There are lies. There are damn lies. Then there is the stuff that Blue Cross Blue Shield of North Carolina (BCBSNC) puts on its website.
Someone had to speak scientific truth to the flat earth society that is BCBSNC and, to his great credit, one very busy neurosurgeon did exactly that.
His name is Domagoj Coric, M.D., and he’s the President-elect, Southern Neurosurgical Society and Chief of Neurosurgery for the Carolinas Medical Center. It takes a lot to get Dr. Coric off his schedule. But Blue Cross Blue Shield of North Carolina—which has been positively toxic to spine surgeons over the past few years—did it.
“If I don’t advocate for my patients, who will? The insurance companies?” said Dr. Coric when we called him. “We saw this new commentary on the Blue Cross Blue Shield website and we realized that we had to do something. It was inaccurate, misleading and, I think, biased in a way that hurts patient care. Insurance companies seem to be taking a ‘whatever we say goes’ position and I felt that I had to respond on behalf of my patients.”
So Dr. Coric wrote a letter. A phenomenal letter. Here it is:
May 20, 2013
Don W Bradley, MD
MHS–‐CL
Vice President for Healthcare and CMO
Blue Cross and Blue Shield of North Carolina
P.O. Box 2291
Durham, NC 27702
Dear Dr. Bradley:
I am writing you on behalf of International Advocates for Spine Patients (IASP) as well as the patient population of North Carolina. IASP is an organization supported by physicians and patients dedicated to advocacy for high quality, widely accessible and cost effective spine care for patients around the world. I am on the Board of IASP (a sister organization to the International Society for the Advancement of Spine Surgery—ISASS) which was formed in 2011 to complement ISASS’ educational and scientific mission through direct advocacy efforts on the behalf of spine patients. I have spent the last 30 years in NC, generally working in healthcare or related fields. I have been in Charlotte for the last 15 years at Carolina Neurosurgery and Spine Associates and Carolinas Medical Center. I am a past-President of the NC Spine Society, President-Elect of the Southern Neurosurgical Society and currently Chief of Neurosurgery at Carolinas Medical Center.
I have also been the Principal Investigator on eight FDA Investigational Device Exemption (IDE) trials utilizing artificial discs and have been an author on eight peer-reviewed publications on cervical and lumbar arthroplasty.
I am writing to express serious concerns about numerous factual inaccuracies and omissions on the Blue Cross Blue Shield of North Carolina “Let’s Talk Cost” web site.
This site is troubling for several reasons:
First, although the web site touches upon the very real problem of unsustainable increases in the overall cost of healthcare and enumerates several important cost drivers in our system—including unnecessary care, medical errors and inefficient delivery—the content conspicuously avoids describing the substantive value created by many novel devices and procedures. Furthermore, the web site seems designed to perpetuate a simplistic and misleading viewpoint that the resources used to routinely improve the lives of patients do nothing other than add burden to an already overtaxed healthcare system. Relatively little attention is focused on industry-related cost drivers including lack of price transparency, excessive administrative costs and premium increases beyond the average annual inflation rate.
Second—and of prime importance to the patients of North Carolina—is the inclusion of frank misinformation about medical technologies specific to spine care. I refer, specifically, to information contained at: http://connect.bcbsnc.com/lets-talk-cost-2013/the-cost-problem/drugs-technology/posts/cause-costly-technology/—stating that, ‘in some cases, new technology has proven to be less effective. Cases in point: expensive but ineffective artificial spinal disks.’ The only reference provided by the BCBSNC web site for this erroneous statement cites a 2008 article from the New York Times (hardly a primary source of credible medical literature).
Perhaps it would be of greater value to cite some of the latest scientific, peer-reviewed literature, including the following:
- There have been exactly 6 US FDA IDE studies of artificial discs (4 cervical and 2 lumbar) whose results have been published in peer-reviewed literature. These studies represent Level I scientific data from multi-center, prospective, randomized trials. Not a single study end point has shown artificial discs, or total disc replacement (TDR), to be ‘ineffective’. In fact, the exact opposite was demonstrated. The statistical design of these studies was ‘non-inferiority’ comparing artificial discs to fusion. But, on numerous individual clinical and radiographic end-points, artificial discs were found to be statistically superior. For instance, Mummaneni et al (2007) showed statistically higher neurological success for artificial disc (93%) compared to anterior cervical discectomy and fusion (ACDF) (84%). Heller and associates (2008) showed statistically greater improvement in disability and greater overall success (83% versus 73%). Murrey et al (2009) demonstrated statistically significant fewer secondary surgeries in artificial disc patients (1.8%) compared to ACDF patients (8.5%). Coric et al (2011) showed statistically significant superior overall success rate (85%) compared to ACDF (71%). Interestingly, both Murrey and Coric were the highest enrollers in their respective studies and both included patients exclusively from NC.
- Numerous biomechanical and clinical studies have firmly established that artificial discs maintain motion and place decreased stresses on adjacent levels.
