By Eeric Truumees, MD                                                                               Previously published in the May/June issue of SpineLine

The government has a long history of misnaming programs to make them more palatable to the electorate.  There’s a reason so many “Blue Skies” initiatives were drafted by coal and oil interests.  Over time, this process has gradually extended into health care.  Examples are abounding.  We all want “evidence-based medicine.”  The devil lies in the details of how to preserve access to care when the evidence is lacking.  Similarly, rewarding good outcomes carries a great deal of surface logic.  The problems arise when programs are enacted to turn these concepts into reality.  All too often, these programs adversely impact patient access and physician reimbursement far more than any additional value they may deliver.  Two important reasons:
1.  Most “value” propositions emphasize cost savings far more than care quality.
2.  The bureaucracy required significant cost and delay to a system already choked with red tape.
Why do we continue to buy it?  Are we too lazy to understand what these programs really mean to us and our patients?  Have we given up?  Or, are we lulled into a false sense of security because these programs have warm and reassuring names?


The Art and Science of Medicine
With all their emphasis on supporting data, you’d think the government and other payers would be falling all over themselves to support spine research.  You’d be wrong.  In his President’s Message, Dr. Heggeness addresses the shockingly low level of support for spine studies.
We have known that spinal disorders have not been at the forefront of NIH funding priorities.  But, I was amazed to learn that all of musculoskeletal medicine has received funding for only two prospective clinical trials in the more than 30 years since 1980.  Now, we hear that even research monies from the Department of Defense are apportioned with a view toward political expediency and in deference to vocal lobbying.  That the NIH spends more on baldness research than spinal disorders (including spinal cord injury) is disgusting.  To hear that more money was spent by the DOD on neurofibromatosis than spinal cord injury makes one wonder which soldiers they are most concerned about.
Complaining won’t get us anywhere; we have to recognize how business is done in Washington.  Merit and scientific integrity mean little.  Lobbying and advocacy are the keys.  When we approach our lawmakers, we should address the research question for several reasons:
1. Members of Congress must see that our appeals are not just about reimbursements.
2. They must see the shocking lack of research support for spinal disorders in an age where more and more data are being demanded of us.

Ultimately, individual disciplines in medicine have advanced on the back of innovation. Orthopedic surgery is a great example of this.  Over the last 75 years, without the advances in internal fixation, joint arthroplasty and arthroscopy, orthopedics would be a very different and much diminished specialty.  In many ways, spine care remains in its infancy.  But that gives us hope (and our marching orders).
Our Research Notes section provides a great example of an area in which practice patterns affecting large numbers of patients have little supporting data.  Drs. Checo, Swanson, Leger and Mohr survey the NASS membership about the frequency of postoperative office visits, collar usage, imaging and rehabilitation after cervical spine surgery.  A number of interesting findings are presented.  Among them, the utilization of post-operative imaging and physical therapy also seem to decline with surgeon experience. Also, “orthopedic surgeons statistically obtain more postoperative imaging studies for one-level ACDF, posterior and combined fusions compared to neurosurgeons.”  I wonder if this difference relates to the great likelihood an orthopedist has office X-ray facilities.
In our November/December SpineLine, we discussed another common practice pattern for which there had been little supportive data: bracing for spine fractures.  We discussed a NASS “best paper” award winner questioning the benefit of bracing for certain thoracolumbar fracture patterns.  Since then, we received a letter from Ross Bremer detailing his perception of deficiencies in that study.  In our Letters to the Editor section, we offer Mr. Bremer’s letter along with the original study authors’ response. From my perspective, the questions and responses remind me of how much “knee jerk” medicine remains central to spine care.  I applaud Drs. Bailey and Fisher for examining this very basic, but important issue.  I also applaud Mr. Bremer for calling to question important elements of study design that may impact the generalizability of the data.
Also in our Letters section is a question about our January/February “Preseason Training for Golfers” piece.  Dr. Senegor from Stockton California asks about the relative contribution of putting and driving in back pain amongst golfers.
As Stephen Haines suggests in his 2003 paper “Evidence Based Neurosurgery,” we are in the process of evolving from simply applying scientific discoveries to the practice of medicine to practicing medicine according to the principles of science. A higher level of evidence is explored in our Literature Review. Dr. Moshirfar from Johns Hopkins tackles another recent SPORT publication. Here, the impact of duration of symptoms on the outcomes of treatment for lumbar disc herniation is assessed.  In short, the relative improvement from both surgical and nonsurgical care declined in patients with symptoms for more than six months.  At this point, it’s not clear to me if the duration of radiculopathy caused the patients to have ongoing symptoms (eg, nerve damage) or if patients presenting for late management reflected a different clinical syndrome.  On a practical level, I have adjusted my “window” when counseling patients about possible surgery. Most patients should be offered nonoperative care for six to eight weeks.  At the end of four to six months, however, I encourage those patients with significant symptoms and little interval progress to consider surgery.

