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CWCI Measures the Cost and Characteristics of California WC Spinal Fusion Claims

Oakland -- A new study on the use of spinal fusion surgeries in California workers’ compensation finds that in 60% of all spinal fusion claims the initial report of injury was for a sprain or strain; a majority of the fusions occurred within two years of the injury; and as the claims aged, more than 20% involved at least one subsequent fusion surgery. 

The analysis by the California Workers’ Compensation Institute (CWCI) is based on data from more than 18,266 California work injury claims from accident years (AY) 2000 through 2014 in which one or more spinal fusions were performed. Using claims data from the Institute’s Industry Research Information System database, CWCI Senior Research Associate Stacy L. Jones identified spinal fusion claim characteristics (cause and nature of injury, part of the spine that was fused and the number of spinal segments involved); patient demographics; the presence of comorbidities; and the average amounts paid in indemnity and medical benefits. In addition the study measured the timing of the initial fusion and the presence and timing of any subsequent fusions; independent medical review outcomes for spinal fusion requests; utilization trends for MRIs, pre- and post-surgery physical therapy, and the level of pre- and post-surgical opioid use. Among the findings:

• Men accounted for more than 64% of the spinal fusion claims in each of the 15 years studied, and average amounts paid across the entire span were higher for males than females (15.5% more for temporary disability; 27.1% more for permanent disability; and 16% more for medical).
• 62% of the claims that involved a spinal fusion were initially reported as strain and sprains; followed by cumulative traumas (including mental stress), which comprised 14%.
• Lumbar fusions accounted for nearly half of the workers’ comp spinal fusions; while fusions involving additional vertebral segments (i.e., multiple-level fusions) represented 1/3 of all fusions.
• Mental health disorders were the leading comorbidity (noted in 37% of spinal fusion cases), while 29.9% involved circulatory problems, and 17.1% listed substance abuse as a comorbid condition.
• Loss payments on medical back diagnoses without spinal cord involvement averaged as much as $378,392 in AY 2003, or 6.7 times the average for similar claims without a spinal fusion.

The Institute has published a full report on the study, including additional results, background information, tables, and commentary as a CWCI Report to the Industry, “Spinal Fusion Claims in California Workers’ Compensation.” CWCI members and subscribers may log on to the Research section at www.cwci.org to access the report, while others may purchase the report for $32 from http://www.cwci.org/store.html.