AAOS Now

Published 8/1/2013
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Neal H. Shonnard, MD

Clinician-led Registries Have Role in Spine Care

Neal H. Shonnard, MD

As clinicians who care for vulnerable patients with vertebral compression fractures (VCFs), orthopaedic spine surgeons have seen firsthand how payers’ concerns about variable results has affected their specialty. The controversy about the effectiveness of vertebroplasty and kyphoplasty in managing VCFs is one example. Because the spine community has failed to control the data vacuum in a way that shows that spine surgeons are aware of and controlling variability and evaluating effectiveness, it now finds itself on the defensive end of a conversation about the value of these procedures.

For example, Noridian Administrative Services (NAS), a Medicare administrative contractor, has issued a local coverage decision (LCD) that links reimbursement for VCF procedures to participation in a registry focused on patient-reported outcomes such as function and pain. The NAS LCD requires that all spine surgeons participate in a surveillance registry that tracks outcomes at multiple time points. If an audit shows that the appropriate functional outcome information is missing, NAS will “claw back” payments.

Perhaps the best reason for the clinical community to “own” safety and effectiveness data is that real questions about these issues can only be determined by registries and studies that use metrics that clinicians know are really important. As a result, members of the spine community have developed a VCF registry that will allow clinicians to participate in determining the safety and efficacy of VCF treatments.

The solution
The NAS LCD requires busy offices to become survey centers and ask patients to return at unusual time intervals to complete patient-reported outcome (PRO) assessments. Although some offices have adopted a “do-it-yourself” approach and are hoping they will be paid for what they know is suboptimal compliance with the LCD, other offices are simply waiting and hoping for new industry-funded studies to change the dynamic.

Because a planned review of the data is expected to inform a decision about future payments, many spine surgeons are concerned that the timeline of any new industry-sponsored study and the credibility of its data will be less effective than needed. Other spine surgeons have given up and no longer perform these procedures at all.

A new VCF registry, created by a clinician-led, Seattle-based company—BenchMarket Medical (www.benchmarketmedical.com)—may be an alternative that helps clinicians be part of determining the safety and effectiveness of VCF interventions while meeting the NAS requirement. In developing the registry, BenchMarket Medical worked with NAS staff to create a step-by-step pathway to successful outcomes measurement that meets the LCD requirement and results in reimbursement for treatment.

According to Bernice Hecker, MD, MHA, FACC, Medicare medical director for NAS, “Noridian supports the use of the BenchMarket registry for establishing the required follow-up and as a primary means for reporting outcomes.”

Other procedure options
Clinician-led performance surveillance activities are a new wave in quality assessment and registry initiatives. They are designed to ensure that relevant data points are being used to assess performance and procedures. This work is modeled in part on Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP).

Since 2006, SCOAP has engaged communities of clinicians in selecting metrics that matter, using data points from the medical record, and driving system change around these metrics. SCOAP has reduced the rates of complications and reoperations, saving millions of dollars in unnecessary costs by reasserting the role of clinicians in driving quality improvement.

Spine SCOAP, created in 2012, was the first statewide, clinician-developed and led spine surgery surveillance initiative. Now, 80 percent of the hospitals that deliver spine surgery participate in the program. Spine SCOAP has been endorsed by both insurers and the state’s healthcare stakeholder community as a “standard.” Its focus on PROs is helping change the dynamics of performance surveillance in spine care. It is a dynamic platform that aims to evaluate the effectiveness and the value of the procedures performed by orthopaedic spine surgeons. The BenchMarket Medical VCF Registry is modeled, in part, on the Spine SCOAP platform.

Conclusion
Spine surgeons are increasingly recognizing payer and regulator pressure to determine treatment effectiveness, address variability, and improve the quality of the care delivered. Although once an abstract consideration, new payer pressures—as seen in the Medicare decisions about VCF care—have made clinician-led performance surveillance a necessity. The models described in this article meet clinician needs and interests; involvement in these initiatives is welcomed.

For more information about how to join the BenchMarket VCF registry, contact Justine Norwitz (Justine.norwitz@benchmarketmedical.com). For more information regarding Spine SCOAP, please contact Vickie Kolios-Morris (vkolios@qualityhealth.org)

Neal H. Shonnard, MD, is an orthopaedic spine surgeon at the Rainier Orthopaedic Institute in Puyallup, Wash. He can be reached at n.shonnard@proliancesurgeons.com

Additional resources:
SCOAP

BenchMarket Medical VCF registry