Securing coverage in a value-based world


In a value-based healthcare landscape, even when providing greater levels of evidence, US surgeons increasingly face coverage denials from insurance companies for proven spinal procedures and treatments. While spine care providers continue to raise concerns regarding this issue, it was important for the North American Spine Society (NASS) leaders to take a proactive approach and collaborate with insurance companies to maintain patient access to high- quality, evidence-based and ethical spine care.

With these challenges in mind, the North American Spine Society created a Coverage Task Force in 2012. Now a full-fledged Coverage Committee, this multidisciplinary team of spinal specialists systematically reviews literature to develop evidence-based coverage recommendations for common spine care treatments, procedures, and diagnostics. Spinal News International explores the biggest issues facing spinal coverage in the coming months.

Led by Christopher M Bono, MD up until his NASS presidency in 2015, the Coverage Committee is comprised of 31 members (two co-chairs, John Glaser, MD and Scott Kreiner, MD), eight senior reviewers and 21 authors.

Acceptable evidence for the development of coverage recommendations includes systematic reviews, meta-analyses, clinical guidelines, and most importantly, randomised controlled trials. In the absence of high-level data, NASS recommendations reflect the multidisciplinary experience and expertise of committee members in order to present reasonable standard US practice indications. The Coverage Committee aims to offer detailed recommendations on the scope and clinical indications of the treatments it evaluates, as well as those circumstances which preclude such treatment.

Committed to creating new recommendations each year, NASS periodically reviews scientific literature and stakeholder feedback to ensure they are relevant, executable and truly evidence-based. NASS publishes draft coverage recommendations on their website for a 30-day public comment period providing an opportunity for NASS members and non-members to participate in this important initiative.

NASS has published 22 topics and the committee is now developing recommendations for an additional 15 topics. The first 13 of these were published in 2014. Insurance companies like Cigna actively use such recommendations to guide their coverage policies.

“Our efforts in promoting two-level cervical arthroplasty, minimally invasive sacroiliac joint fusion, spinal injections and various other proven technologies and procedures have resulted into positive coverage by payers,” Shweta Trivedi, Director of Health Policy at NASS, told Spinal News International. “NASS coverage recommendations are frequently utilised by all major payers, and this effort is appreciated by spine care providers, patients, and device manufacturers. Recently, NASS also received an endorsement from the Spine Intervention Society (SIS) for several coverage documents. This increased collaboration between all interested parties is considered the organisation’s biggest success.”

Recommendations are revised according to new developments in the literature, to make sure that they continue to satisfy the needs of physicians and their patients. The recommendations are intended to serve as a reference for payers and physicians on appropriate reimbursement, and to guard against inappropriate denial of quality spine care. It is important to note that the coverage recommendations do not represent a “standard of care,” nor are they intended as a fixed treatment protocol.

Where there may appear to be inconsistencies between results across the literature—such as in the case of vertebral augmentation, the Coverage Committee aims to thoroughly balance and evaluate all of the available literature to come to a decision. Dr. Bono  explains, “In this case, the inconsistencies in the literature are largely thought to arise from differences in selection criteria in the famed New England Journal of Medicine randomised controlled trials compared to what is generally recommended. In other words, the broader inclusion criteria in the NEJM trials may have led to the “negative” findings, while other studies in which inclusion criteria are more stringent have shown more supportive results.” Balancing all of the available evidence in order to develop reasonable coverage criteria for this procedure, that is likely to benefit a subgroup of patients with osteoporotic compression fractures and neoplastic lesions.

This proactive approach has been very well received by NASS members and the leadership is looking forward to continuing to work closely with payers in the upcoming months in order to increase awareness of NASS’ coverage efforts and evidence-based medicine.

Political actions, of course, have an effect on coverage decisions, and coverage guidelines. The Affordable Care Act, for example, probably did not have any direct effect on the work of the Coverage Committee, as there was no dramatic change in coverage criteria or implementation thereof by insurance companies. However, Dr. Bono says, a trickle-down effect can be seen in the increase in insured individuals, which will have made the decisions of the Committee relevant for a greater number of patients. It is unknown at this time how current political upheaval—including the proposed repeal of the Affordable Care Act—will affect insurance decisions, and so, the work of the Coverage Committee.

The biggest upcoming challenge for the Committee, Trivedi says, is updating existing coverage recommendations while continuing to produce new ones. “Although, we have made great progress in the last couple of years, it is extremely important for the NASS team to continue to collaborate with insurance companies so NASS  coverage recommendations continue to get visibility while being implemented appropriately in payer policies.”

Considering the increasing demand from members and non-members, as of October 2016, NASS has been offering evidence-based coverage recommendations in an individual chapter format for each published topic. This valuable resource is free to NASS members and payers, and for a one-time purchase to others. For more information, please contact NASS staff at [email protected].