. Bressler HB, Keyes WJ, Rochon PA, et al. The prevalence of low back pain in the elderly: a systematic review of the literature. Spine (Phila Pa 1976). 1999;24(17):1813-1819. Koch H, Smith MC. Advance data from Vital and Health Statistics, National Center for Health Statistics (NCHS). In: Ofce-Based Ambulatory Care for Patients 75 Years Old and Over, National Ambulatory Medical Care Survey, 1980 and 1981. Hyattsville, MD: National Center for Health Statistics; 1985:85-1250. DHHS publication (PHS). Johnson KC. Unneeded, riskier spinal fusion surgery on the rise. http:// www.msnbc.msn.com/id/36197896/ns/health-health_care/t/unneeded-riskierspinal-fusion-surgery-rise/.Accessed January 1, 2013.

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