With reimbursement change, ELIH’s promising spinal procedure could be in jeopardy

08/25/2011 6:02 AM |

When Eastern Long Island Hospital pain specialist Dr. Frank Adipietro added a new procedure to his treatment options last May, he and hospital officials hailed it as a major breakthrough for patients who suffer spinal stenosis, a common cause of back and leg pain.

Not only has Dr. Adipietro had excellent results in relieving pain, the procedure, called minimally invasive lumbar decompression, was seen as a potential boon to the hospital’s finances, according to ELIH president and CEO Paul Connor III.

With an aging patient population, the hospital viewed the $6,000 procedure as a revenue generator. As with many local hospitals, ELIH’s operating expenses regularly exceed revenues and the hospital counts on both donations and innovative procedures to cover the gap,

Just a few months after first offering the procedure, which the hospital says provides remarkable pain relief, ELIH may find itself having to absorb the cost on procedures completed since July 1, Mr. Connor said. Patients scheduled for the procedure have been notified to keep their dates for the outpatient operation open, but they have also been told Medicare reimbursements are in doubt.

This situation is the result of a Medicare billing code change effective July 1, Mr. Connor said.

“We’re concerned about all those who need it and may not be able to get the treatment,” he said. For those who had the procedure since July 1 thinking Medicare would foot much of the bill, there’s no worry.

“We’re obviously not going to bill those patients,” Mr. Connor said. Meanwhile, he and his financial staff are pursuing appeals to secure Medicare coverage for those in need of the MILD procedure, he said. About 99.5 percent of patients diagnosed at ELIH as likely to benefit from MILD are Medicare recipients, he said.

ELIH isn’t alone in its experience. Practiced around the country since about 2008, MILD is still classified as experimental and under investigation, according to Medicare. The Houston-based North American Spine Institute partners with doctors in various Texas practices, and University General Hospital in Texas has been offering the procedure since 2008. But doctors partnering with the institute have all opted out of Medicare because they would receive less than a one percent reimbursement, according to an institute spokeswoman.

Similarly, an Internet search reveals many doctors throughout the country are reporting great pain relief and enhanced mobility for patients undergoing MILD. But many also report little luck in gaining reimbursement from Medicare or other insurers.

The procedure involves using fluoroscopic imaging that enables the doctor to remove portions of bone adjacent to the narrowed area, thereby restoring space in the spinal canal and relieving pain, according to ELIH. It’s an outpatient procedure performed using a local anesthetic and light sedation.

Dr. Adipietro does provide more conservative treatments, including epidural steroid injections, but when these fail to provide sufficient relief, MILD offers effective treatment by opening the spinal canal that has been compressing nerve tissues and causing pain, numbness and disability, he said.

“This narrowing or stenosis in the lower back, called lumbar spinal stenosis, is a common cause of low back or leg pain, and is diagnosed in 1.2 million patients annually in the USA,” according to the hospital’s website.

“I see many people with lumbar spinal stenosis and we now have a longer-lasting treatment option for this disease,” Dr. Adipietro is quoted as saying on the website.

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