Our Imaging Corner provides a very “sexy” but less commonly applied treatment approach.  Dr. David Lee from the Neuroradiology section at Brigham and Women’s Hospital describes a “Contrast Enhanced CT Guided Transpedicular Cervical Vertebroplasty.”  Using a 75-year-old male with metastatic lung cancer and a C5 pathologic fracture as an example, Dr. Lee demonstrates a transpedicular technique for PMMA augmentation of the vertebral body.
In my previous practice in Michigan, I had the pleasure of working closely with two excellent neuroradiologists, Chris Kazmierczak, MD of William Beaumont Hospital and William Sanders, MD of Henry Ford Hospital. Drs. Sanders and Kazmierczak cited some limitations to this otherwise elegant technique.  When injecting the PMMA, CT fluoroscopy yields a 10 mm maximal slice thickness.  In larger structures, the PMMA can flow outside the field of view.  Extra-osseous extravasation should be avoided.  At SpineLine, we’d be interested in similar image-guided augmentation approaches.  Please send your comments or, even better, images from a recent case.

This issue’s Spine In Sports column also highlights the importance of advanced imaging.  Drs. Laine M. Watanabe, Matthew Smuck and Michael Fredericson, from the Division of PM&R at Stanford describe “Sacral Stress Fractures in Athletes.”  The authors report that these injuries are often missed, especially in the athletic population, because their presentation can be non-specific.  They discuss the risk factors for sacral stress fractures as well as physical examination and imaging findings. Critically, as part of their discussion of treatment, they offer the reader advice on how to return these athletes to sports participation.

