Financial incentives for lumbar surgery: a critical analysis of physician reimbursement for decompression and fusion procedures.

STUDY DESIGN

Retrospective case-control study/economic analysis.

OBJECTIVE

To determine the treatment times required for isolated lumbar decompressions and for combined decompression and instrumented fusion procedures to compare the relative reimbursements for each type of operation as a function of time expenditure by the surgeon.

SUMMARY OF BACKGROUND DATA

Under current Medicare fee schedules, the payment for a fusion procedure is higher than of an isolated decompression. It has been recently suggested in the lay press that the greater reimbursement for a lumbar arthrodesis may inappropriately influence the manner in which surgeons elect to treat lumbar degenerative conditions, resulting in what they believe to be a substantial number of unnecessary spinal fusions.

METHODS

A consecutive series of 50 single-level decompression cases performed by single surgeon were retrospectively analyzed and compared with an equivalent cohort of subjects who underwent single-level decompression and instrumented posterolateral fusion with autogenous iliac crest bone grafting. The operative reports, office charts, and billing records were reviewed to determine the total clinical time invested by the surgeon and the Medicare reimbursement for each surgery.

RESULTS

Relative to the corresponding values of the decompression group, combined decompression and fusion procedures were associated with a longer mean surgical time (134.6 min vs. 47.3 min, P<0.0001), a greater number of postoperative visits (1.0 vs. 3.2, P<0.0001), a higher mean total clinical time expenditure (186.6 min vs. 62.2 min, P<0.0001), and a lower mean dollars received per minute of surgeon time ($12.51 vs. $15.51, P<0.001).

CONCLUSIONS

These findings challenge the assertion that spine surgeons have an undue financial incentive to recommend a combined decompression and instrumented fusion procedure over an isolated decompression to patients with symptomatic lumbar degeneration, especially when considering the greater time, effort, and risk characteristic of this more complex operation.