Social and Legal Ramifications of Spine Care: The Challenges

Challenges abound in our quest to define the “Social and Legal Ramifications of Spine Care.” These challenges exist not only in regards the present-day practice of spinal surgery but particularly with regard to delineating the “value” of spinal treatments to patients and society as a whole as healthcare reform is implemented in the United States. The principles of comparative effectiveness research (CER) have been adopted as parameters for measuring “value” in healthcare reform legislation. The CER approach uses economic analyses such as cost-effectiveness to deduce whether a particular intervention will be reimbursed. The conclusion of a cost-effectiveness analysis will be generally expressed as a cost (in $, €, £, etc) per patient gain in quality-adjusted life year (QALY). The National Institute for Health and Clinical Excellence in the United Kingdom has set a threshold of £30,000 (approximately 50,000 US dollars) per QALY gained as a ceiling for recommending a procedure be reimbursed under the UK National Health Service. No definite criteria have been set in the United States. Defining the value of spine care to society has a number of unresolved issues. These include who should define value (patients, physicians, government), how should we measure value (CER, clinical outcomes, direct cost only vs including indirect costs), and how much is society willing to pay for spine care ($50,000 per QALY as in the United Kingdom or should it be more in the United States). We will define many of these issues in the challenges article and leave subsequent authors in this issue to expound the details so that readers have a greater understanding of the challenges faced by us all in terms of defining the societal value of spine care. The final challenge, of course, is applying the value principles in a practice environment where many clinical decisions are influenced by legal ramifications. Important information for practitioners will be imparted in the final article of this issue.