Regulations, Fraud and Sunshine
Often, expanding diagnostic and treatment options increase the complexity of medical care.  Lately, that complexity as been added through federal fiat.  Critics cite the planned implementation of ICD 10 as an example of increased complexity without evidence of patient benefit.
In her Regulatory Policy column, NASS Staffer Allison Waxler reports that HHS is planning to delay again implementation of the ICD-10 coding system.  In a separate report, the Texas Medical Association has written to HHS Secretary Sibelius requesting that ICD-10 be eliminated.
Unlike CPT, which is owned by the AMA, the ICD coding system has been developed by the World Health Organization.  The system evolved from the 1893 introduction of the Bertillon Classification of Causes of Death.  ICD 9 was completed in 1979 and includes 15,000 codes. Work on ICD 10 began in 1983 and was completed in 1992 yielding approximately 68,000 codes.
Proponents of ICD 10 state that ICD 9 is outdated and obsolete. Further, there are few available places for expansion in its 5 character length.  ICD10 has 7 available characters allowing far greater specificity and precision in coding.  Many countries have already moved to ICD 10, hampering international comparison of quality and outcomes data.  There have been proposals to incorporate ICD 10 into US coding systems for years.  So far, they have been delayed by critics citing the system’s complexity and the costs associated with software and personnel training.
Ms. Waxler also reports that CMS contractor SafeGuard Services, LLC has released a report on coding and billing practices for pain management providers.
In another federal delay, Modern Physician, has reported that CMS intends to postpone data collection for the Sunshine Act to 2013.  As a result of the input the agency received, it would reportedly like “additional time to address operational and implementation issues in a thoughtful manner, and the ability to ensure the accuracy of the data that is collected.”1
This seems like a very reasonable plan.  Why add another layer of bureaucracy that, seemingly helpful on the surface, has not been fully vetted and may add more problems than it solves?  Unfortunately, this is not the tactic CMS is employing in other areas.  Over the last couple of issues of SpineLine, we have discussed an increasing line of failed demonstration projects.  This month provides more reasons to be suspicious of well-named but poorly performing government initiatives.
In another example of a program gone awry, the GAO recently reported on the Quality Bonus Payment Demonstration.  This project seeks to pay $8.35 billion over 10 years to 3-star and 3.5-star Medicare Advantage plans.  The project’s goal: to “test whether a scaled bonus structure leads to larger and faster annual quality improvement compared with what would have occurred under PPACA.”2
As many of you know, the Medicare Advantage program is offered to seniors as an alternative to the original Medicare fee-for-service program.  Medicare Advantage provides Medicare beneficiaries coverage through private health plans.   The programs offer enrollees add-ons such as vision and dental coverage as well as varying cost sharing options.  In 2011, there were 3,300 Medicare Advantage plans sponsored by 175 organizations.  About a quarter of all Medicare beneficiaries were enrolled at a cost of about $115 billion (which was roughly 25% of Medicare’s Part A and Part B spending for the year).  CMS rates Medicare Advantage plans on an ascending five-star scale indicating better performance relative to other plans on “about 50 measures of clinical quality, patient experience, and contractor performance.”
This program “dwarfs all other Medicare demonstrations” conducted since 1995.  In fact, the GAO review suggests that its budgetary impact is greater than all previous, non–Part D programs combined.  Unfortunately, the GAO reports that the project’s design “precludes a credible evaluation of its effectiveness in achieving CMS’ stated research goal.” Among the reasons: most of the data were collected “before the demonstration’s final specifications were published.”  Also, “because the demonstration lacks a direct comparison group, it may not be possible to isolate its effects, and any effects that are observed could be attributable, at least in part, to other Medicare Advantage payment and policy changes.”
Given that the PPACA provided incentives for plans to achieve high star ratings, the current demonstration project could be moot.  On the other hand, CMS’ Office of the Actuary estimated that, over nine years, the PPACA’s changes would reduce payments to Medicare Advantage plans by $145 billion. They further predicted this change would “cause plans to offer less generous benefit packages” and reduce Medicare Advantage enrollment 50% by 2017.  So, “rather than implement PPACA’s bonus structure, CMS announced… it would… test an alternative method” for calculating bonuses.
After reviewing the data, the GAO recommended the HHS “cancel the Medicare Advantage Quality Bonus Payment Demonstration and allow the Medicare Advantage quality bonus payment system established by PPACA to take effect.”
Another way CMS intends to save money lies in recouping fraudulent fees paid to Medicare and Medicaid providers.  An HHS Office of Inspector General audit found that one long-running program cost more than it recouped.  As reported in Modern Healthcare, in 2007 and 2008, the fraud program received $60 million in funding but only recouped or avoided $57.8 million in inappropriate spending.  About $30 of that funding went into a computer system meant to “unify state and federal medical claims data.”  In 2009 and 2010, an additional $69 million went into the system which has been “delayed until at least 2105 because of technical difficulties.”3

