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Increased costs for low back pain services seen with health plan prior authorization programs
Mandatory referrals to a physiatrist prior to surgical evaluation did not reduce the number of lumbar fusions in a study population. In addition, programs that required such prior authorization were linked with higher costs from conservative care for only brief changes in the lumbar fusion rate, which investigators likely attributed to delays in the introduction of these programs.
Researchers analyzed the change in standardized costs of services for low back pain for 501 commercial members who were enrolled in a health maintenance organization and who underwent lumbar fusion either before or after implementation of prior authorization (PA) program that required a physiatrist consultation. The investigators categorized the period from 2008 to 2010 as prior to the physiatrist PA program.
Findings showed the rate of lumbar fusions went from 76.27 per 100,000 members in 2010 to 62.23 per 100,000 members in 2011. In 2012 and 2013, the rate of lumbar infusions increased from 64.24 per 100,000 members to 73.84 per 100,000. Investigators noted members who underwent lumbar fusion saw increases of $2,233 in per-member and pre-surgical costs with the physiatrist PA program, with an additional $1,370 after the lower back pain surgery PA was implemented.
According to researchers, the greatest contributors to the increase in costs overall were spinal injections and inpatient admissions. Lower back pain surgery PA programs and the physiatrist also correlated with longer lower back pain episodes which led to surgery by 198 days and 309 days, respectively. ‒ by Monica Jaramillo
Disclosure: The researchers report no relevant financial disclosures.