In recent years, growing concern about the overuse of certain spinal procedures, especially spinal fusion, has led to a more restrictive attitude by payers about such interventions. Skepticism about the clinical value — coupled with concerns about ballooning cost — has led to a higher bar for approval and reduced coverage for spinal fusion surgeries. Payers are insisting that these surgeries only be performed after other, less expensive and invasive solutions have been tried. In order to counter this understandable resistance by payers, the spine surgery community needs to develop more precise differential diagnosis to determine when surgery can be helpful for a particular patient, to empirically demonstrate both reliable economic and clinical value of surgical interventions, and to ensure that nonsurgical procedures are given due consideration in the treatment process.

Physicians may need to spend additional time gathering information from patients to improve differential diagnostic accuracy so they can more effectively identify patients likely to respond to specific surgical treatments. Physicians may also need to further educate patients and offer assistance in determining the best approach… rather than providing a pro forma six weeks of physical therapy before recommending surgery. Value-based guidelines may call for consideration of the impact of such factors as the patient’s weight, exercise routine, ergonomics in the workplace, use of pain management techniques or an assessment by a physiatrist — all of which may help demonstrate reliable value.