Explosive growth of facet joint interventions in the medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data

  • Laxmaiah Manchikanti1Email author,

    Affiliated with

    • Vidyasagar Pampati1,

      Affiliated with

      • Vijay Singh2,

        Affiliated with

        • Mark V Boswell3,

          Affiliated with

          • Howard S Smith4 and

            Affiliated with

            • Joshua A Hirsch5

              Affiliated with

              BMC Health Services Research201010:84

              DOI: 10.1186/1472-6963-10-84

              Received: 4 November 2009

              Accepted: 30 March 2010

              Published: 30 March 2010

              Abstract

              Background

              The Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006.

              The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing spinal pain.

              Methods

              This analysis was performed to determine trends of frequency and cost of facet joint

              Interventions in managing spinal pain, utilizing the annual 5% national sample of the Centers for

              Medicare and Medicaid Services (CMS) for 1997, 2002, and 2006.

              Outcome measures included overall characteristics of Medicare beneficiaries receiving facet joint interventions, utilization of facet joint interventions by place of service, by specialty, reimbursement characteristics, and other variables.

              Results

              From 1997 to 2006, the number of patients receiving facet joint interventions per 100,000

              Medicare population increased 386%, facet joint visits increased 446%, and facet joint interventions increased 543%. The increases were higher in patients aged less than 65 years compared to those 65 or older with patients increasing 504% vs. 355%, visits increasing 587% vs. 404%, and services increasing 683% vs. 498%.

              Total expenditures for facet joint interventions in the Medicare population increased from over $229 million in 2002 to over $511 million in 2006, with an overall increase of 123%. In 2006, there was a 26.8-fold difference in utilization of facet joint intervention services in Florida compared to the state with the lowest utilization - Hawaii.

              There was an annual increase of 277.3% in the utilization of facet joint interventions by general physicians, whereas a 99.5% annual increase was seen for nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) from 2002 to 2006. Further, in Florida, 47% of facet joint interventions were performed by general physicians.

              Conclusions

              The reported explosive growth of facet joint interventions in managing spinal pain in certain regions and by certain specialties may result in increased regulations and scrutiny with reduced access.

              Background

              The Office of Inspector General (OIG)of the Department of Health and Human Services (OIG-DHHS), issued a report in September 2008 [1] noting that Medicare paid over $2 billion in 2006 for interventional pain management (IPM) procedures. This report also showed that Medicare payments for facet joint injections increased from $141 million in 2003 to $307 million in 2006. Of concern, 63% of facet joint injection services allowed by Medicare in 2006 did not meet the Centers for Medicare and Medicaid Services (CMS) program requirements, resulting in approximately $129 million in improper payments. This report illustrated that facet joint injection services provided in an office were more likely to have an error than those provided in an ambulatory surgery center (ASC) or hospital outpatient department (HOPD). The OIG report also illustrated that approximately 35% of the Medicare facet joint injections were performed by non-interventional pain physicians. The OIG report recommended some radical changes in monitoring utilization of interventional techniques. Further, independent investigators also have shown an exponential increase in the performance of facet joint interventions [25].

              Friedly et al [3, 6] reviewed trends in injection procedures focusing mainly on epidural injections from 1994 to 2001. Manchikanti et al [2] analyzed the growth of all interventional techniques in managing chronic pain in Medicare beneficiaries from 1997 to 2006. Both investigators demonstrated an overall increase of interventional techniques in all settings and in all parts of the country. The increase in the number of patients receiving IPM services per 100,000 of Medicare recipients was 137% with an overall increase of IPM services of 197% per 100,000 Medicare beneficiaries increasing by 197%. However, the most dramatic increase was found to be for facet joint interventions with a 543% increase per 100,000 Medicare beneficiaries.

              Chronic spinal pain in the United States is highly prevalent with substantial economic impact [716]. However, the treatment of spinal pain is controversial, in part related to the wide variability in the treatments utilized [16]. The rising prevalence of chronic low back pain has been demonstrated with continued high levels of disability and health care use [7]. Freburger et al [7] showed an annual increase of 11.6% of chronic low back pain and attributed a substantial portion of rising low back pain care costs over the past 2 decades to this rising prevalence. Chronic spinal pain is associated with functional and psychological disabilities and health, social, and economic impact, especially in the elderly [1013, 17, 18].

              Epidural injections and facet joint interventions are the 2 most commonly utilized procedures in IPM [16, 19, 20]. However, the literature addressing the effectiveness of facet joint interventions, though emerging, is highly variable, based on the technique, outcome measures, patient selection, and methodology [2128].

