Background to Understanding Value-Based Surgical Spine Care (2014)

The Patient Protection and Affordable Care Act has rapidly shifted the focus of health care from volume to value (Quality/Cost). Although much of the value-based reform movement has focused on transitioning incentives from quantity to quality of care, the escalating and unsustainable cost of health care has garnered even more attention. Hence, all stakeholders in the range from health care purchasers, employers, and third-party payers to hospital systems, physicians, and patients alike are demanding more transparency in the relative value of their health care options. Understanding what works best for which patients at what costs in real-world settings of care is now of highest priority. Spine pathology is among the most prevalent disease states worldwide. The annual cost of spine care as a whole is estimated at $100 billion in the United States alone.1 On a per case basis, spine surgery is among the most costly procedures in US health care system.2 However, this needs to be balanced against the significant impairment and disability that can occur as a result of disorders of the spine and the spinal cord. Now more than ever, the scientific measurement of health economic value is a critical component of effective reform for a sustainable, and more importantly, high-quality health care system. As demonstrated in the article by Resnick et al,3 legislative and economic imperatives mandate that resource allocation be made only toward treatments with proven value. For the majority of spine treatments, their value remains undefined when compared with competing spinal treatment options as well as when compared with established therapies in other disease states. As a roadmap for spine care providers to fill this value evidence gap, Angevine and Berven4 provided a detailed overview of currently accepted methods to measure the relative cost-effectiveness and cost-utility of competing treatment options. While these traditional patient-centered definitions of cost-effectiveness provide a “quantitative” measure of the relative value of one treatment versus another, the “qualitative” thresholds which determine what is cost-effective or high value are not well defined and may vary dramatically as a function of the decision-maker's perspective. For example, the costs of treating oncological conditions are high and yet typically do meet such qualitative thresholds. It is clear that cost-effectiveness assessments need to be individualized according to the type of pathology treated.5 Nevertheless, these well accepted methods provide a recognized metric for spine care providers and researchers to generate and interpret evidence on spine care value. Given the current evidence gap in spine care value, decision-analysis modeling is being increasingly used to estimate value when high-level evidence does not exist. Edwards et al6 describe the common methods of modeling cost-effectiveness by piecing together many complementary but separate studies with the “glue” of clinical assumptions. The authors appropriately highlight the equal importance of the validity of both economic and clinical assumptions that drive these models. Without active input from the spine clinician, both construction and analytical interpretation of decision-analysis models of cost-effectiveness cannot be reliably performed to help inform resource allocations. It is not enough for models of cost-effectiveness to adhere to sound statistical rules if they violate simple clinical face validity. Because these models are being increasingly used to support payer policy, spine clinicians must play an active role in critically examining their validity. The convergence of value measurement and clinical spine care delivery is a relatively new phenomenon that all spine care providers will have to increasingly navigate. Spine care providers and researchers are now at a crossroads, define the value of spine care, or have it defined for them. The perceived value of spine care treatments will define their place in tomorrow's value-based health care system. The introductory articles in this Value Focus Issue provide a starting road map for such a path forward.