In an effort to improve patient access to appropriate, evidence-based care, the North American Spine Society (NASS) recently released detailed policy recommendations for coverage of 13 common spine care treatments, procedures and diagnostics.
The first-of-their-kind reference documents outline when it is … and when it is not … appropriate to utilize each of the options based on an extensive review of current literature by a multidisciplinary team of experts.
William Watters, MD, president of NASS, said, “Maintaining patient access to high-quality, evidence-based and ethical spine care is the single most important part of NASS’ mission. It is our hope that payers, spine specialists and their patients will use these evidence-based coverage recommendations as a reference to advocate for appropriate care for patients.”
Watters added the society was uniquely positioned to take the lead on such an extensive project because of the multispecialty nature of the organization, which includes the expertise of surgeons and allied health professionals. “We cover the full spectrum of spine care,” he noted.
Watters, who is a board certified orthopaedic surgeon in private practice at the Bone & Joint Clinic of Houston and a clinical associate professor at both the University of Texas Medical Branch in Galveston and Baylor College of Medicine, said the society already had experience weighing the evidence at the request of physicians, patients and payers. “NASS began a number of years ago becoming involved in third party payer coverage decisions,” he noted. However, he continued, the turnaround time was often tight and the number of studies to consider extensive.
“We decided to proactively create our own coverage decisions based on the best evidence available … and where evidence was lacking, based on the expertise in this group,” he explained. “We came up with what we feel is the most sound group of recommendations based on the best evidence available at this point and time.”
Watters continued, “One of the hopes that we have is that we bring a bit of uniformity to the whole process of spinal care.”
Christopher Kauffman, MD, health policy council director for NASS, concurred. He said allowed treatments and diagnostics vary by state and by payer. These recommendations outline the scope and clinical indications for a therapeutic measure when a patient meets appropriate inclusion criteria. They also clearly state scenarios in which employing the measure is not indicated.
While not recommending payers reimburse for every procedure under every circumstance might be controversial among some providers, Kauffman said, “People who understand where medicine is going with outcome measures get it. So far, the response has been overwhelmingly positive.”
He added, “People may confuse coverage with medical appropriateness. The two are not equal. People assume payment equals medical appropriateness. I can’t stress enough this isn’t true. Payment equals treatments where the literature has reached a certain bar of evidence.”
Kauffman, a board certified orthopaedic surgeon in practice at Premier Orthopaedics in Nashville, said, “For everything we recommend, we think the evidence does reach the bar for coverage. This is what we think should be covered by any payer.”
However, he continued, it doesn’t mean other treatments being employed don’t have therapeutic benefits. “You can’t ever throw out the art of medicine.” Yet, Kauffman noted, “If you’re falling outside the clinical guidelines, you have to expect that you’re going to do a peer-to-peer review, or it might not be a covered service.” He added the recommendations would be routinely revisited to incorporate new evidence.
In addition to the 13 coverage policy recommendations published in May, Watters said NASS is already in process or planning to create documents for 14 additional diagnostic and therapeutic modalities including annular repair, cervical and lumbar radiofrequency neurotomy, cervical fusion, cervical laminectomy and laminoplasty, minimally invasive lumbar fusion, SI joint fusion and injections, DNA-based scoliosis test and electrical stimulation for bone healing, among others. “The remainder will be released within a year,” he said.
“The plan is to reassess the literature at least every two years,” he continued, emphasizing the need to stay current as new studies are published and new treatment options become available. “This has to be a living document.”
He added it’s a nearly impossible task to ask physicians, surgeons, nurses, therapists and other providers to wade through all the literature required to practice evidence-based, contemporary medicine. Having the committee go through the best, most soundly crafted studies to create each of the 5-30 page recommendations, which include supporting details behind the rationale and a thorough list of references, simplifies the process for practitioners and their patients. “These turned out to be remarkably educational documents,” Watters stated.
Both Kauffman and Watters stressed at the end of the day, the coverage recommendations are an effort to ensure patients have equal access to the best possible treatments.
“It’s making sure that good spine care is available for patients across the U.S.,” Kauffman concluded.
Coverage Policy Recommendations
To access the documents for each of the procedures listed below, go online to www.spine.org and click on the “Policy & Practice” heading.
Cervical artificial disk replacement
Endoscopic discectomy
Epidural cervical spinal injections
Interspinous device without fusion
Interspinous fixation with fusion
Laser spine surgery
Lumbar artificial dis replacement
Lumbar discectomy
Lumbar fusion
Lumbar laminotomy
Lumbar spinal injections
Percutaneous thoracolumbar stabilization
Recombinant human bone morphogenetic protein (rhBMP-2)
RELATED LINKS:
Direct link to policy pages:
https://www.spine.org/Pages/PolicyPractice/Coverage/CoverageRecommendations.aspx
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