Physician Discipline
Outright health care fraud is a major problem, but recently increased attention has been given to “disruptive” doctors.  In May, the Federation of State Medical Boards published its “Summary of 2011 Board Actions.”  This compilation of disciplinary actions initiated by its 70-member medical and osteopathic boards report includes disciplinary data for each board for the five-year period from 2007-2011.4
In most of the major categories, such as Loss of License or Licensed Privilege Actions (includes revocations, suspensions, surrender or mandatory retirement of licenses, or loss of privileges afforded by those licenses), there were more actions in 2011 than in the years before.  For loss of license, for example, 1,905 physicians were sanctioned in 2011 versus 1,815 the year before.
The report, which lists the number of licensed physicians as a type of denominator, cautions against using the data to compare states.  It suggests that each state’s medical board operates “with different financial resources, levels of autonomy, legal constraints and staffing levels.”  These differences may also account for differences in state to state disciplinary profiles.  The data can, however, be used to track trends within each state.
I find this data interesting, but I’ll be more curious to see how these numbers change with increasing pressure on physicians.  Similarly, we are offered little data as to each state’s stance in rehabilitating versus punishing physicians.  Finally, as more physicians find themselves employed by large hospital chains, how will their behavior change?
In a recent, but undated, post on the physician blog site KevinMD.com, neurologist Bradley Evans, MD, discussed physician susceptibility to “hardball tactics” and the often benign guise under which these tactics appear.5
Interestingly, his example was a hospital’s effort to save money in its spine surgery service line.  Hospital administrators and the neurosurgical spine staff favored newer “minimally invasive” approaches because they offered higher margins.  The orthopedic surgeons, on the other hand, preferred to continue to practice “the old way.”
In discussing the situation, one of the orthopedic surgeons, a hospital employee, was described as having “a long history of disruptive behavior.”  The term disruptive was not defined, allowing most to assume it meant abusive behavior to nurses or others.  Instead, the term could be employed (as has the term professionalism) as a vague, but critical appraisal of “dissident” physicians.  Dr. Evans notes that most medical staff disciplinary procedures do not offer due process protections.  In that physicians often face noncompete clauses, one or two “example” firings allow the hospital to increasingly control physician behavior.  Sadly, the motivation, is often not enhanced patient care, but rather cost savings.