              Health care spending in the United States is escalating and the long-range fiscal sustainability of Medicare is in question [2629]. In a report titled Accounting for the Cost of US Health Care: A New Look at Why Americans Spend More [30] it was found that in 2006 the United States spent $650 billion more on health care than any of its peer Organisation for Economic Co-operation and Development (OECD) countries, even after adjusting for wealth. The majority of the excess spending was derived from outpatient care. One of the means of controlling health care expenditures is by ensuring that all care is medically necessary and avoiding overuse, abuse, and fraud. The OIG report suggests that there is significant overuse, abuse, and potential fraud in performing facet joint interventions in the United States.

              In this study, we sought to evaluate the use of all types of facet joint interventions (i.e., intraarticular injections, facet joint nerve blocks, and facet joint neurotomy) in the lumbar, cervical, and thoracic spine. In addition, our purpose was to identify trends in the number of procedures, reimbursement, specialty involvement, fluoroscopy use, and indications. Finally, we sought to explore the association between overall injection costs and the volume of services provided in HOPD settings, ACSs, and in-office settings.

              Methods

              The data for this study was used from the standard 5% national sample of the CMS physician outpatient billing claims for 1997, 2002, and 2006. The data set is a sample of those enrolled in the fee-for-service Medicare program based on selecting records with specific numbers in positions 8 and 9 of the health insurance claim number and is generated by CMS. The CMS 5% sample data set is therefore unbiased and unpredictable in terms of any patient characteristics, but does allow appropriate tracking of patients over time and across databases. Consequently, CMS makes this 5% sample available to researchers. In addition, a 100% data set is so large that it is not feasible to use for research purposes. Thus, Institutional Review Board (IRB) approval was not required. CMS's providing the data also does not require IRB approval prior to analysis or publication.

              Previous studies [3, 6] generally included patients aged 65 and older. We have studied all patients enrolled in Medicare who received interventional techniques [2]. Overall Medicare enrolled over 43 million beneficiaries in 2006, and is the single largest health care payor in the United States [31]. Consequently, the Medicare data set includes a large proportion of procedures for spinal pain being performed in the United States, including facet joint interventions. In addition to patient age, the database included the Current Procedural Terminology (CPT) procedure codes; the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes; date of service, provider specialty, provider zip code, and allowed charges.

              To yield data for the entire beneficiary population of Medicare, results from the 5% sample were multiplied by 20. In addition, rates were calculated based on Medicare beneficiaries for the corresponding year and are reported as per 100,000 Medicare beneficiaries. The data were tabulated based on the place of service - HOPD, ASC, or office for the years 1997, 2002, and 2006. Facility charges were also identified for HOPDs, ASCs, and offices (office facility portion as overhead expense equals total office payment minus physician payment). Facility payments for HOPD were estimated based on national payment rates with consideration of modifiers, due to the non-availability of HOPD data in the data set. Allowed charges were used to estimate the costs of Medicare for these procedures and costs were adjusted for health care inflation using the U.S. Bureau of Labor Statistics Consumer Price Index (CPI) for medical care services and represent costs for 2006 [32].

              In this study, all types of facet joint interventions with CPT codes 64470, 64472, 64475, 64476, 64622, 64623, 64626, and 64627, with evaluation of Medicare data of 1997, 2002, and 2006 were utilized. Appropriate considerations were given to the changes in the CPT with introduction of new codes or replacement codes.

              In addition, diagnostic codes were utilized from the ICD-9-CM. The previous studies excluded cervical and thoracic facet joint interventions [3, 6]; they argued that cervical and thoracic spine disorders differ clinically from lumbar spine disorders and may be the result of different disease processes. They believed that cervical and thoracic interventions represent a very small proportion of patients. However, the emerging statistics show that cervical and thoracic facet joint interventions occupy a large proportion of facet joint interventions. Thus, it was felt essential to include these interventions.

              To analyze the data based on specialty, the IPM specialties were described as those providers designated in IPM -09, pain medicine -72, anesthesiology -05, physical medicine and rehabilitation -25, neurology -13, psychiatry -26, orthopedic surgery -20, and neurosurgery -14 [33]. General practitioners -01, family practitioners -08, and internists -11 were considered as general physicians. All other providers were considered as other physicians and providers.

              Data Synthesis

              The data were analyzed using SPSS (9.0) statistical software, Microsoft Access 2003, and Microsoft Excel (2003). The procedure rates were calculated per 100,000 Medicare beneficiaries.

              Results

              Population Characteristics

              Table 1 illustrates the characteristics of Medicare beneficiaries and facet joint interventions. During the same period, Medicare recipients receiving facet joint interventions increased 386%. Facet joint interventions increased from 606 per 100,000 in 1997 to 3,895 per 100,000 in 2006, a 543% increase.
              Table 1

              Characteristics of Medicare beneficiaries and facet joint interventions.

