The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain

Abstract

Study design: An observational study.

Objective: The aim of this study was to evaluate the impact of a health plan's prior authorization (PA) programs for low back pain (LBP) in a non-Medicare population by assessing changes in pre-surgical nonoperative care; lumbar fusion trends; and overall back surgery rates compared with another health plan with a similar program and national benchmarks. The PA programs require mandatory physiatrist consultation before surgical evaluation, with subsequent additional LBP surgery PA.

Summary of background data: LBP is prevalent and concern exists that spinal fusion is overutilized for LBP.

Methods: Annual rates of lumbar fusion trended over 6 years, and analysis of changes in standardized costs for LBP-related services among a 501-member subset who underwent lumbar fusion before and after program implementations, during the period January 1, 2008, through December 31, 2013, among commercial members aged 18 and 65 years enrolled in a health maintenance organization with commercial membership averaging >500,000 annually.

Results: After initiation of the physiatrist PA in December 2010, lumbar fusions decreased from 76.27/100,000 in 2010 to 62.63/100,000 in 2011 with subsequent increases to 64.24/100,000 and 73.84/100,000 in years 2012 and 2013. For members who had lumbar fusion, per-member, pre-surgical costs increased by $2,233 with the physiatrist PA and an additional $1,370 with implementation of the LBP surgery PA (March 2013). Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs. The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days.

Conclusion: Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions. Instead, these programs were associated with the unintended consequence of increased costs from more nonoperative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs.

Level of evidence: 3.

Figure 1

SHP commercial lumbar fusion surgeries per 100,000, ages 18 to 65 years, regions 1 and 2 only. SHP program start dates: SCR PA December 1, 2010, lumbar surgery PA March 1, 2013.

Figure 2

Overall HEDIS back surgery rates per 1000 by US population insured age/sex weights. HEDIS rates include all spinal regions with no diagnosis code criteria. Program start dates: Priority Health SCOE November 2007 (all spinal regions with diagnosis criteria), SHP SCR PA December 1, 2010 (low back only with diagnosis criteria), SHP lumbar surgery PA March 1, 2013.