Evaluating Policy Effects in the Treatment of Lumbar Fusion

Procedure rates and costs for lumbar fusion are increasing, especially for age-related pathology such as spondylolisthesis. The high cost and wide geographic variation makes fusion a common target for state and national payment reforms. The effects of such policy are best understood by summarizing state and national discharge databases, such as the National Inpatient Sample (NIS) and select State Inpatient Databases (SID) made available by the Agency for Healthcare Research and Quality (AHRQ), which include diagnosis and procedure codes. Specific state and insurer programs have halted reimbursement for less certain indications, resulting in decreased utilization and costs. Other initiatives have gone as far as profiling individual surgeons and denying reimbursement to surgeons who they believe provide low-quality care. At a national level, Medicare has attempted to guide practice patterns through their bundled payment programs, even though early findings for spinal fusion suggest that these reforms do not appear to have meaningful impacts on utilization or reimbursement. Other factors, including published evidence, public pressure, and legal investigations, can impact utilization in spine surgery, exemplified by the decrease in use of bone morphogenetic protein-2 following FDA public health notification and deep scrutiny. Quantifying the value of spine surgery requires assessing quality as well as incidence and cost. However, ascertaining meaningful quality measures through the collection of patient-reported outcomes has proven challenging and difficult to fairly compare between hospitals and providers. Modifying patterns of reimbursement and analyzing of the effects of these policies are necessary steps toward improving the value of spinal care.