                    

              % of increase from

                 

              1997

              2002

              2006

              2002-2006

              1997-2006

              US Population (,000)

              267,784

              288,369

              299,395

              3.8%

              11.8%

                 > = 65 years (,000)

              34,933

              35,602

              37,125

              4.3%

              6.3%

              Medicare Beneficiaries (,000)

              38,465

              40,503

              43,339

              7.0%

              12.7%

              Age

              ≥ 65 years

              33,636

              34,698

              36,317

              4.7%

              8.0%

                

              < 65 years

              4,829

              5,805

              7,022

              21.0%

              45.4%

              Gender

              Male

              40.70%

              43.85%

              44.16%

              0.7%

              8.5%

                

              Female

              59.30%

              56.15%

              55.84%

              -0.6%

              -5.8%

              Facet joint intervention patients and visits

                     

              Number of Medicare patients receiving facet joint interventions

              46,640

              119,160

              254,720

              114%

              446%

                 Patients per 100,000 Medicare beneficiaries

              121

              294

              588

              100%

              386%

                 Number of visits

              88,280

              225,280

              543,900

              141%

              516%

                 Visits per 100,000 Medicare beneficiaries

              230

              556

              1,255

              126%

              446%

                 Services

              233,200

              607,760

              1,688,180

              178%

              624%

                 Interventions per 100,000 Medicare beneficiaries

              606

              1,501

              3,895

              160%

              543%

                 Average visits per patient

              1.9

              1.9

              2.1

              0

              0.2%

              Facet joint interventions by age

                 Patients

              < 65 years

              Number of patients

              9,800

              27,060

              65,420

              142%

              568%

                

              Rate (per 100,000)

              25

              67

              151

              125%

              504%

               

              ≥ 65 years

              Number of patients

              36,840

              92,100

              189,300

              106%

              414%

                

              Rate (per 100,000)

              96

              227

              437

              93%

              355%

                 Visits

              < 65 years

              Number of visits

              19,840

              54,960

              154,760

              182%

              680%

                

              Rate (per 100,000)

              52

              136

              357

              163%

              587%

               

              ≥ 65 years

              Number of visits

              68,440

              170,320

              389,140

              128%

              469%

                

              Rate (per 100,000)

              178

              421

              898

              113%

              404%

                 Services

              < 65 years

              Number of services

              56,040

              148,720

              495,480

              233%

              784%

                

              Rate (per 100,000)

              146

              367

              1,143

              211%

              683%

               

              ≥ 65 years

              Number of services

              177,160

              459,040

              1,192,700

              160%

              573%

                

              Rate (per 100,000)

              461

              1,131

              2,752

              143%

              498%

              The results illustrate a higher proportion of increase for patients under 65; that proportion of patients increased 504% vs. 355%. For those 65 or over, visits increased 404% versus 587% for those under 65; services for those over 65 increased 498% versus 683% for those under 65. The Medicare population below the age of 65 years increased 45.4% in contrast to 8% of those 65 years or older.

              Utilization Characteristics

              Table 2 illustrates the summary of frequency of utilization of facet joint interventions based on CPT code and place of service. Due to the 1997 data being non-comparable and not comprehensive, the data from 2002 and 2006 were utilized. The majority of the procedures (80% in 2002 and 77% in 2006) were performed in the lumbar region, with cervical and thoracic procedures constituting 20% in 2002 and 23% in 2006. The most commonly performed procedure was subsequent lumbar facet joint injection/nerve block (CPT 64476). Cervical/thoracic interventions increased 194% per 100,000 Medicare beneficiaries, whereas lumbar procedures increased 151%. In 2002, 40% of procedures were performed in HOPD settings and 41.7% in office settings; whereas in 2006, 59.6% were performed in office settings. The overall rate (per 100,000 Medicare beneficiaries) increased by 160% from 2002 to 2006; whereas in office settings the rate increased significantly (271%), followed by ASCs (168%) and HOPD settings (40%). Cervical procedures increased 194% with a distribution of 259%, 224%, and 59% in office, ASC, and HOPD settings.
              Table 2

              Utilization of facet joint interventions by place of service.

              CPT

              2002

              2006

              Change from 2002

               

              Place of Service

              Place of Service

              Place of Service

               

              ASC

              HOPD

              Office

              Total

              ASC

              HOPD

              Office

              Total

              ASC

              HOPD

              Office

              Total

              Cervical/Thoracic (C/T)

