Medical Groups Take Issue With Insurers' Spine Surgery Rule
December 22 2010 - 5:15PM
Dow Jones News
A collection of nine medical associations is arguing against new
restrictions on spinal-fusion surgery set by a health insurer in
North Carolina amid concerns such restrictions could limit patient
care and spread to other states.
Whether the groups can alter the new rules from Blue Cross and
Blue Shield of North Carolina, which go into effect Jan. 1, remains
to be seen. But the response is evidence doctors are joining forces
to battle ongoing insurance pressure on the spinal-fusion market.
Several spinal device-makers, most recently NuVasive Inc. (NUVA),
have cited signs insurers are raising barriers to such procedures
amid concerns they're over-utilized.
Doctors worry the new policy in North Carolina, which is seen as
particularly restrictive, could further dampen an already slowed
market if it spreads elsewhere.
"We certainly see that once even a local area starts coming up
with these policies, others may start adopting it," said Joseph
Cheng, who directs the neurosurgery spine program at Vanderbilt
University Medical Center in Nashville, Tenn. He also serves on the
coding and reimbursement team for the American Association of
Neurological Surgeons, which co-signed the letter.
The letter was sent last week and also signed by the American
Association of Orthopaedic Surgeons, the Scoliosis Research Society
and the North American Spine Society, among other groups. They said
they "have concerns regarding the criteria and guidelines" in the
new coverage policy, and they proposed less restrictive
language.
That policy includes detailed descriptions of conditions for
which fusion surgery in the lower back should and shouldn't be
covered. In one case, the new policy denies coverage for patients
with degenerative disc disease. There is also new requirement for
prior authorization before patients get surgery.
According to Lew Borman, a spokesman for Blue Cross Blue Shield
of North Carolina, the new policy was reviewed with several spine
surgeons before it was finalized. He also noted that it references
several medical studies. The insurer responded to the letter from
the medical associations in an email and plans to meet with
representatives from those groups in January to discuss their
perspective, Borman said.
"We'll certainly hear out their concerns," he said. He added
that it's too soon to speculate on whether any changes could be
made as a result.
Jefferies & Co. analyst Raj Denhoy said it's a good sign the
doctors' groups banded together to raise issues with the North
Carolina policy, which he called "probably the most restrictive
that has been written thus far.
"What has been missing from the dialogue on insurance push back
of spine procedures is the clinical spine community's response,"
Denhoy wrote in a research note.
-By Jon Kamp, Dow Jones Newswires; 617-654-6728;
jon.kamp@dowjones.com
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