How Do We Determine the Value of Spine Care?

Spine Treatment Models

Direct costs are directly attributed to patient care and commonly include physician visits, procedures, hospital stay, physical/occupational therapy, prescription medication, diagnostic testing/imaging, equipment and staff. Indirect costs are not directly related to patient care and mainly arise from loss of workforce productivity (missed time from work, decreased productivity when (and if) worker returns to work, and missed time from work by caregivers).

With increasing costs for spine treatments and more push-back from insurance companies questioning effectiveness, safety and value, cost containment strategies have become a major factor influencing spine treatment choices for patients.¹ Currently, a large part of the value equation includes process of care measures and direct costs associated with devices, surgery and length-of-stay. Jesse Bible, M.D., assistant professor and orthopaedic spine surgeon, Bone and Joint Institute, predicts a potential shift toward a broader, patient outcomes-driven value equation within the next five years.

“While short-term process of care measures may be objective and easy to track, I expect payers to recognize that process measures may not predict costs over the long-term. Patient-reported outcomes (PROs), such as pain, daily activities and work disability are probably bigger drivers of spine care cost over the long-term,” says Dr. Bible. (See Figure.) A non-surgical procedure may save money initially. However, it may lack effectiveness and durability, as recurrent pain and disability require additional treatment efforts later and often cause indirect costs related to work disability and need for assistance at home. With integration of the electronic medical record, orthopaedists may increasingly be required to collect PROs to evaluate effectiveness and value of a given treatment.

Increasing standardized practice is key to measuring the value of spinal surgery. Dr. Bible notes, “It’s impossible to measure value when each patient receives a unique course of care. This is slowly starting to change, as treatment protocols and algorithms are being developed and consistently applied, particularly at larger facilities like Milton S. Hershey Medical Center.” Care protocols may generate reliable data and serve as a proxy for randomized controlled trials, which are not feasible in most spine surgery settings. Protocols may also hasten the “bundling” of care, which could help to control costs. Patient registries are likely to gain ground in the coming years as a useful approach toward value, but they require significant financial support and staffing.

Dr. Bible recognizes the importance of assessing value for patients and knows that his colleagues understand as well, noting, “We all intuitively judge treatment success based on return to work, participation in normal activities or reduced analgesic use. The challenge is to routinely record these successes and consider them part of the value equation.” He adds, “There are great examples of how to measure value within the field of joint replacement and other medical specialties, like cardiology. Spine surgeons can build on these as models to improve how we provide care and place value on success.”

Jesse E. Bible, M.D., MHSJesse E. Bible, M.D., MHS
Assistant Professor, Orthopaedics and Rehabilitation
Orthopaedic Spine Surgeon
PHONE: 717-531-0003, ext 281127
FELLOWSHIP: Orthopaedic spine surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
RESIDENCY: Orthopaedic surgery, Vanderbilt University Medical Center, Nashville, Tenn.
MEDICAL SCHOOL: Yale University School of Medicine, New Haven, Conn.

Connect with Jesse E. Bible, M.D. on Doximity


1. Asher AL, Devin CJ, Mroz T, et al. 2014. Spine. 39:S136-138.

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