Curiouser and Curiouser! The Disconnect Between the Burden and Costs of Spine Care in the U.S.: Commentary on an article by Hyunkyu Ko, PhD, et al.: "Is Discretionary Care Associated with Safety Among Medicare Beneficiaries Undergoing Spine Surgery?"

Abstract

Commentary The cost of spine care in the U.S. is remarkable and growing. Between 1996 and 2016, the annualized rate of change for low back and neck pain expenditures was 5.3%, with $134.5 billion spent in 2016, representing the largest expenditure for any single condition. Over the same period, self-reported spine health was unchanged. Together, these data raise questions about the effectiveness and necessity of the spine care being provided. The challenge with such high-level data is that they represent an average across the population and do not tell us whether, buried in those averages, there are patients who benefit—or do not benefit—from the indisputably large sums of money that we spend on spine care. Peeling back that onion, we know that there is wide geographic variation in the utilization3 and cost4 of spine surgery. In this issue of JBJS, Ko et al. peel the onion back a bit further, finding no relationship between 90-day episode costs of spine surgery and illness severity, age, or pricing among Medicare beneficiaries. Using a novel application of the Centers for Medicare & Medicaid Services (CMS) End-of-Life Inpatient Care Index as a proxy for discretionary care, the authors found no association between discretionary care and adverse events (including mortality, all-cause readmission, pulmonary embolism, and deep vein thrombosis) after spine surgery. Collectively, these studies suggest that health-care resources may be used inefficiently in the management of spine diseases. However, we do not have direct evidence because we do not routinely collect and/or report the data elements that would be needed to make this determination. Knowledge about whether patients have clinically meaningful improvement in their health as a result of the many different surgical and non-surgical modalities used to treat spine disease is critical to understanding whether spending for spine care is valuable. Routine collection of patient-reported outcome measures (PROMs) as a standard of care, and reporting of whether patients achieve improvement or an acceptable health state based on PROMs, would go a long way toward answering this question5. CMS has signaled its intention to measure PROMs in the future6,7, and, to that end, has contracted the National Quality Forum to develop a “roadmap from patient-reported outcome measures to patient-reported outcome performance measures”—essentially a “how to” guide for measure developers so that they can develop more PROM-based quality measures. Related to spine care, several PROM-based quality measures are now included in the Merit-Based Incentive Payment System measure set for spine procedures. Based on these communications and actions by CMS, we should anticipate public reporting of PROMs in Hospital and Physician Compare and perhaps reporting to CMS as a requirement to participate in CMS-sponsored episode-payment programs. Such PROM data could be combined with existing safety and cost data to understand the value of health care and ultimately develop a rational value-based reimbursement framework. Comprehensive, user-friendly reporting of outcomes, utilization, and cost data, along with national and regional benchmarks, are essential to produce high-value care. Once PROMs are routinely reported, objective evidence about the relative real-world effectiveness of different approaches to spine disease will drive shifts toward more effective care regardless of payment mechanisms. Shifts from inefficient utilization likely will require both reporting and a financial incentive. CMS currently shares useful utilization information to various health entities, including hospitals, through its Program for Evaluating Payment Patterns Electronic Report (PEPPER) on a quarterly or annual basis. More detailed reports and, in some cases, datasets are available to health entities that participate in CMS episode-payment programs. Expansion of these sorts of reports to more procedures, providing additional utilization detail for all procedures, and making these types of reports available to physician groups would enable providers to identify and act on value opportunities. My sense is that much of the spine surgery being done in the U.S. is appropriate and beneficial to patients. That said, a large and growing body of literature, including the study by Ko et al., demonstrates large variations in utilization, suggesting that a fair amount of this care is of greater intensity than needed or possibly inappropriate. We will gain certainty only with the routine measurement of PROMs. Value creation will occur when outcomes, utilization, and costs are routinely measured and reported to providers, purchasers, and consumers.