Patients must see a specialist first to review nonsurgical options.
HealthPartners is changing the way it covers people who are considering back surgery, as costs rise and federal health reform measures call for a more satisfying patient experience.
The Bloomington-based company said Thursday that as of Jan. 1, its members first have to be evaluated by a spine specialist to focus on nonsurgical treatment options before they can see a surgeon.
The company said it is motivated by growing evidence that aggressive treatments may not always be the most effective for low-back pain, and that patients often choose different routes when given more information about options other than surgery.
HealthPartners has selected 102 locations in Minnesota and Wisconsin as "designated spine specialists" to do the evaluations. Staff members specialize in such areas physical medicine and rehabilitation, occupational medicine and sports medicine.
"They are not the gatekeepers," said Dr. Thomas Marr, HealthPartners' medical director of clinical relations. "Patients can still see a surgeon if they wish. But after this visit, they'll be better informed about all of their options, and can make decisions more aligned with their own values."
Many of the larger hospital systems and spinal care practices already use this approach, including Fairview Health Services, Allina Hospitals and Clinics and HealthEast Care System. HealthPartners is the first insurer to require it.
The company spent more than $28.3 million on lumbar fusions and other spine surgeries in 2011, but couldn't predict how much cost savings the new rules might bring in. Had this program been in place in 2010, about 8,800 people out of the 1.36 million enrolled in a HealthPartners plan would have been eligible for the evaluations.
Dr. Jeffrey Dick, a spine surgeon with Twin Cities Orthopedics in Edina, generally supports the idea. He said only about one in every eight patients he sees requires surgery for low-back pain.
"In general, it's a bad thing when the doctor and patient can't determine the treatment without interference from the insurance company or the government," Dick said. "For most things, that's not going to come out well. But for a patient who has a back problem, they should see somebody who is an expert right from the start. I see too many patients a year later who could have had better -- and less expensive -- care if they'd gotten the appropriate care right from the start."
Both surgeon and evaluator
Twin Cities Orthopedics, along with St. Croix Orthopedics, is part of a test group in which the surgeon also acts as the evaluator. The move likely is aimed at heading off concerns by surgeons that their practice would be harmed if they could only see patients who were eligible for surgery.
Dick said back surgery is just a small percentage of his practice.
Todd Ginkel, a chiropractor and director of clinical operations with Physicians' Diagnostics and Rehabilitation, expects to see more patients at his five clinics because of the change at HealthPartners.
"I know some people are going to have anxiety over this, but I think it's going to be a benefit for the patient," he said. "At least they can be exposed to a number of different therapeutic approaches prior to being funneled toward the surgeon. If they don't want anything we have ... the worst inconvenience is one visit to a non-surgical site. Others might say, 'This is a possibility. I'll take it before I do surgery.'"
HealthPartners modeled its program after one instituted in Grand Rapids, Mich., by Priority Health.
In 2007, that insurance company began requiring that its members meet about nonsurgical options with a physiatrist, a doctor who is a rehab specialist. Over the past four years, surgeries have dropped by 26 percent and orders for high-tech radiology have fallen by 12 percent, according to a Priority Health spokeswoman. About 87 percent of patients said they understood their options better, and nearly three-quarters reported being satisfied or very satisfied with the care they received.
HealthPartners has been studying treatment costs and outcomes associated with low-back pain since 2004. It described its new rules as part of a "collaborative process" that came from town hall style meetings and roundtables with spine surgeons, primary care providers and other spine specialists.
As to expected criticism from spine surgeons who say they don't like meddling from insurance companies, HealthPartners said it will spend the first three months of the year interviewing patients on the phone and surveying the surgeons and nonsurgical specialists. It also will closely monitor patient outcomes.
It's too soon to say how controversial the change will be among spine surgeons.
"Truthfully, we've been adhering to these criteria well before they put them in place," said Dick. "These aren't HealthPartners criteria. These are treatment algorithms for low-back pain that we all should be following -- but maybe haven't been by all practitioners."
Jackie Crosby • 612-673-7335