Looking Forward
How much change will we get?  Before the November election, we will hear from the Supreme Court. In the last issue of SpineLine, we examined the issues the court is facing.  Recently, American Medical News covered a Moody’s report calculating the fiscal impact of a Supreme Court rejection of the PPACA.6
Moody’s Investors Service noted that for-profit hospital systems such as Tenet Healthcare and Hospital Corp of America would be among the hardest hit.  They invested heavily in preparing for a “post-reform environment.”  This spending included physician hiring and upgraded technology.  If the reform law is repealed, Moody’s questions whether these systems will see any benefit from the investments.
Physicians and nonprofit hospital systems also face rising costs in caring for uninsured patients if the individual mandate fails. In 2008, for example, uninsured patients received $86 billion in care, $56 billion of which was written off by doctors and health systems.  The report noted, over the past two years, Moody’s already downgraded credit ratings for many nonprofit hospitals due to decreasing revenue from slashed Medicaid and commercial insurer payment rates.
What happens to individual health care access if the law is struck down?  A recent Reuters Health piece published in the Chicago Tribune detailed the “decade-long erosion in access to medical services” most Americans have experienced.  The article details a May Health Affairs study of access for 195 million adults aged 19 to 64.  Between 2000 and 2010, access to health care deteriorated even among those with private health insurance.7
For example, by 2010, adults were 66% more likely to report unmet medical needs than they had in 2000.  Of the insured adults, 10.2% reported unmet needs, versus 5.8% in 2000.  In this group, those delaying treatment climbed from 3.9% in 2000 to 6.8% in 2010.
The article, from the nonpartisan Urban Institute cited the recent recession and its attendant high unemployment rates, but noted that the decline had started earlier.  They highlighted reductions in employer-sponsored insurance benefits and an increasing strain on the Medicaid system.
Not coincidentally, this is also the age group most targeted for expanded coverage by Obama’s PPACA.  By 2014, the PPACA seeks to extend coverage to many of the more than 32 million uninsured Americans through two paths: subsidized, state-regulated health insurance markets and expansion of the Medicaid program.
Unfortunately, even before its expansion, the Medicaid program is over-stretched. Given the program’s below–cost reimbursement, many practices do not accept Medicaid. For example, the rate for which eligible adults apply for Medicaid ranges widely from 43% in Arkansas to 83% in Massachusetts.  Doubling or tripling Medicaid rolls may not substantially increase the number of appointments or other access to care available to these patients.
Then, the November election will pit Mitt Romney against Barack Obama.  If Obama wins, we have a sense of the health care system he wants.  At this point, it would be reasonable to ask, what type of health care system would Romney offer?  Noam Levey addressed this question in the Los Angeles Times.
According to Levey, Romney has thus far only “sketched the outlines of a plan.”  His aides have declined to answer detailed questions.  Reading between the lines, however, Levey sees a Romney strategy that “in crucial ways is more revolutionary—and potentially more disruptive—than the law Obama signed two years ago.”8
The central idea of a Romney plan would reportedly transfer health insurance purchases from employers to individuals.  Americans would get a tax break to buy their own plan, giving them both more choice and more risk.  This plan, in sharp contrast to the plan instituted in Massachusetts when Romney was governor of that state, adopts proposals long championed by conservative health care experts, such as Hoover Institution fellow, Dr. Scott Atlas.
Romney’s plan would strongly dis-incentivize companies from providing insurance to their workers.  Critics say the approach would increase the number of uninsured Americans.  While offering consumers more choices, it also would overhaul Medicare and Medicaid.  In a stance reminiscent of the Ryan budget plan, Romney allows seniors to shop for their own health plans with vouchers rather than use the existing Medicare program.  The Romney plan would convert the Medicaid program into a series of block grants to the states.
Critics worry that young, healthy workers would either buy low-cost plans or skip insurance altogether.  This would leave older, sicker workers in smaller groups facing much higher premiums.  Either way, the plan is not likely to be cheaper than the PPACA.  The Congressional Budget office estimated that a similar plan backed by Senator John McCain (R-AZ) during the 2008 presidential campaign would have cost more than $1 trillion over 10 years.
Both Republicans and Democrats insist the current system cannot stand.  Medicare’s hospital trust fund expenditures have exceeded its income each year since 2008. In a recent article, Modern Healthcare projected Medicare’s insolvency by 2024.  If planned reductions in provider payments are eliminated, that day will arrive sooner. Once insolvent, tax revenues would be “inadequate to fully cover costs.”9
A recent Harris Interactive/HealthDay poll examined Americans’ attitudes toward the coming Medicare program insolvency.  The online survey, conducted in early April 2012, included 2,229 adults and weights respondents’ age, sex, race/ethnicity, education, geographic region and household income data to “make them representative of actual proportions in the population” and “to adjust for respondents’ likelihood to be online.”10
To keep Medicare affordable and sustainable, 83% believe changes are needed, but “they’d rather not make any personal sacrifices.”  Specifically, proposals to increase co-pays, deductibles or taxes were rejected.  More popular were cuts to reimbursements for drug companies, hospitals and doctors.  Interestingly, cutting physicians’ fees received only “modest support” with 41% in favor and 35% opposed.  Fifty-seven per cent favored increased fees for higher income Medicare beneficiaries.  Also popular were pay-for-performance proposals in which “doctors and hospitals should be paid based on quality and results, rather than the volume of care provided.”  Sadly, none of these programs has been found to be effective.
Most solutions have sought decreased health care spending.  The Institute of Medicine (IOM), on the other hand, called for doubling federal spending on public health from $11.6 billion to $24 billion a year.  In a story on The Hill.com, the IOM’s Committee on Public Health Strategies to Improve Health claims United States lags behind the rest of the industrialized world in life expectancy and childhood mortality because the government “chronically” underfunds public health systems.11
The key to the IOM report is the distinction between medical care spending ($8,086 per person in 2009) and public health spending ($251).  These public health expenditures would, among other things, reduce obesity and tobacco use.  Investments in public health are often stripped because budget officers balk at forecasting the long-term savings these investments might provide.  The article notes that the $15 billion Prevention and Public Health Fund created by the PPACA has already been cut by $5 billion.

