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Large firms take workers shopping for spine surgery

The likes of Lowe's and Walmart are moving ahead with the providers of excellence bundled payment model, applying it to a costly surgical treatment that's being marketed to an aging workforce with a low back pain epidemic.

Walmart and Lowes,  with the Pacific Business Group on Health, have expanded the Employers Centers of Excellence Network to include spine surgery--a growing treatment area that is at once expensive, risky and subject to skepticism about its benefits.  Under the bundled payment program, workers will use one of three hospitals depending on where they live: Geisinger Medical Center in Danville, Pennsylvania, Mercy Hospital, Springfield, Missouri, and Virginia Mason Medical Center in Seattle.

The centers for excellence program uses bundled rates for joint replacement and spine care, with all costs included as a single lump sum. Under the program, employers offer the program at no extra cost to their employees, who can choose that option--which might mean a trip out-of-state--or rely on local providers with the associated cost-sharing.

The addition of spine surgery comes after the first full year of the hip and knee replacement program led by the Pacific Business Group of Health. More than 500 workers treated through a center of excellence at no cost to them, and at savings for the employer, according to the PBGH.

The PBGH's centers of excellence expansion into spine surgery is also an investment in ensuring that the treatment is used in people who will benefit, and not in those at high risk of long-term complications or with less-severe conditions who may be better served by less invasive therapy like guided exercise.

"We vigorously evaluated the participating hospitals' experience in evidence-based medicine and use of consistently applied patient appropriateness criteria to ensure that participating employees are receiving higher quality care," said David Lansky, president and CEO of the Pacific Business Group on Health.

Some 600,000 Americans get spine surgery each year, including for the problem of "low back pain," and the number is growing, "despite mounting clinical evidence that many spine surgeries are not only inappropriate but ultimately cause patient harm," as Lansky said.

Some studies have found complications rates in spine surgeries as high as 15 to 30 percent for certain procedures and patients, and one study found that 20 percent of lumbar spinal fusion surgery patients end up experiencing post-traumatic stress disorder, including those without any underlying psychiatric disorders.

Richard Deyo, MD, a researcher at Oregon Health and Science University, argues that as many as half of all spinal fusions--one of the most common surgeries for low back pain--in the U.S. are unnecessary.  "Spinal fusions require long operations and are associated with an increase in the rate of complications, particularly in older patients," Deyo warned in the New England Journal of Medicine more than a decade ago. "The benefits of surgery may be only modest, and pain relief is affected by many factors besides the anatomy."

Even though spinal surgeries have proliferated, Deyo's view about using cautiously is increasingly among the mainstream of evidence-based medicine advocates. "Back pain is extremely common, and surgery often fails to relieve it," says the Mayo Clinic's patient education site.

Along with saving Lowe's, Walmart and others money, then, one of the benefits of the PGBH's program may help expand the rigorous appropriateness criteria used by Geisinger and other providers of excellence.

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