The current transformations affecting US health care are profound and unprecedented. We find ourselves at a unique confluence of change marked by ever-expanding and costly technological developments that can provide tremendous patient benefit. But, at the same time, we face staggering health economic challenges. In addition, there is an increasingly larger population base of aging people in developed countries and underfunded patients in emerging nations around the world who require access to quality care. As identified by the Institute for Health Care Metrics and Evaluations in its Global Burden of Disease Study 2011, we lead longer lives than ever before but with more disabilities. Of the 8 leading disability conditions, 4 are musculoskeletal and 2 of these pertain to the spine. Injury is a third and has a spine trauma subset. Economies around the world have become painfully aware that resources are finite. In the United States, a primary focus now is on controlling the US health care expenditures to help manage strained national and state budgets. From a business perspective, the success of the health care industry has been nothing short of astounding with its 2-decade period of expansive growth. The realization of the unsustainability of the latter in light of the finite nature of our resources is the new reality of health care delivery.
Calls for demonstrating “value” and “quality” in health care while increasing “transparency” and “accountability” of providers have become popular catch phrases for politicians of all backgrounds.
With its current size and growth over the last 2 decades, spine care finds itself squarely in the middle of this emerging focus on cost containment. Of note, the annual direct costs to care for patients with spine disorders in the United States is approximately $90 billion, an unsustainable expenditure that represents one of the major motivating forces at the heart of health care reform. Such reform is no longer a hypothetical for the future. It has arrived because all major stakeholders in spine care are currently demanding infrastructure to support value measurement and value-based care delivery. Early efforts range widely and include efforts to curtail spinal procedures overall, reducing the heterogeneity of treatments of common pathologies, profiling hospitals and providers on utilization and quality, decreasing reimbursements to providers and hospitals or linking payment to quality, homogenizing utilization across regions, insisting on enhanced provider and industry disclosures, heightening industry competition while applying downward pressure on implant costs, and asserting more control of cost-effective treatment choices. The concept of value-based care is a paramount component of this reform, and it will impact spine care providers everywhere.
One response is to staunchly oppose these anticipated changes and preserve the present state wherever possible. The opposite, and more productive, approach is to embrace the need for change, understand all pertinent factors, including the best types of care for patients, and then become a central participant and driver of the solution. Spine care providers must play a central role in defining the numerator of the value equation—patient benefit. The shift toward value-based spine care requires appropriately designed and executed studies to define treatments that are most effective (i.e., highest quality) at the lowest cost to both the patient and the health care system. The enormous heterogeneity of delivered spine care in countries such as the United States is reflected in the varying levels of evidence in the peer-reviewed spine literature. This Focus Issue represents a rigorous review of all economic spine surgery–related studies and highlights the many limitations associated with the contemporary evidence such as differences in follow-up, methodology, reporting, clinical and economic assumptions, pathology, and, importantly, used outcomes measures. Although this variety hinders the ability to make conclusions about which surgery, or nonoperative care path, is presently most cost-effective, the cumulative insights of this Focus Issue will hopefully provide a helpful outlook toward directions for future value-based spine care research.
The stark disparity between our current understanding of value care and the trajectory put forth by policies such as the Patient Protection and Affordable Care Act in the United States requires a unified approach of researchers, clinicians, economists, and policy makers intent on filling in the existing knowledge gaps. Investments in well-planned, longitudinal, patient-reported outcomes studies and “big data” analyses conducted through emerging resources, such as open-access registries that provide incentives toward quality data contribution, have the potential to power meaningful quality improvement and bring the volume to value transition into focus. Increasing emphasis on standardized data gathering methods and using communicable databases would surely enhance opportunities for engagement of all stakeholders including patients, providers, hospitals, payers, and the government. Such coordination of research efforts to include value of care is not an easy feat, but nevertheless, it is a necessary endeavor to define value for our patients and the future of our specialty.
The intent of AOSpine North America and this issue's editors was to thoroughly review the currently available evidence pertinent to cost-effectiveness of surgical spine care and establish, in the form of this Spine Focus issue, a benchmark of progress to date, to identify gaps requiring further study, and to outline investigational methods that will help identify preferred treatment strategies for our patients.