1. 2010;13;199-212Analysis of the Growth of Epidural Injections and Costs in the Medicare Population: A Comparative Evaluation of 1997, 2002, and 2006 Data
   Health Policy Review
   Laxmaiah Manchikanti, MD, Vidyasagar Pampati, MSc, Mark V. Boswell, MD, PhD, Howard S. Smith, MD, and Joshua A. Hirsch, MD.

BACKGROUND: Interventional techniques for the treatment of spinal techniques are commonly used and are increasing exponentially. Epidural injections and facet joint interventions are the 2 most commonly utilized procedures in interventional pain management. The current literature regarding the effectiveness of epidural injections is sparse with highly variable outcomes based on the technique, outcome measures, patient selection, and methodology.

Multiple reports have illustrated the exponential growth of lumbosacral injections with significant geographic variations in the administration of epidural injections in Medicare patients. However, an analysis of the growth of epidural injections and costs in the Medicare population has not been performed with recent data and has not been looked at from an interventional pain management perspective.

STUDY DESIGN: Analysis of epidural injection growth and costs in Medicare’s population 1997, 2002, and 2006.

OBJECTIVES: The primary purpose of this study was to evaluate the use of all types of epidural injections (i.e. caudal, interlaminar, and transforaminal in lumbar, cervical and thoracic regions), and other epidural procedures, including epidural adhesiolysis. In addition, the purpose was to identify trends in the number of procedures, reimbursement, specialty involvement, fluoroscopy use, and indications from 1997 to 2006.

METHODS: The Centers for Medicare and Medicaid Services (CMS) 5% national sample carrier claim record data from 1997, 2002, and 2006 was utilized.

OUTCOMES ASSESSMENT: Outcome measures included Medicare beneficiaries’ characteristics receiving epidural injections, epidural injections by place of service, type of specialty, reimbursement characteristics, and other variables.

RESULTS: Epidural injections increased significantly in Medicare beneficiaries from 1997 to 2006. Patients receiving epidurals increased by 106.3%; visits per 100,000 population increased 102.7%.

Hospital outpatient department (HOPD) payments increased significantly; ASC average payments decreased; overall payments increased. The increase in procedures performed by general physicians outpaced that of interventional pain management (IPM) physicians.

LIMITATIONS: Study limitations include no Medicare Advantage patients; potential documentation, coding, and billing errors.

CONCLUSIONS: Epidural injections grew significantly. This growth appears to coincide with chronic low back pain growth and other treatments for low back pain. Since many procedures are performed without fluoroscopy, continued growth and inappropriate provision of services might reduce access.