- A common early criticism of the artificial disc scientific literature is a relative lack of data with long-term follow-up. Yet, that data is now available. Burkus et al (2010) reported 5-year results which showed statistically higher rate of disability improvement and lower rate of reoperation for artificial discs at 5-year follow-up. Delamarter and associates (2010) demonstrated statistically higher rate of pain satisfaction scores at all time points as well as statistically lower rate of index level surgery for TDR at 4-year follow-up. Zigler et al (2012), also at 5-year follow-up, showed TDR patients with significantly less neck pain intensity and frequency as well as a lower probability of secondary surgery. Garrido (also a NC surgeon) and co- authors (2010) demonstrated continued efficacy of cervical artificial disc at 4-year follow-up. Recently, our group at CNSA (2013) published our long-term experience of NC patients which showed, in both TDR and ACDF patients, statistically significant improvement in disability and pain scores by 6-week follow-up which was maintained from 4- to 8-year follow-up.
- Recently, Delamarter and Zigler (2012) specifically addressed re-operation rates for cervical artificial disc patients and concluded, ‘5-year follow-up of a prospective RCT revealed 5-fold difference in re-operation rates when comparing ACDF treated patients (14.5%) to TDR (2.9%). These findings suggest the durability of TDR, as well its potential to slow the rate of adjacent level disease.’9 Additionally, Upadhyaya and associates (2012) completed a meta -analysis of over 1200 patients, which showed statistically lower adjacent level re-operation rates for artificial discs.
Also interesting to note, the reimbursement for surgeons performing disc arthroplasty is lower than that for fusion surgery (at least based on Medicare’s RBRVS system, which is replicated by nearly all commercial payers). In fact, several national insurers (including Aetna, Cigna, United Healthcare and Humana) cover cervical artificial discs and NC surgeons, such as myself, continue to implant them despite surgeon reimbursement rates ~30 – 70% less than comparative ACDF. This certainly begs the question, if artificial discs are ‘ineffective’ as described by the BCBSNC website, why are there multiple FDA approvals (eight overall, three in the last year alone), why are several other large insurers providing coverage for them and why are surgeons implanting them despite a significant pay cut to do so?
BCBSNC is certainly entitled to hold its own opinion of artificial discs, despite a preponderance of scientific evidence to the contrary, but it is simply inaccurate and misleading to represent that opinion as fact on a public web site. Furthermore, while it is BCBSNC’s prerogative to deny their patients access to new technology, it is inappropriate to mask that choice by incorrectly labeling artificial discs as ineffective.
We request that BCBSNC immediately delete this misleading and outright inaccurate information from your web site. Since this is a patient care related issue, Wayne Goodwin, Commissioner of NC State Department of Insurance, has also been copied. We welcome any open and constructive dialogue concerning this specific topic and coverage determinations for artificial discs in general.
Please contact me if I can provide any further information or clarification.
Sincerely,
Domagoj Coric, MD
IASP Board Member
President-elect, Southern Neurosurgical Society
Chief of Neurosurgery, Carolinas Medical Center
Carolina Neurosurgery & Spine Associates
Charlotte, NC
cc: Mr. Wayne Goodwin, Commissioner
North Carolina Department of Insurance
430 N. Salisbury Street
Raleigh, North Carolina 27603-5926
Paul Slosar M.D., put Dr. Coric’s letter out to his circulation list calling the letter “remarkable”. Dr. Richard Guyer, President of TBIRF emailed Dr. Coric saying: “Dom…you set the example for all of us!!”
No Response, So Far
As for Blue Cross Blue Shield of North Carolina—there has been no response so far.
We note that Dr. Coric could have also mentioned Dr. Paul McAfee’s CPM studies (1, 200 patients) or Dr. Frank Phillip’s recent metastudy of spine fusion studies. The issue isn’t evidence. There is substantial and overwhelming scientific evidence supporting both fusion and disc replacement for the appropriate patient populations.
The issue is bias at the insurance company level. Even hypocrisy.
Bottom Line
No pun intended, but patients are the lifeblood for every medical practice. Insurance companies come as part of the patient package. What drives physicians up the wall is when they have to fight insurance companies like Blue Cross Blue Shield of North Carolina to do the right thing. Aren’t patients also insurance company customers?
To his credit, Dr. Coric looks at this problem from all sides. Insurance is part of the patient package. So, in Coric’s view the answer is to work collaboratively with BCBSNC. And to recognize that the insurance company perspective is not the same as his.
Most insurance company customers are healthy. All of Dr. Coric’s customers are not healthy. So the insurance company bias is toward their healthy customers—and to keep premiums low. By contrast, Dr. Coric’s customers spend those insurance company premiums.
The bottom line? According to Dr. Coric, insurance companies must work collaboratively with their physicians not only on behalf of patient’s welfare, but to also keep costs in line so that the healthy customers are served as well.
And, for God’s sake, get the science right.
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To see references for all studies mentioned in this article Click here.
