NASS Aims for Transparency in Spine Care

A multidisciplinary medical task force of the North American Spine Society is recommending best clinical practices for more than a dozen spinal treatments, surgical procedures, and diagnostics. The information is being shared with health plans.

The North American Spine Society is seeking to boost transparency in spine care, with a set of new insurance coverage policy recommendations.

"These are coverage recommendations that have been vetted extensively," says Christopher Bono, MD, an orthopedic surgeon and second vice president of NASS.

The recommendations, released this month, cover 13 treatments, surgical procedures, and diagnostics, such as cervical artificial disc replacement (CADR) and lumbar fusion. They include clinical criteria that indicate whether or not a particular kind of spine care is indicated for a patient with specific diagnoses and symptoms. NASS is expecting to release 14 more coverage policy recommendations.

The Burr Ridge, IL-based organization's coverage task force, which helped craft the recommendations featured "the whole gamut" of spine health professionals including surgeons and radiologists. "It's a product that's different than anything NASS has done before," says Bono.

The chief of spine service at Brigham and Women's Hospital in Boston, Bono says improving transparency in spine care is a top goal of the NASS recommendations. "The status quo has been insurance companies developing their own coverage policies," he said, characterizing NASS's traditional role in the process as reactive. "NASS would see a draft and it was not always clear how the policies were set."

A key directive to the NASS coverage task force was to apply the principles of evidence-based medicine. "For most things that we do, fair coverage will be based on published data," Bono says.

In the past, when the evidence was not available or not clear, the task force followed the "reasonable man theory" of the US justice system as its guide. "We tried to strike that balance on those procedures where data was absent," he said. "We tried to present what a reasonable spine surgeon would think is appropriate."

For example, the NASS recommendations portray cervical artificial disk replacement as an "emerging/emerged technology" that appears capable of achieving results similar to cervical fusion procedures.

"Though not currently to be considered the standard of care for treatment of degenerative cervical disorders, [CADR] has shown promising results in the available data, indicating at least equivalence to cervical fusion following adequate decompression," The NASS guidelines say.

Bono said it will take time for the NASS recommendations to have an impact in the marketplace. "I would anticipate this is a five- to ten-year project," he said. "It's going to take multiple patients and multiple years to see if this makes a difference."

The Boston-based surgeon says early contacts with payers about the recommendations have been encouraging. NASS shared the organization's lumbar fusion recommendations with United Healthcare officials about seven months ago. "The feeling was quite positive," he said. "They made some requests to make it more useable."

Another payer, Cigna, is also weighing in on the NASS recommendations. David H. Finley MD, Cigna's national medical officer for enterprise affordability and policy, says the NASS guidelines should help the insurer set insurance coverage guidelines.

"Cigna appreciates the recommendations from NASS and will take them into consideration," he said. "Most of Cigna's coverage policies are reviewed annually and our decisions are based on a thorough study and analysis of the latest scientific evidence. We also consider guidance from medical societies."

Joseph Gregory, a surgical devices analyst at London-based GlobalData, says the NASS recommendations are a positive contribution to the spine surgery field, which has drawn scrutiny over explosive growth in spine fusion procedures. From 2002 to 2011, the annual number of US spine fusion procedures increased 77 percent, rising from 260,000 surgeries to 460,000, according to the federal Agency for Healthcare Research and Quality.

"They're a fantastic initiative by NASS," Gregory says of the new recommendations, adding the International Association of Spine Surgeons has released similar guidelines to "promote education on payment."

Gregory, who has been working on a spine fusion report that GlobalData is set to release soon, says the "The level of detail [in the NASS recommendations] is really great. "The breadth is definitely there."

In a prepared statement released with the spine care coverage recommendations, NASS President William Watter III, MD, MMS, MS, said better guidance is needed in the field for several reasons. "Maintaining patient access to high-quality, evidenced-based and ethical spine care is the single most important part of NASS' mission," he said.

"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."