              64470

              6,100

              10,220

              26,320

              42,640

              18,520

              17,300

              89,300

              125,120

              204%

              69%

              239%

              193%

              64472

              10,380

              19,380

              34,360

              64,120

              34,340

              32,300

              145,400

              212,040

              231%

              67%

              323%

              231%

              64470-72

              16,480

              29,600

              60,680

              106,760

              52,860

              49,600

              234,700

              337,160

              221%

              68%

              287%

              216%

              Rate

              41

              73

              150

              264

              122

              114

              542

              778

              200%

              57%

              261%

              195%

              64626

              1,020

              2,280

              1,400

              4,700

              4,700

              3,580

              5,340

              13,620

              361%

              57%

              281%

              190%

              64627

              2,120

              4,160

              3,760

              10,040

              10,360

              8,180

              12,800

              31,340

              389%

              97%

              240%

              212%

              64626-27

              3,140

              6,440

              5,160

              14,740

              15,060

              11,760

              18,140

              44,960

              380%

              83%

              252%

              205%

              Rate

              8

              16

              13

              36

              35

              27

              42

              104

              348%

              71%

              229%

              185%

              C/T Total

              19,620

              36,040

              65,840

              121,500

              67,920

              61,360

              252,840

              382,120

              246%

              70%

              284%

              215%

              Rate

              48

              89

              163

              300

              157

              142

              583

              882

              224%

              59%

              259%

              194%

              Lumbar/Sacral (L/S)

              64475

              26,120

              60,340

              69,960

              156,420

              67,580

              84,420

              214,160

              366,160

              159%

              40%

              206%

              134%

              64476

              47,300

              101,560

              93,680

              242,540

              114,400

              143,040

              375,980

              633,420

              142%

              41%

              301%

              161%

              64475-76

              73,420

              161,900

              163,640

              398,960

              181,980

              227,460

              590,140

              999,580

              148%

              40%

              261%

              151%

              Rate

              181

              400

              404

              985

              420

              525

              1,362

              2,306

              132%

              31%

              237%

              134%

              64622

              5,420

              13,360

              6,660

              25,440

              20,400

              22,880

              37,780

              81,060

              276%

              71%

              467%

              219%

              64623

              12,660

              31,660

              17,540

              61,860

              47,940

              51,840

              125,640

              225,420

              279%

              64%

              616%

              264%

              64622-23

              18,080

              45,020

              24,200

              87,300

              68,340

              74,720

              163,420

              306,480

              278%

              66%

              575%

              251%

              Rate

              45

              111

              60

              216

              158

              172

              377

              707

              253%

              55%

              531%

              228%

              L/S Total

              91500

              206,920

              187,840

              486,260

              250,320

              302,180

              753,560

              1,306,060

              174%

              46%

              301%

              169%

              Rate

              226

              511

              464

              1,201

              578

              697

              1,739

              3,014

              156

              36%

              275%

              151%

              Grand Total

              Services

              111,120

              242,960

              253,680

              607,760

              318,240

              363,540

              1,006,400

              1,688,180

              186%

              50%

              297%

              178%

              Rate

              274

              600

              626

              1,501

              734

              839

              2,322

              3,895

              168%

              40%

              271%

              160%

              Reimbursement Characteristics

              Additional file 1 illustrates physician and facility reimbursement by place of service adjusted for inflation for years 2002 and 2006. As seen in Additional file 1, overall facility average charges decreased by 26%.

              Specialty Characteristics

              Figure 1 illustrates the increase in utilization of facet joint interventions by various specialty groups assigned as IPM, general practice, NPs/CRNAs, and others from 2002 to 2006. Across the country, the majority of procedures were performed by IPM physicians with 87% in 2002 and 74.5% in 2006. However, in 2006 general physicians performed 18.6% of these procedures, while all others performed 6.9% of the procedures (Table 3). Overall increases were greatest for general physicians, increasing by over 1,109% from 2002 to 2006, an annual growth of 277.3%. There was also an increase of 398% from 2002 to 2006 among NPs and CRNAs, an annual increase of 99.5%. In Florida in 2006, 47% of the procedures were performed by general physicians with specialties of general practice, family practice, and internal medicine.
              http://static-content.springer.com/image/art%3A10.1186%2F1472-6963-10-84/MediaObjects/12913_2009_Article_1221_Fig1_HTML.jpg
              Figure 1

              Annual percentage of increase of facet joint intervention services per 100,000 Medicare recipients from 2002 to 2006.

              Table 3

              Utilization of facet joint interventions by speciality.

               

