Health Front: Big Audits May Stop Excessive Back Surgeries
By DR. JERRY DeCAPUA, TRT Contributing Writer
• Low back pain is a common disorder that will affect at least 80% of people at some time in their lives. Causes stem from a wide variety of conditions that include dysfunctional vertebral joint movement, unrepaired back sprains, and compression and degeneration of the vertebral discs. The over dependence on spinal surgery now appears to be a national scandal, notes some spine research journals. The seriousness of excessive surgeries and the loss of money have initiated the Centers for Medicare & Medicaid Services (CMS) to investigate the spinal care industry.
The money involved is jaw dropping. According to a CMS report, the total cost of spinal fusion for quarter 4 of 2012 to quarter 3 of 2013 was $3,886,261,000, which is why CMS is auditing physicians and surgeons involved in spinal operations. Considering that in 2006, the Dartmouth Institute of Health policy suggested that 30-40 percent of spinal surgeries (and hospital cost) were unnecessary, Medicare has realized that $1.5 billion could be saved every year if they can address peoples’ back conditions without radical surgery or steroid injections.
The Office of Inspector General also believes there is an abundance of Medicare and MediCal fraud. Due to the need to control the excessive cost to Medicare and MediCal, the CMS has developed the PEPPER program. The PEPPER program allows the CMS to withhold payment for disc operations. CMS has already begun to deny payment for many procedures and surgeries related to degenerative disc conditions. Many spinal operations will be denied for payment in the near future.
A Washington Post investigation revealed a 16-fold increase in spinal fusions in Florida from 1992 to 2012. Half of those Florida surgeries are now considered of questionable necessity by Medicare. Apparently the hospitals’ “open door” policy for any surgeon doing any surgery for any reason is coming to an end. One of the requirements prior to scheduling an elective surgery for the spine will be well intentioned and well documented attempts at some care conservative rehabilitation before-hand.
The CMS and Blue Cross/ Blue Shield now basically realize that “bad discs” are a red flag. After a prepayment review of 251 claims in North Carolina, Virginia and West Virginia, 168 back surgery request claims were denied. The total amount reviewed was $6,356,890, and $4,141,771 was denied, resulting in a denial rate of 65 percent. This shock to hospitals and surgeons has created a whole new way to do business. Medicare and insurance companies now have the authority to squelch excessive surgeries before they happen.
• It’s new, improved, and approved by the FDA, but it still appears to be repackaged hydrocodone. The Pittsburgh Post-Gazette says there is an upstart physician at Allegheny Health Network who has joined the outcry over the FDA approval of a potent new synthetic opioid painkiller. The extended-release painkiller, Zohydro ER, consists solely of hydrocodone and has recently been approved by the FDA, despite an 11-2 vote by the FDA’s advisory committee against release.
Continuing controversy over FDA approval crescendoed in recent weeks with its pending release to the market (and street). Zogenix announced March 5 that its sales force had begun educating prescribers and pharmacists about Zohydro ER. It is now available at select pharmacies, notes Zogenix.
“I would have liked to see the FDA follow its advisory panel recommendation and not approve Zohydro ER for release,” said Jack Kabazie, director of Allegheny Health Network’s division of pain medicine. “There is no need for it. There are other extended-release drugs at our disposal to treat malignant and nonmalignant pain.” About 40 consumer watchdog groups and addiction-treatment organizations petitioned the FDA to reconsider approval on grounds that the Hydrocodone is too dangerous, very addictive and is expected to cause many overdoses. Opposition also comes from attorney generals in 28 states.