Studies have shown that Medicare and VA (Veterans Administration) patients receive a large number of spinal injection procedures. The report of this pattern of overutilization of spinal injections set this new study into motion. Researchers at the University of Colorado School of Medicine looked for similar patterns of overutilization among privately insured adults.
Spinal injections are used for people with back pain that has not improved with conservative care. Such injections include epidural steroid injections, nerve blocks, radiofrequency neurotomy (heat nerves to stop pain transmission), sacroiliac injections, and discography (injecting dye into the disc to look for disc protrusion or herniation).
There is a concern about this pattern of overuse because research does NOT support this treatment as an effective way to manage back pain. And in the case of spinal injection treatment, more is not better. In other words, if the first three injections didn’t help, further injection therapy isn’t likely to benefit the patient either.
In studies of Medicare and VA patients, the majority of spinal injection procedures were being done by a small number of medical specialists. Anesthesiologists, neurologists, and physicians at specialty pain clinics were the ones most likely to be giving these injections. And the top 10 per cent of providers were responsible for one-third of all spinal injections. Over half of all injections were being given by 20 per cent of all providers.
Similar patterns of overuse were found for privately insured adults between the ages of 18 and 99. Billing codes entered into a national central database were used to calculate how many of each type of spinal injection were given to each patient over a 12-month period of time.
Ten per cent of all injections were given by the same providers (neurologist and pain management specialists). This group of physicians did nine times as many procedures per patient than providers in the lowest 10 per cent group. And more than half of all spinal injection procedures were done by 20 per cent of the providers who did these kinds of injections.
This was not a small study. There were 200,000 patients, 20,000 physicians, and over 875,000 injections given. Besides the groups already mentioned (anesthesiologists, pain management specialists, neurologists), other types of providers giving spinal injections included orthopedic surgeons, radiologists, internal medicine physicians, neurosurgeons, physiatrists, and family practice physicians.
When Medicare saw there was an overutilization of spinal procedures, the response was to pay closer attention to claims submitted. They also cut reimbursement for these procedures. The authors of this study raise the same question for private insurance: what should be done to cut back overuse of spinal injections when research doesn’t show this treatment is effective?
First, it is important to remember that all high utilization doesn’t necessarily mean overuse. There may simply be some physicians who are so skilled at this treatment that patients do get better. They spread the word and before you know it, more patients are going to the same physicians. But there is a way to find out if this is really what is happening.
And this study sheds light on the subject. By showing who is doing how many procedures and then evaluating the results, it is possible to see that this isn’t the case. It looks more like a certain group of physicians are using spinal injections to treat more people than should be included (based on evidence of who is a good candidate for this procedure). It is also possible (though not proven yet) that these same providers are accepting less than optimal results. And profit can certainly be a strong motivator for some physicians.
That brings us back to the same question. What can be done about this pattern of overutilization of spinal injection procedures? Guidelines for the responsible use of injection spine procedures must be published based on high-quality evidence. Such guidelines would give physicians a standard by which to guide treatment decisions. Insurance companies could also use the guidelines to base reimbursement on.
That sounds simple enough but what may be excessive for one patient may be just right for another. Some insurance companies have set some limits and restrictions (e.g., only covering four injections in a six month period).
Until major guiding organizations such as the North American Spine Society can give more than suggestions for the use of spinal injections then perhaps treatment can be guided by practice consensus (best opinions of current experts based on current evidence).
If physicians do not follow the “best practice” guidelines, then insurance companies should look their claims over more carefully. If there are no special patient circumstances to justify the increased use of spinal injections, then coverage for the extra injection procedures would be denied. Likewise, denial of coverage for services is suggested if there are not significantly improved clinical results. And because one provider might be performing a broad range of spinal injection procedures under the same billing code, cases should be reviewed individually.
The authors conclude that policy makers must be very careful with the information provided in their study. It would not be in the best interest of patients to rush in and cut and slash services — especially if those services (i.e., spinal injections) are helping someone in pain. It may be too soon for aggressive regulations. But certainly when a small number of physicians are providing a large number of treatments that have not been shown effective, it’s time to target those cases and take a closer look.