              2002

              2006

              Change from 2002

              Speciality

              Services

              Percent

              Rate

              Services

              Percent

              Rate

              Percent

              Rate

              Interventional Pain Management

              529,220

              87.1%

              1,307

              1,256,860

              74.5%

              2,900

              -15%

              122%

                 Anesthesiology

              338,660

              55.7%

              836

              524,340

              31.1%

              1,210

              -44%

              45%

                 Pain Management

              78,080

              12.8%

              193

              459,520

              27.2%

              1,060

              112%

              450%

              Anesthesiology & Pain Management

              416,740

              68.5%

              1,029

              983,860

              58.3%

              2,270

              -15%

              121%

                 Physical Medicine and Rehabilitation

              54,000

              8.9%

              133

              148,980

              8.8%

              344

              -1%

              158%

                 Orthopedic Surgery

              24,600

              4.0%

              61

              51,860

              3.1%

              120

              -24%

              97%

                 Neurology

              23,140

              3.8%

              57

              49,400

              2.9%

              114

              -23%

              100%

                 Neurosurgery

              9,320

              1.5%

              23

              21,080

              1.2%

              49

              -19%

              111%

                 Psychiatry

              1,420

              0.2%

              4

              1,680

              0.1%

              4

              -57%

              11%

              Family & General Practice/Internal Medicine

              24,300

              4.0%

              60

              314,420

              18.6%

              725

              366%

              1109%

              Others

              54,240

              8.9%

              134

              116,900

              6.9%

              270

              -22%

              101%

                 Diagnostic Radiology

              14,100

              2.3%

              35

              20,140

              1.2%

              46

              -49%

              33%

                 Nurse Practitioners/CRNA's

              860

              0.1%

              2

              4,580

              0.3%

              11

              92%

              398%

                 Others

              39,280

              6.5%

              97

              92,180

              5.5%

              213

              -16%

              119%

              Total

              607,760

              100%

              1,501

              1,688,180

              100%

              3,895

              178%

              160%

              Fluoroscopy Utilization

              Figure 2 illustrates fluoroscopy utilization based on specialty. Overall in 2002, 48% of all visits included fluoroscopy, compared to 63% visits of all visits in 2006.
              http://static-content.springer.com/image/art%3A10.1186%2F1472-6963-10-84/MediaObjects/12913_2009_Article_1221_Fig2_HTML.jpg
              Figure 2

              Percentage of visits utilizing fluoroscopy based on specialty.

              Procedural Characteristics by State

              Table 4 illustrates facet joint interventions for each state. South Dakota showed the highest increase of 504% with Alabama showing the lowest increase of 14% per 100,000 Medicare beneficiaries. The overall increase for the United States was 160% from 2002 to 2006. However, smaller states with a small number of procedures, such as South Dakota, preclude any conclusions to be drawn as per the increases. Thus, when normalized for population, Florida showed a 26.8-fold difference from Hawaii, the state with the lowest, for 2006. All other states showed a difference of less than 10-fold with Michigan showing a 9.87-fold difference, Texas showing an 8.42-fold difference, Arkansas showing a 7.34-fold difference, and Delaware showing a 6.47-fold difference, compared to the lowest state for 2006. Further, facet joint procedures per state as a proportion of national utilization declined in multiple states.
              Table 4

              Number of facet joint interventions and procedures per 100,000 Medicare beneficiaries provided by state.

               

              2002

               

              2006

               

              % of change from 2002

              Fold difference from the lowest state for 2006

              State

              Services

              Rate per 100,000 population

              Services

              Rate per 100,000 population

              Services

              Rate per 100,000 population

               

