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

Low back pain (LBP) is prevalent being the fifth most common reason for physician visits and the most frequent discomfort experienced by adults in the US.1,2 Concern has increased that surgery, specifically lumbar fusion, is overutilized. In a study involving the Nationwide Inpatient Sample database, total lumbar fusions increased 356% from 1993 to 2001.3 In evaluating lumbar fusions for degenerative disease, rates increased from 3.20/100,000 in 1993 to 21.07/100,000 in 2001. A similar trend was noted in the Medicare population with lumbar fusions increasing from 0.3/1000 in 1992 to 1.1/1000 in 2003.4 In the same investigation, assessment of regional differences in lumbar fusions showed greater than 20-fold variability, suggesting inconsistent surgical criteria. Although limitations of administrative data and other factors could have impacted analysis, the high degree of variability raises concerns for surgery overutilization, as exact indications for when fusion is appropriate remains controversial. Some label LBP surgery a so-called low-value service, as an apparently anecdotal axiom is surgical outcomes are 33% improved, 33% worsened, and 33% were unchanged.5,6 A Cochrane Collaboration review through March 2005 offered no clear guidance.7 Another review through July 2008 concluded that surgery may not be more effective than “intensive rehabilitation” for one situation but was not the case when compared with “standard (nonintensive)” nonsurgical treatments, with evidence supporting surgery for other circumstances.8 To address concerns over back surgery overutilization, Priority Health (PH), a West Michigan based health plan, began requiring in November 2007 that members be evaluated at a health plan approved “spine center of excellence” (SCOE) led by a physiatrist—a physical medicine and rehabilitation specialist—before a spine surgeon referral.9,10 According to a published analysis of PH's program, when this requirement was initiated PH's back surgery rates were above the 90th percentile per the National Committee for Quality Assurance's (NCQA) Quality Compass (a registered trademark of the NCQA) and concluded mandatory physiatrist evaluation resulted in decreased surgical rates while maintaining patient satisfaction.11 Starting December 2010, the study health plan (SHP), a health plan different from PH functioning as a Health Maintenance Organization (HMO), implemented a similar policy. Our objective was to examine the impact of mandatory physiatrist consultation before spine surgeon referral in a non-Medicare population. Specifically, changes in lumbar spinal fusion rates as well as changes in utilization and costs of pre-surgery care with implementation of SHP's PA programs.