Non-surgeons performing fusions: Why is there exponential growth?

Saturday, May 4, 2024

2:19 PM – 2:24 PM CT

Location: S402ab

Presenting Author(s)

Abraham Dada, BA (he/him/his)

Medical Student
Department of Neurological Surgery, University of California, San Francisco

Co-Author(s)

Joseph Cheng, MD, MS

Frank H. Mayfield Chair of Neurological Surgery
University of Cincinnati College of Medicine
Cincinnati, OH, US
CD

Cecilia Dalle Ore, MD

Resident Physician
University of California, San Francisco
San Francisco, California, United States
Anthony M. DiGiorgio, DO, MHA

Assistant Professor
Department of Neurological Surgery, University of California, San Francisco
San Francisco, California, United States
John Knightly, MD, FAANS (he/him/his)

Vice President
AANS
Cedar Knolls, NJ, US
Praveen V. Mummaneni, MD, MBA

Joan O'Reilly Endowed Professor and Vice Chair of Neurosurgery
Department of Neurological Surgery, University of California, San Francisco
San Francisco, CA, US
Katie O. Orrico, JD

AANS CEO
AANS
Rolling Meadows, IL, US
Arati Patel, MD

Resident Physician
Department of Neurological Surgery, University of California, San Francisco
San Francisco, California, United States
Luis M. Tumialan, MD

Professor of Neurosurgery
Barrow Brain and Spine
Paradise Valley, AZ, US

Disclosure(s):

Abraham Dada, BA: No financial relationships to disclose

Joseph Cheng, MD, MS: No financial relationships to disclose

Anthony M. DiGiorgio, DO, MHA: AOSpine Foundation: Grant/Research Support (Ongoing); DePuy Synthes Spine: Grant/Research Support (Ongoing)

John Knightly, MD, FAANS: No financial relationships to disclose

Praveen V. Mummaneni, MD, MBA: AO Spine: Grant/Research Support (Ongoing); BK Medical: Speaker/Honoraria (Ongoing); Brainlab: Speaker/Honoraria (Ongoing); Depuy Synthes: Consultant (Ongoing); DOD: Research Grant (Ongoing); Globus: Consultant (Ongoing); ISSG: Grant/Research Support (Ongoing); NIH: Research Grant (Ongoing); NREF: Grant/Research Support (Ongoing); Pacira: Grant/Research Support (Ongoing); PCORI: Grant/Research Support (Ongoing); SI Bone: Speaker/Honoraria (Ongoing); SLIP II: Grant/Research Support (Ongoing); Springer Publisher: Royalty Recipient (Ongoing); Thieme Publisher: Royalty Recipient (Ongoing)

Katie O. Orrico, JD: No financial relationships to disclose

Arati Patel, MD: No financial relationships to disclose

Luis M. Tumialan, MD: No financial relationships to disclose

Introduction: Surgical procedures to treat back pain have risen steeply. This study aims to report utilization and expenditure trends.

Methods: Medicare Part B National Summary Data files were used to gather annual utilization and Centers for Medicare and Medicaid Services (CMS) payments data for back pain interventions from 2000-2021. Healthcare Common procedure Coding System (HCPCS) codes were grouped as laminectomy, spinal fusion, SI-joint fusion, epidural steroid injections (ESI), physical therapy (PT), and chiropractic manipulation (Chiro). The total allowed services and payments were collected for each HCPCS group. CMS provider-level files, available from 2013-2021, were used to collect neurosurgeon, orthopedic surgeon, and non-surgeon providers (interventional radiology and pain management) data for each surgical HCPCS code group (laminectomy, spinal fusion and SI-joint fusion). The United States Consumer Price Index was used to adjust for inflation.

Results: From 2000-2021 there were 338,339,667 Medicare-approved interventions and payments of $20 billion in 2021 dollars (cumulative expenditure: 44% Chiro, 17% ESI, 15% PT, 15% spinal fusion, 8% laminectomy, and < 1% SI-joint fusion).
In a specialty-specific analysis, spinal fusions were performed by neurosurgeons (40.5%), orthopedic surgeons (59.2%), and non-surgical interventionalists ( < 1%) from 2013-2021.
While neurosurgeon and orthopedic surgeon fusion utilization grew by < 3% and Medicare spending for both declined by 1%, non-surgeon providers utilization grew 26% and non-surgeon Medicare spending for spine fusions grew 62%.
In a subgroup analysis, SI-fusions were performed by neurosurgeons (24.8%), orthopedic surgeons (50.7%), and non-surgical interventionalists (24.5%), from 2018-2021. Non-surgeon providers utilization of SI-joint fusions grew 415% and payments grew 435%. Meanwhile, neurosurgeon and orthopedic surgeon SI-fusion utilization both declined by 1%, and Medicare payments for both grew by < 4%.

Conclusion : Fusions represent a small percentage of overall Medicare spending on back pain. Increases in spending on surgery for back pain is largely driven by exponential growth of non-surgeon providers performing spinal and SI-joint fusions.