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NASS 2010: The Value of Spine Care

In a morning session on the penultimate day of the North American Spine Society's annual sessions, a series of speakers presented on establishing value in spine care. The session was emblematic of several threads of discussion that have been dominant at this year's meeting. All of the high profile talks this week have reacted to this year's passage of health care reform. Sessions on how to win favor with legislators and the necessity of creating a consumer-driven health care market were presented in the conext of the flaws of this new legislation. Another high-profile session specifically on the impact of health care reform provided a brief overview of the legislation before walking through how it will negatively impact the practice of spine practitioners. At this morning sessions, demonstrated value was emphasized as essential for spine specialists given the "fundamental realignment of health care."

The common refrain of each of this morning's speakers illuminated the lack of strong quality metrics for spine surgery.  In light of this data shortfall, process measures are too often used to demonstrate value, but focusing on these measures can perversely decrease quality--for example, trying to reduce length of stay may result in a poorer post-operative recovery. A rallying call was sounded to start collecting more patient-centric data such as reduction in pain or return to pre-symptomatic functionality, though physcians admitted that standard data collection and metrics would need to be established for such attempts to be fruitful.  In that vein, an effort is underway to create a registry that collects national data to demonstrate comparative effectiveness in the treatment of lumbar spinal disorders. The imperative to collect more and better data was emphasized due to the increasing cost conciousness of providers and payers, which would force physicians to demonstrate superior care at a lower cost.  Physicians were admitting that spine care in the United States, while delivered at a high standard, was becoming unsustainably expensive, and innovative therapies had to be developed to deliver better care at a lower cost.

An interesting dynamic woven throughout these discussions exposed the extent to which NASS and their members are in agreement with the vision of health care reform even while expressing their discontent.  Clearly the need to display value can be construed as a defensive reaction to the anticipation of more stringent regulations around the provision of care, but even in this context the spine community seems to accept the need to define quality outcomes in order to measure the success of spine care. 

With the development of accountable care organizations, which aim to deliver comprehensive care to patients through an integrated network of providers, spine specialists are aware of the need to demonstrate the clinical value of their procedures--even those such as vertebroplasty and fusion that have come under scrutiny in recent years--while also admitting that they may only be appropriate for a limited number of people.  In accepting that these types of procedures may not always be necessary in the treatment of lower back pain, presenters at many sessions were explicitly supportive of the their practices being integrated with non-operative physicians. 

NASS itself has grown its membership of physiatrists and physical medicine specialists.  At one session a former of president of NASS stressed that good back care lies in multidisciplinary partnerships with physiatrists often providing conservative therapy and screening patients before referring them to surgeons when necessary.  To that end, recent focuses of the society have been around developing criteria for the use of injections, exercise, and rehab in the treatment of back pain.

This week, it was refreshing to see major figures within spine medicine highlight the importance of moving to comprehensive care of lower back pain, expressing this as both a clinical imperative for delivering better care to patients, while also being the best model in a changing delivery system.  We at Technology Insights have been investigating the development of comprehensive spine care programs with these same goals in mind, digging into the implications of health care reform and trying to grasp how spine care may change within that context.