Costs Associated with the Treatment of Low Back Disorders: A Comparison of Surgeons and Physiatrists

Abstract

Background: Spine care is costly and subject to wide variability. Defining costs and patterns of care for different specialties is critical to improving value. Objective: Determine costs, utilization, and differences therein for nonoperative and operative specialists in treating low back disorders. We hypothesized costs associated with nonoperative specialists would be lower. Design: Retrospective cohort. Setting: Medicare Limited Data Set (5% sample), 2011 to 2014. Participants: A total of 170 011 patients saw a primary care provider for a low back disorder between 1 July 2011, and 1 January 2013. Excluding those seen for a low back disorder in the preceding 6 months, final cohorts totaled 11 829 patients subsequently evaluated by a physiatrist (specialist in physical medicine and rehabilitation; 3183 patients) or surgeon (orthopedic or neurosurgeon; 8646 patients) within the following 6 months. Main Outcome Measures: Total Medicare expenditures, spine-specific costs, spine surgical rates over 24 months. Results: Cohorts had comparable demographics, initial diagnoses, and baseline mean per-member per-month (PMPM) total spending. Mean 2-year spine-specific spending was $3978 for the physiatrist cohort and $7387 for the surgeon cohort. Comparatively, the physiatrist cohort had lower total mean 2-year spine-specific spending (−$3409; 95% confidence interval [CI] −$3824 to −$2994), mean PMPM total spending (−$122/mo; CI −$184 to −$60), and surgical rate (7.8% vs. 18.9%, risk ratio [RR] = 0.41; CI 0.36-0.47). Surgery predominantly drove cost differential. Mean PMPM total spending for both cohorts remained elevated at 24 months compared to baseline mean spending (physiatrist: +$293; CI $447 to $138; surgeon: +$325; CI $425 to $225). Conclusions: Following a new episode of a low back disorder, substantial costs were seen for those subsequently evaluated by a physiatrist or surgeon. Costs were considerably lower for those first seen by a physiatrist. Patients in both cohorts displayed long-term increases in health care costs. Our data suggest that early engagement in nonoperative care, when appropriate, may improve value.

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

“…The Primary Spine Practitioner is another model proposed in the United States in which chiropractors and physical therapists serve as the initial or early point of contact for patients with LBP . Another potentially beneficial organizational strategy is the use of multidisciplinary teams comprised of medical specialists and other health professionals (eg, integrated practice units) . Future studies need to evaluate whether different models of care in conjunction with risk stratification can improve guideline concordance, patient outcomes, and decrease the total cost of care.…”

“…40 Another potentially beneficial organizational strategy is the use of multidisciplinary teams comprised of medical specialists and other health professionals (eg, integrated practice units). [41][42][43] Future studies need to evaluate whether different models of care in conjunction with risk stratification can improve guideline concordance, patient outcomes, and decrease the total cost of care.…”

Comprehensive analysis of trends in Medicare utilization and reimbursement in Physical Medicine & Rehabilitation: 2012 to 2017

“…For example, patients evaluated by a physiatrist versus a surgeon for a new lowback disorder incurred significantly lower long-term costs despite comparable demographics, initial diagnoses, and baseline per-member per-month (PMPM) spending, demonstrating the value of nonoperative care for low back pain and related disability. 43 The geographic distribution of physiatrists providing Medicare services correlates with population density, with Medicare utilization concentrated in urban and metropolitan areas. Although there was no major shift in distribution of physiatrists between 2012 and 2017, gradual microshifts as physiatrists further cluster in urban areas may have financial implications for individual physiatrists, as they provide services to a shared limited Medicare beneficiary pool.…”

PM&R BOLD: A closer look at the American Academy of Physical Medicine and Rehabilitationʼs strategic initiative to envision – and effectuate – the future of musculoskeletal care

“…In another study, Standaert et al 11 reviewed Medicare claims data from 2011 to 2014 to assess whether there was a difference in costs and utilization for treatment of low back disorders between patients who were first evaluated by a PM&R specialist versus those who were first evaluated by surgeons. The authors found that surgery rates were significantly lower among the PM&R cohort (7.8% vs. 18.9%), as was 2‐year spine‐specific spending ($3978 vs. $7387).…”