Spine Symposium 2017

ACA Success

ACA Exchanges Possible Yearly Expenses: $24,213 3 Levels of Coverage: Gold, Sliver, Bronze Silver Plan 2016, Family of 4 Premium - $9,913 Out-of-pocket Expenses - $14,300 Family of 4 earn more than $61,000 / yr (250% FPL) Possible Yearly Expenses: $24,213 62% of all personal bankruptcies due to medical expenses. 78% had health insurance. OOP Expenses very regressive – African continent instituted user fees in 1987, based on single study by world bank, as a means of increasing revenue. Resulted in poor not seeking care, explosion of AIDs, Malaria and diarrheal diseases. When user fees abolished – poor seeking care jumped dramatically. As OOP expenses increase – more will shift to governmental plans – further increasing governmental costs and crowding out other programs.

Equity Equity = Access to care that is determined by need, not ability to pay. Equity in healthcare is elusive Access to healthcare is a right, not a privilege Societies are judged by how we treat our most vulnerable

Access - Equity Having Health Insurance does not equate to healthcare access.  ”But historically, Medicaid has faced a major challenge — a relatively low rate of physician participation” 62% of all personal bankruptcies due to medical expenses. 78% had health insurance. 2013 and 2014 Medicaid payments doubled for primary care – access for Medicaid patients improved – but was only a 2 year program.

How are we viewed?

You have your own book!

 If the spending plan is enacted, Maine hospitals would lose more than $66 million per year when each of the various cuts are fully implemented. Hospitals in Maine oppose the budget as drafted and urge the Appropriations Committee to oppose it as well.

I’m here from the government, I want to help ACA: Repeal / Replace “The Solution???”

I’m here from the government, I want to help ACA: Repeal / Replace All about who pays – not cost Governmental programs have not reduced spending MSSP - gross savings of $429 million, paid out $646 million in shared savings bonus payments-net loss of $216 million Bundled Payments Cardiac / Joints - cost savings 3% - all attributed to changes in post-acute treatment choices.  Many hospital systems across the country seem to be responding with the purchase of post-acute facilities, as reported by Health Affairs. Spine Bundle - 10% increase in costs compared to traditional fee-for- service. Patient Centered Medical Home (PCMH)-redesign of primary care no cost reductions, no cost savings and no improved quality.

For consumers, cost is still king

% of Population with LBP

Worldwide LBP UK Sweden US work days lost LBP most common cause of disability in young adults more than 100 million workdays lost per year Sweden LBP accounted for a quadrupling of the number of work days lost 7 million in 1980 28 million by 1987 US work days lost 149 million total costs estimated to be US$ 100 to 200 billion a year (of which two-thirds is due to lost wages and lower productivity)

Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs).  DALY = Disability adjusted life year YLD – years living with disbilty

 Spinal fusion is by far the most common spine procedure in the U.S. 87% of spinal procedures in 2013 were fusion-based 465,000 fusion operations in the U.S. in 2011 252,400 fusion operations in the U.S. in 2001

The volume of spine surgery in the U. S   The volume of spine surgery in the U.S. is about double the rate in Canada, Western Europe, and Australia, and about five times the rate in the United Kingdom, Median compensation for U.S. orthopedic spine surgeons in 2012, not including ancillary income, was $730,246, making them the second highest-paid surgeons after orthopedic hip and joint surgeons, That compared with median compensation of $538,533 for all orthopedic surgeons.

According to the Agency for Healthcare Research and Quality, less than 1% of all imaging scans found the problem initial treatment costs were 50% lower when patients were referred to physical therapy, rather than an advanced imaging referral at their primary care consultation.

Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals Prevalence of disk degeneration 37% of 20-year-old individuals 96% of 80-year-old individuals  Disk bulge prevalence 30% of those 20 years of age 84% of those 80 years of age Disk protrusion prevalence 29% of those 20 years of age 43% of those 80 years of age

2015 CMS Charge Master Data 460 - SPINAL FUSION EXCEPT CERVICAL

We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment.

Even though the number of spinal fusions has been on the rise, experts estimate that fewer than half of them are appropriate and research confirms that the same proportion are successful.

What Can Be Done Pathway driven care Decreases variations in care Variation account for up to 30% of unnecessary cost Be Careful who first sees patients When you are a hammer, everything looks like a nail