At the recent Innovative Techniques in Spine Surgery meeting in Los Cabos, Mexico, spine surgeons on a panel were complaining about insurance companies.
That’s not newsworthy.
The speakers at the Drs. Frank Phillips, Todd Albert and Alex Vaccaro meeting were speaking in general terms about insurance company reviewers denying surgeons’ requests for spine procedures as a matter of course. The speakers obviously were preaching to the choir, receiving lots of nodding heads from their colleagues in the room.
One lone voice spoke up.
“Not so, ” said the lone voice belonging to Gaetano Scuderi, M.D.
Gaetano Scuderi, M.D.
“I’m a spine surgeon and a reviewer for insurance carriers. I can tell you that I routinely approve spine procedures if the surgeon provides the information required to let me see that the procedure is in the best interest of the patient.”
The exchange and ensuing conversation between the surgeons was a vivid reminder of why, in spite of frequent complaints that there are too many spine meetings, there is a need for surgeons to meet and share their experiences.
The science of spine care is unsettled. The opportunity for surgeons to learn from Scuderi, their colleague reviewing their requests to get insurance coverage for a procedure for their patients, only moves the science along and benefits individual patients. It just shows that more opportunities for spine surgeons to get together should be encouraged.
New Era of Decision Making
“We are entering a new era, ” Scuderi told OTW. “Peer review and evidence-based medicine are increasingly being factored into the decision making process. Cost containment, while providing value for services, is becoming the norm. For too long we have accepted irrational disbursement of medical care. Recall bias and errors by physicians cause more mishaps and deaths monthly than 9-11. Doctors are fast no longer becoming the captain of the ship—except when he or she gets sued—and even there that argument has worn thin.”
“The new era I am talking about refers to the difficulty in getting ‘fusions’ approved following traditional discectomy or laminectomy. More data has been published showing no significant improvement over conservative care, and fusion is very expensive. Unless someone can show increased work capacity or earlier RTW (return to work), to justify the added cost, this will be increasingly difficult.”
Scuderi brings some gravitas to his comments. He’s a Clinical Assistant Professor at Stanford University, a Diplomat of the National Board of Medical Examiners, holds four patents, including one on biomarkers and methods for detecting and treating spinal pain. Scuderi has also published 35 articles that include physician coauthors named Garfin, Vaccaro and Carragee.
He’s also been an orthopedic reviewer for 15 years and performs reviews for several local and national companies. They include medical insurance companies, auto insurance and contract review companies.
“Often it is difficult to assess the treating providers’ thoughts based upon the file and charts that I receive. Physicians are not adept note takers and often don’t use accepted medical language that will prompt simple approval. My goal is to consider what the best care is for the patient. I try to do my best in determining if a patient will derive a clinically significant benefit from a recommended intervention.”
“My perspective is that the insurance companies are just trying to obtain the best outcome for intervention. Increasingly they are turning to evidence-based medical outcomes, though there isn’t much in the landscape.”
Spine Surgery Influence Model
One of the examples on the landscape is the Spine Surgery Influence Model put into effect on March 22, 2010, by UnitedHealthcare in Arizona, California, Colorado, Missouri, Ohio, Texas and Wisconsin, effective March 22, 2010.
The model is intended to improve the quality and consistency of care for patients who are undergoing inpatient spinal procedures through the use of evidence-based guidelines, review of medical records and peer-to-peer discussions of selected cases. The process is not a precertification, preauthorization, or medical necessity determination.
The insurer says the process will be used as an educational program to “promote physician discussion around providing spinal care consistent with nationally developed guidelines.” The insurer also says that the application of this model is, “expected to result in a reduction of unnecessary spine surgeries.”
The model leverages existing notification requirements and processes to compare the planned procedure to predefined criteria established by North American Spine Society Guidelines (NASS) and Milliman CareGuidelines to determine adherence with guidelines for the planned inpatient spine surgery.