              Florida

              108,800

              3,603

              534,000

              17,340

              391%

              381%

              26.80

              Michigan

              44,940

              3,514

              96,460

              6,386

              115%

              82%

              9.87

              Texas

              62,680

              2,680

              142,960

              5,445

              128%

              103%

              8.42

              Arkansas

              8,240

              1,692

              23,040

              4,752

              180%

              181%

              7.34

              Delaware

              800

              714

              5,520

              4,187

              590%

              486%

              6.47

              Alaska

              400

              874

              2,000

              4,026

              400%

              361%

              6.22

              Mississippi

              6,920

              1,788

              16,600

              3,596

              140%

              101%

              5.56

              Kentucky

              11,520

              1,797

              24,900

              3,583

              116%

              99%

              5.54

              Utah

              2,620

              1,365

              8,440

              3,431

              222%

              151%

              5.30

              Tennessee

              12,440

              1,695

              32,460

              3,419

              161%

              102%

              5.29

              West Virginia

              3,160

              878

              12,080

              3,343

              282%

              281%

              5.17

              Montana

              2,740

              1,745

              5,060

              3,335

              85%

              91%

              5.15

              Maryland

              8,500

              1,302

              23,320

              3,294

              174%

              153%

              5.09

              North Carolina

              15,840

              1,331

              42,400

              3,218

              168%

              142%

              4.97

              Ohio

              17,620

              1,134

              56,060

              3,153

              218%

              178%

              4.87

              Vermont

              800

              875

              2,900

              3,150

              263%

              260%

              4.87

              South Carolina

              6,540

              965

              21,160

              3,140

              224%

              225%

              4.85

              Missouri

              8,260

              1,109

              29,160

              3,137

              253%

              183%

              4.85

              New Hampshire

              3,320

              2,024

              6,200

              3,134

              87%

              55%

              4.84

              Alabama

              20,220

              2,682

              23,620

              3,058

              17%

              14%

              4.73

              Indiana

              12,620

              1,485

              28,140

              3,050

              123%

              105%

              4.71

              Pennsylvania

              31,560

              1,552

              63,740

              2,957

              102%

              90%

              4.57

              Georgia

              14,820

              1,705

              31,360

              2,916

              112%

              71%

              4.51

              South Dakota

              580

              480

              3,460

              2,904

              497%

              504%

              4.49

              Iowa

              7,780

              1,784

              13,960

              2,823

              79%

              58%

              4.36

              Louisiana

              4,220

              701

              17,500

              2,804

              315%

              300%

              4.33

              Arizona

              5,960

              753

              22,540

              2,765

              278%

              267%

              4.27

              Wyoming

              780

              1,158

              1,780

              2,593

              128%

              124%

              4.01

              Massachusetts

              10,280

              1,155

              25,240

              2,571

              146%

              123%

              3.97

              California

              55,060

              1,458

              103,000

              2,409

              87%

              65%

              3.72

              Wisconsin

              10,060

              1,435

              19,660

              2,341

              95%

              63%

              3.62

              Maine

              2,640

              1,153

              5,560

              2,311

              111%

              100%

              3.57

              New York

              27,660

              1,057

              63,840

              2,276

              131%

              115%

              3.52

              New Mexico

              2,720

              925

              6,120

              2,219

              125%

              140%

              3.43

              Kansas

              2,000

              531

              8,980

              2,209

              349%

              316%

              3.41

              Illinois

              17,060

              1,054

              37,180

              2,171

              118%

              106%

              3.35

              Nevada

              2,640

              996

              6,580

              2,145

              149%

              115%

              3.32

              Virginia

              10,720

              1,203

              19,900

              1,955

              86%

              62%

              3.02

              New Jersey

              13,320

              1,073

              23,180

              1,867

              74%

              74%

              2.89

              Colorado

              4,740

              946

              10,020

              1,856

              111%

              96%

              2.87

              Oklahoma

              5,920

              1,159

              10,260

              1,854

              73%

              60%

              2.86

              Connecticut

              3,040

              559

              9,160

              1,728

              201%

              209%

              2.67

              Minnesota

              3,440

              587

              11,940

              1,674

              247%

              185%

              2.59

              Idaho

              1,760

              1,019

              3,100

              1,656

              76%

              63%

              2.56

              Nebraska

              1,100

              430

              3,440

              1,382

              213%

              222%

              2.14

              Washington

              4,560

              667

              11,560

              1,365

              154%

              105%

              2.11

              Rhode Island

              880

              511

              2,060

              1,332

              134%

              161%

              2.06

              Oregon

              1,440

              295

              7,240

              1,310

              403%

              344%

              2.02

              North Dakota

              960

              930

              1,160

              1,184

              21%

              27%

              1.83

              District of Columbia

              360

              485

              620

              1,021

              72%

              110%

              1.58

              Hawaii

              720

              420

              1,100

              647

              53%

              54%

              1.00

              Overall

              607,760

              1,501

              1,688,180

              3,895

              178%

              160%

              6.02

              Diagnostic Characteristics

              Table 5 illustrates the utilization of ICD-9-CM diagnostic codes for facet joint interventions. The most common diagnoses documented were "lumbosacral spondylosis" in the lumbar spine of 32.3% and cervical spondylosis in the cervical spine of 5.3%. Degenerative disc disease was the diagnosis criteria utilized in 6.2% and 1.2% of cases in the lumbar and cervical spine respectively. Thus, accurate diagnosis was utilized in fewer than 50% of patients in 2006.
              Table 5

              Line of diagnosis for facet joint interventions.

