Tuesday, January 14, 2014

2009 - Bad Year to Compare Spine Surgery

A study recently published in the professional journal, Spine, found the rate of lumbar fusions was 47% higher in California than Washington.

Of course the cost is higher per surgery by about 23%, but that's not disconcerting by itself.

What does cause some deliberation is that Californian's undergo fusion for “controversial indications” at a higher rate than similarly situated patients in Washington with 28% of fusions in California for complaints of nonspecific back pain, compared to 21% of the fusions in Washington. About 37% of the procedures performed in California were on herniated discs, compared to 21% in Washington.

“How Do Coverage Policies Influence Practice Patterns, Safety and Cost of Initial Lumbar Fusion Surgery? A Population-Based Comparison of Workers' Compensation Systems,” examined 4,628 patients who underwent an inpatient lumbar fusion for degenerative disease in 2008 and 2009.

Both states use "evidence based medicine" guidelines to regulate medical procedures.

I guess Washington has better evidence? Or are there incentives that existed creating a path to such disparity?

While the study compares and contrasts different procedures and outcomes in the two states, what is most shocking is that injured workers receiving spinal fusions in California were 2.28 times more likely to need a second surgery, 2.64 times more likely to have “wound problems” and 2.49 times more likely to have device complications, as compared to those in Washington.

These are not small margins.

In the meantime, yesterday the California Division of Workers' Compensation held its first meeting on the well publicized "problem" of utilization review and independent medical review volume in Van Nuys yesterday.

Much like the volume of IMR requests, DWC didn't anticipate the volume of people interested in the topic. The auditorium of the Van Nuys State Office Building was filled past capacity, with roughly 150 people attempting to crowd into a room with a maximum occupancy of 117.

There were a handful of injured workers and doctors present and about a dozen attorneys. Most of the audience identified themselves as being claims adjusters or employer representatives.

The meeting, which many thought would be a complaint session, or at least an open forum for discussing UR/IMR backlog and volume, was more about DWC telling everyone that things are working, and for those things that aren't working, they'll be working shortly.

But DWC Medical Director, Dr. Rupali Das, told the audience that the agency next month hopes to release an update to the medical treatment utilization schedule.

The MTUS hasn't been updated since 2009. Other developments have occurred in this time frame that would affect any of the statistics behind the Spine study.

Dr. Gary Franklin, Washington Department of Labor and Industries Medical Director, and one of the authors of the Spine study, said broader lumbar fusion coverage policies such as those in effect in California in 2008 and 2009 were associated with greater use of lumbar fusions, use of more invasive procedures, more follow-up operations, higher rates of complications and greater inpatient costs.

The numbers examined by the Spine study were before attention was brought upon Tri-City Regional Medical Center in Hawaiian Gardens, Pacific Hospital of Long Beach, Michael Drobot, and Paul Randall by the U.S. attorney's office and the Wall Street Journal alleging excessive and unnecessary surgeries to take advantage of the hardware pass-through provisions of the Labor Code.

The Journal reported that Pacific Hospital of Long Beach, owned by Michael Drobot, performed 5,138 fusions between 2001 and 2010, billing workers' compensation carriers $533 million for the procedures. Drobot and Randall worked together from 1998 until 2008, when the two parted ways because of a business dispute and Randall went to work for Tri-City.

I don't think the numbers are any coincidence. My suspicion is that Washington doesn't have any better evidence. The state likely just didn't have as many profiteering incentives.

Friend, fellow blogger and sometime co-panelist at conferences Joe Paduda told WorkCompCentral that "people in California are saying UR and IMR are denying care unfairly to workers. What the Washington research indicates is that, in fact, the lumbar fusions in California are more expensive, there are far too many and they are far more damaging to the claimants than the similar claimant population in Washington.”

I don't think the Washington research says that at all. I suspect that if the Washington study cohorts were geographically isolated we would see significant concentration in the Los Angeles area, and particularly in Long Beach and Hawaiian Gardens...

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