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Reimbursement in Spine: A NASS Priority

I’m reminded of a BONEZONE® article we published about five years ago, in which author Kelli Hallas asserted,

Bottom line is this…no matter how unique or innovative a product, no matter how fine-tuned your internal processes, no matter how great the initial demand, in order to be successful in today’s marketplace, everybody needs to be paid.”

Ms. Hallas’ statement, by way of its use of the word “everybody,” alludes to the reality that you should take an interest in helping those downstream from you get paid. In other words, don’t send your products to market without confidence that everyone involved in the process will be compensated.

The North American Spne Society (NASS) is taking action. Specifically, proactive reimbursement measures are a prime initiative for the society. For instance, its coverage policy recommendations are seen by the society as a powerful tool for surgeons as well as device companies.

“Members and industry benefit greatly from this [living document],” says Eric Muehlbauer, Executive Director and CEO of NASS. “In this hierarchy of developing evidenced-based comments there are clinical guidelines, which are the highest form of evidence; then there are things like appropriate use criteria documents. The coverage recommendation documents are evidence-informed. We know that insurance companies will use whatever they can to formulate a policy, so we try to do all of that homework for them.”

To date, NASS has produced 25 coverage recommendations addressing treatments and procedures such as cervical and lumbar disc replacement, cervical and lumbar fusion, percutaneous sacroiliac joint fusion and certain discectomies and injections. More than 30 recommendations remain in the works, including one for facet joints, which is under final review by the initiative’s multi-specialty committee.

A measure of the initiative’s success is the fact that insurance companies often cite these recommendations in policy revisions, and sometimes adopt them verbatim, Muehlbauer says.

Still, work needs to be done. For all of the years that reimbursement has been a pain point, Muehlbauer says that industry mindsets have not sufficiently shifted from reactive to proactive.

“Focus on proving value,” Muehlbauer urges.

All too often, from Muehlbauer’s perspective, companies neglect to develop a reimbursement strategy alongside their device approval strategy. FDA might want you to prove safety and effectiveness, but insurance companies work by the standard of reasonable and necessary.

Device companies must play a role in evidence generation to positively impact reimbursement, not only for themselves, but for their customers. One way to do that is to be published in the literature and presented at meetings.