              Group

              2002

              Percent

              2006

              Percent

              LUMBOSACRAL SPONDYLOSIS

              168,980

              32.3%

              3,379,600

              32.3%

              LUMBAGO/BACK PAIN

              151,240

              28.9%

              3,024,800

              28.9%

              CERVICAL SPONDYLOSIS W/WO MYELOPATHY

              27,960

              5.3%

              559,200

              5.3%

              DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC

              32,180

              6.2%

              643,600

              6.2%

              CERVICALGIA

              29,320

              5.6%

              586,400

              5.6%

              SCIATICA

              2,800

              0.5%

              56,000

              0.5%

              THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

              21,680

              4.1%

              433,600

              4.1%

              THORACIC SPONDYLOSIS W/WO MYELOPATHY

              4,320

              0.8%

              86,400

              0.8%

              SPINAL STENOSIS

              11,940

              2.3%

              238,800

              2.3%

              POSTLAMINECTOMY SYNDROME

              10,860

              2.1%

              217,200

              2.1%

              DEGENERATION OF CERVICAL INTERVERTEBRAL DISC

              6,040

              1.2%

              120,800

              1.2%

              LUMBAR DISC DISPLACEMENT

              6,980

              1.3%

              139,600

              1.3%

              PAIN IN JOINT UNSPECIFIED/SPECIFIED AREA

              5,320

              1.0%

              106,400

              1.0%

              BRACHIAL NEURITIS OR RADICULITIS NOT OTHERWISE SPECIFIED

              4,560

              0.9%

              91,200

              0.9%

              ARTHROPATHY

              1,680

              0.3%

              33,600

              0.3%

              OTHER SYNDROMES AFFECTING CERVICAL REGION

              5,640

              1.1%

              112,800

              1.1%

              POSTLAMINECTOMY SYNDROME OF CERVICAL REGION

              1,000

              0.2%

              20,000

              0.2%

              LUMBOSACRAL SPRAIN

              1,680

              0.3%

              33,600

              0.3%

              DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC

              1,220

              0.2%

              24,400

              0.2%

              CONGENITAL ANOMALIES OF SPINE

              1,200

              0.2%

              24,000

              0.2%

              DISORDERS OF SACRUM

              2,300

              0.4%

              46,000

              0.4%

              SPONDYLOLISTHESIS

              1,120

              0.2%

              22,400

              0.2%

              MYALGIA AND MYOSITIS

              1,560

              0.3%

              31,200

              0.3%

              DEGENERATION OF INTERVERTEBRAL DISC SITE UNSPECIFIED

              940

              0.2%

              18,800

              0.2%

              NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED

              520

              0.1%

              10,400

              0.1%

              OSTEOARTHROSIS

              1,180

              0.2%

              23,600

              0.2%

              SPINAL STENOSIS IN CERVICAL REGION

              800

              0.2%

              16,000

              0.2%

              SPASM OF MUSCLE

              840

              0.2%

              16,800

              0.2%

              PATHOLOGICAL FRACTURE OF VERTEBRAE

              400

              0.1%

              8,000

              0.1%

              LUMBOSACRAL PLEXUS LESIONS

              800

              0.2%

              16,000

              0.2%

              INFLAMMATORY SPONDYLOPATHY

              520

              0.1%

              10,400

              0.1%

              OTHERS

              12,840

              2.5%

              256,800

              2.5%

              Overall Growth Pattern

              Figure 3 illustrates the overall growth pattern of facet joint interventions. These annual rates of increase for facet joint interventions represent the years from 1997 to 2006. There was an increase of facet joint interventions by general physicians of over 1,109%.
              http://static-content.springer.com/image/art%3A10.1186%2F1472-6963-10-84/MediaObjects/12913_2009_Article_1221_Fig3_HTML.jpg
              Figure 3

              Illustration of overall annual growth patterns.

              Discussion

              Facet joint intervention rates for spinal disorders increased dramatically over the study period from 1997 to 2006. This increase per 100,000 Medicare population from 1997 to 2006 was relatively constant over time, resulting in an increase of facet joint patients of 386%, facet joint visits of 446%, and facet joint interventions of 543%. Facet joint interventions also increased based on age. Among Medicare recipients per 100,000, less than 65 years of age, compared to those 65 or older, the patient population receiving facet joint interventions increased 504% vs. 355%, visits increased 587% compared to 404%, and services increased 683% compared to 498%. In addition, total expenditures also increased from over $229 million in 2002 to over $511 million in 2006, with an overall increase of 123% from 2002 to 2006. There was a significant increase of 1,109% in the utilization of facet joint interventions by general physicians -- composed of general practice, family practice, and internal medicine -- from 2002 to 2006, an annual increase of 277.3%. There were also significant usage or utilization increases among NPs and CRNAs from 2002 to 2006 of 398%, an annual increase of 99.5%. These increases were substantially higher than any other specialty, even though overall increases were significant: 160% from 2002 to 2006, an annual increase of 40%.

              There was a 26.8-fold difference in the utilization pattern in Florida from Hawaii, the state with the lowest pattern for 2006. The remaining 49 states showed less than a 10-fold difference. Further, it has been shown that 47% of facet joint interventions in Florida were performed by general physicians. There has been an exponential growth of facet joint interventions in office settings of 271% with ASC settings showing 168% growth and HOPD settings showing 40% growth. However, moving the procedures to hospital settings will not resolve the issue as the average cost of the total procedure in HOPD settings in 2006 was $467.80, whereas in in-office settings, it was $227.60 and in ASC settings, it was $352.20.

              Fluoroscopy utilization was lowest among family and general practice and internal medicine physicians and highest among pain management specialties. Non-fluoroscopically guided procedures present multiple issues regarding the accuracy of the procedure, medical necessity, and documentation.

              With respect to evidence for facet joint interventions, there is emerging evidence to show the effectiveness of medial branch blocks and radiofrequency neurotomy along with effective diagnosis, when patients are selected appropriately meeting indications and medical necessity criteria [2028]. While this evidence is emerging, some systematic reviews [19] have not utilized these trials [2628] in their evidence synthesis.