Inappropriate Procedures
Cases found to be inconsistent with guidelines will be reviewed by licensed staff using requested medical records. If the secondary review of the case does not demonstrate adherence to the guidelines, a health services medical director will engage the surgeon in a peer-to-peer discussion to better understand the therapeutic decision made for the patient. The surgery will be covered regardless of the outcome of this medical review process.
The request for medical records and/or a peer-to-peer discussion is triggered by the receipt of a notification from a physician for an inpatient spine surgery that is considered “potentially inappropriate, ” by the NASS and Milliman guidelines.
The initial reason the procedure may be considered “potentially inappropriate” could be due to limited information contained in the notification. The request for records is to obtain more detailed information as suggested by evidence-based guidelines, and to determine whether a peer-to-peer discussion should occur. While UnitedHealthcare facilitates this discussion, the insurer says the ultimate decision about appropriate treatment is still in the hands of the physician.
No claims payment reductions will take place, even if the procedure is found to be inappropriate during the notification process, or if there is lack of participation in clinical record submission and/or peer-to-peer discussion.
Lessons From the Reviewer
Scuderi says the current treating provider often has no idea of what was done in the past, what did and did not work, what co-morbid conditions the patient may have that would preclude a particular surgery or intervention that might put the patient at risk.
“Sometimes there is a lack of knowledge on what the peer-reviewed research informs on a specific intervention. Physicians need to be aware of current literature and if they are recommending something outside usual parameters, be ready to justify their decision-making process, ” says Scuderi.
According to Scuderi, surgeons commonly use the PA (physician’s assistants) or ARNP (advanced registered nurse practitioners) to do the initial evaluation. The surgeon on the next visit sees the patient personally and for the PMH [past medical history] portion states “See Past History” or “See Medications” without ever having consulted these data.
“As a reviewing doctor it is not uncommon for me to know more about the patient than does the treating doctor, ” added Scuderi. “When I speak to the treater and inform him/her of co-morbidities, or that what the patient had is uncommon to what the physician recommended previously, the reply many times is ‘Oh. I did not know that. Then that changes my opinion about what should be done. Thanks for telling me.’”
Physician’s assistants, as well as advanced registered nurse practitioners, commonly see and screen patients, or at the very least write the notes or dictate for the attending physician. Scuderi notes that these individuals are usually not familiar with important phrases in getting a treatment approved.
Scuderi’s advice highlights why it is key to keep in mind what is being submitted and tailor notes in a way to suit the reviewer.
Confession
But sometimes even a review pro hits a snag.
Recently Scuderi was the subject of a review for a procedure that was subsequently denied. “I probably did a poor job in communicating my intentions and rationale to the physician reviewer and subsequently the intervention was denied. A written appeal thoroughly outlining my justification led to a successful outcome.
“In retrospect, I should have included my thought process into my original surgical recommendation which probably would have obviated the process.”
Documentation is very important to reviewers. Scuderi says reviewers are looking to save the treating physician’s time and prevent unnecessary delays in patient care. If proper documentation describing the necessity of an epidural injection, for example, describes a positive SLR test and dermatomal pattern consistent with a disc herniation finding on MRI, then it is likely to be approved.
“Contrarily, a disc bulge identified on an imaging study together with a lack of any specific findings and no tension signs and the complaint of primarily low back pain will likely lead to reviewer denial of a proposed epidural injection, ” Scuderi warned.
The Discography Hotbed
A current hotbed, according to Scuderi, is in the area of spinal fusion surgery, where surgeons are required to document the necessity of stabilization following a procedure.
“With current evidence on discography quite negative, (long-term complications, accelerated degeneration and failure of this diagnostic modality to improve outcomes of fusion), reviewers are increasingly denying this diagnostic! We need the AAOS/NASS to step up and coordinate a multicenter study (especially from big volume centers) to show carriers the utility of these interventions. Maybe the answer is in the high volume centers, like they found in cardiac surgery and hip replacement surgery, ” concluded Scuderi.
Scuderi may have been a lone voice in Los Cabos, but he’s worth listening to.