Is There Hope?
According to a new report from the IMS Institute for Healthcare Informatics, health care will improve at reduced cost due to “transformative treatment options.”12 The report noted that 2011 saw the launch of the most medicines in a decade.  These “new,  transformative treatment options” affected more than 20 million Americans. Last year, 34 “new molecular entities” were launched, the most in a decade. These included new therapies for several types of cancer, multiple sclerosis, hepatitis C and cardiovascular problems.
While patient visits and prescription drugs use declined overall, per capita medication costs increased only 0.5% to $320 billion. Another factor in this “minimal” increase was the number of new generic drugs for chronic diseases.  Eighty percent of dispensed medications are now generics. Seniors reduced their use of prescription drugs by 3.1%.  The only group increasing utilization in 2011 were individuals aged 19 to 25. Their 2% increase was mainly in the form of increased use of ADHD and antidepressant drugs.

In spine, we continue to explore new procedures. In their Coding column, Coding Committee members Scott Horn, MD and William Sullivan, MD discuss Category III codes.  They describe the differences between these and Category I and their impact on billing and reimbursement.  Down the road, we hope to offer some biological solutions to degenerative disc problems, as outlined in last issue’s Invited Review.  Some of you may have seen SpineLine author Dr. Michael DePalma present balanced comments on CBS Sunday Morning May 6th.  At 4.8 million viewers, it is the number one Sunday morning news program.  Congratulations, Dr. DePalma.

References
1.     Lee J. CMS delays data collection for Sunshine Act to 2013. Modern Physician. May 4, 2012. Available at: http://www.modernphysician.com/article/20120504/MODERN
PHYSICIAN/305049957/cms-delays-data-collection-for-sunshine-act-to-2013
2.    US GAO. Medicare Advantage: Quality bonus payment demonstration undermined by high estimated costs and design shortcomings. Available at:  http://gao.gov/products/GAO-12-409R
3.    Carlson J. CMS anti-fraud program sees slow start. Modern Healthcare. April 18, 2012. Available at:  http://www.modernhealthcare.com/article/20120418/NEWS/304189969
4.    Federation of State Medical Boards. Summary of 2011 Board Actions. Available at: http://www.fsmb.org/pdf/2011-summary-of-board-actions.pdf
5.    Evans B. Why physicians are susceptible to hardball tactics. MedPage Today’s KevinMD.com. Available at:  http://www.kevinmd.com/blog/2012/05/physicians-susceptible-hardball-tactics.html
6.    Berry E. Moody’s: Ending health reform would hurt for-profit hospitals,.amednews. April 24, 2012. Available at: http://www.ama-assn.org/amednews/2012/04/23/bisd0424.htm
7.    Morgan D. Healthcare access to erode if law struck down: study, May 07, 2012.  Available at:  http://articles.chicagotribune.com/2012-05-07/news/sns-rt-us-usa-healthcare-accessbre8460zs-20120507_1_healthcare-law-health-insurance-health-coverage
8.    Levey NN. What would Romney offer? Los Angeles Times. April 23, 2012. Available at: http://www.latimes.com/health/la-na-romney-healthcare-20120423,0,2324970,full.story
9.    Daly R. Medicare hospital trust fund insolvency date remains 2024: Trustee stresses uncertainty of Medicare projections, Modern Healthcare. April 23, 2012. Available at: http://www.modernhealthcare.com/article/20120423/NEWS/304239943/
10.    Pallarito K. Americans support Medicare reform, but not on their dime: poll. HealthDay. April 26, 2012. Available at: http://health.usnews.com/health-news/news/articles /2012/04/26/americans-support-medicare-reform-but-not-on-their-dime-poll
11.    Pecquet J. Report calls for doubling nation’s public health spending, The Hill.Com. April 10, 2012. Available at:  http://thehill.com/blogs/healthwatch/public-global-health/220769-government-report-calls-for-doubling-nations-public-health-spending
12.    IMS Institute for Healthcare Informatics.  Press release: Real per capita spending on US Medicines grows 0.5 percent.  April 4, 2012. Available at:  http://www.imshealth.com/portal/site/ims/menuitem.d248e29c86589c9c30e81c033208c22a/?vgnextoid=81c63fc68b876310VgnVCM10000076192ca2RCRD&vgnextchannel=3e382115cc4be210VgnVCM10000071812ca2RCRD&vgnextfmt=default