              Friedly et al [3] postulated that there was a disproportionate increase in procedures in ACSs, and that ACSs received higher payments. The implication is that these procedures had been shifted to ACSs as self referrals. Also that there was excessive use by facilitating physician investors to increase practice revenues by receiving facility payments for procedures. However, our study shows that this is not an issue. Rather, it may be due to the providing of more efficient services as a result of specialized staff and equipment, and convenient locations with short waiting times as well as better physician production. Further, the data illustrates that the procedures are more expensive in HOPD settings compared to ASC settings.

              Based on the current data, it appears that the annual increase in the population with chronic low back pain is 11.6% [7], and the increase in facet joint intervention visits is approximately 50%. The increases are much lower in states with stricter regulations and LCDs [34, 35]. Kentucky showed an annual increase of 25% and Indiana, 26%; whereas the annual increase in Florida was 95%. The overall increase across the country was 40% from 2002 to 2006.

              McKinsey Global Institute [30] postulated multiple factors for the increased growth of outpatient health care services in the United States. First, provider capacity growth and response to high outpatient margins is illustrated in this study based on significant increases in in-office settings and also performing these procedures. Other causes are that in outpatient settings, more efficient services are provided as a result of specialized staff and equipment, convenience of the location, short waiting times, and better physician production [34, 35]. The second factor relates to judgment based on the nature of physician care. Over the years there has been significant growth in interventional pain management due to increased understanding and to the availability of a supply of physicians. The third factor described relates to technological innovation that drives prices higher rather than lower [36], which is not proven in this study in the Medicare population in the United States. The fourth factor relates to demand growth that appears to be due to the greater availability of supplies. While this is accurate, there is also demand due to access and also to the increasing prevalence of spinal pain. The final factor relates to relatively price-insensitive patients with limited out-of-pocket costs. This factor may be realistic in the overall health care evaluation. However, in the Medicare population, the application of this is minimal. In this study we included only the patients who were paying fee-for-service. Thus, price insensitivity does not apply. However, the study of the patients with third party insurance with low out-of-pocket costs and workers' compensation patients with no out-of-pocket costs and Medicare Advantage patients with low out-of-pocket costs or no out-of-pocket costs will illustrate these differences. Yet numerous problems continue to exist with overuse and abuse.

              There are multiple limitations to our study. These include the lack of inclusion of participants in Medicare Advantage plans, which includes approximately 10% of enrollees, and potential coding errors [3, 31]. However, we have included all patients over 65 receiving traditional fee-for-service Medicare and under 65 as well. This inclusion is important because patients below the age of 65 represent a significant proportion of patients receiving facet joint interventions, with a higher frequency of services. In general, patients less than 65 years of age received more intense and a higher proportion of services (504% vs. 355%) [2]. This fact is echoed in this evaluation, which shows an increase of facet joint services of 683% vs. 498% from 1997 to 2006. Since the data does not contain HOPD facility charges, we had to estimate the facility charges for outpatient hospital charges, similar to Friedly et al [3]. Another limitation is that some variation may be related to coding errors and diagnostic ambiguity, and to non-reporting of fluoroscopy. However, due to the usage of actual data for physicians, ASCs, and office services, these errors should have very little influence.

              Multiple recommendations have been made to slow the growth of health care costs in general and for interventional techniques in particular [1, 4, 36]. Health care experts have recommended policies that encourage high-growth or high-cost regions to behave more like slow-growth, low-cost regions and to encourage low-cost, slow-growth regions to sustain their current needs for interventional techniques to slow spending growth. The OIG [1] has recommended strengthening program efforts to prevent improper payments; others [3] have also recommended more stringent regulations on medical necessity, indications, accreditation provisions in the settings performed, and training and qualifications of the physicians performing the procedures.

              Conclusion

              In conclusion, our data summarizes the explosive growth of facet joint interventions in agreement with the OIG report [1] and other reports [2]. This review also demonstrates that the growth has been substantial in certain regions and by certain specialties. Some of the growth may be accounted for by improved access, precision of diagnostic and therapeutic modalities outcomes, and the increasing prevalence of spinal pain. However, there still continue to be multiple problems with ambiguity of diagnosis, lack of fluoroscopic use, disproportionate increase in procedures by some specialties and some regions, and escalating costs.

              Declarations

              Acknowledgements

              The authors wish to thank Sekar Edem for his assistance in the literature search and Tonie M. Hatton and Diane E. Neihoff, transcriptionists, for their assistance in the preparation of this manuscript.

              Authors’ Affiliations

              (1)
              Pain Management Center of Paducah
              (2)
              Pain Diagnostics Associates
              (3)
              Texas Tech. University Health Sciences Center
              (4)
              Albany Medical College
              (5)
              Massachusetts General Hospital

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              37. Pre-publication history

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              Copyright

              © Manchikanti et al. 2010

              This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.