Authors: Andrew J Schoenfeld Heeren Makanji Wei Jiang Tracey Koehlmoos Christopher M Bono Adil H Haider
Publish Date: 2017/01/10
Volume: 475, Issue: 12, Pages: 2838-2844
Abstract
Whether compensation for professional services drives the use of those services is an important question that has not been answered in a robust manner Specifically there is a growing concern that spine care practitioners may preferentially choose more costly or invasive procedures in a feeforservice system irrespective of the underlying lumbar disorder being treated1 Were proportions of interbody fusions higher in the feeforservice setting as opposed to the salaried Department of Defense setting 2 Were the odds of interbody fusion increased in a feeforservice setting after controlling for indications for surgeryPatients surgically treated for lumbar disc herniation spinal stenosis and spondylolisthesis 2006–2014 were identified Patients were divided into two groups based on whether the surgery was performed in the feeforservice setting beneficiaries receive care at a civilian facility with expenses covered by TRICARE insurance or at a Department of Defense facility direct care There were 28344 patients in the entire study 21290 treated in feeforservice and 7054 treated in Department of Defense facilities Differences in the rates of fusionbased procedures discectomy and decompression between both healthcare settings were assessed using multinomial logistic regression to adjust for differences in casemix and surgical indicationTRICARE beneficiaries treated for lumbar spinal disorders in the feeforservice setting had higher odds of receiving interbody fusions feeforservice 7267 of 21290 34 direct care 1539 of 7054 22 odds ratio OR 125 95 confidence interval 120–130 p 0001 Purchased care patients were more likely to receive interbody fusions for a diagnosis of disc herniation adjusted OR 261 236–289 p 0001 and for spinal stenosis adjusted OR 139 115–169 p 0001 however there was no difference for patients with spondylolisthesis adjusted OR 099 084–116 p = 086The preferential use of interbody fusion procedures was higher in the feeforservice setting irrespective of the underlying diagnosis These results speak to the existence of provider inducement within the field of spine surgery This reality portends poor performance for surgical practices and hospitals in Accountable Care Organizations and bundled payment programs in which provider inducement is allowed to persist
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