Economics of Sinus Surgery Evaluated

by David Bronstein •

The lack of such clinical data is exactly why Dr. Rudmik embarked on the economic model described in The Laryngoscope study. “We don’t yet have the definitive head-to-head trial to make these determinations,” he said. “But we do have our paper, and I think the data we cite is a good start.”

Are the findings good enough to serve as ammunition when fighting an ESS payment denial by a government or private payer? “It’s worth a try,” Dr. Smith said. “But remember, payers tend to take a short-term view of cost because of patient migration off their plans. So that initial $7,500 higher cost for sinus surgery, unfortunately, is what resonates most with many insurers—not any downstream benefits.”

For Dr. Rudmik, that type of short-term outlook is unfortunate. “I would challenge payers to find ways to serve the patient rather than ways to maximize profit. If they figured out ways to make their patients healthier and happier under their plans—such as paying for sinus surgery, which we’ve shown yields favorable long-term cost effectiveness—then maybe they wouldn’t be so likely to shop around for different coverage. Payers may well be surprised at how much patient retention—and savings—they could achieve.”

David Bronstein is a medical writer based in New Jersey.

The Payer’s Perspective

Several payers contacted by ENTtoday challenged the idea that they only take a short-term view when deciding on ESS reimbursement. Cynthia B. Michener, a spokeswoman for Aetna, a top-ten insurer in the United States, said in an e-mail that the company’s coverage for sinus surgery “is based on the clinical evidence, including short- and long-term outcomes, rather than cost.”

Julie Kessel, MD, senior medical director for coverage policy, Cigna, also downplayed—but did not dismiss—the role of cost in these coverage determinations. “Cigna makes its assessment of the proven effectiveness of a procedure based on the scientific evidence,” Dr. Kessel said. “We look for evidence that supports an intervention leading to beneficial clinical outcomes. Cost is not a factor in making such assessments; however, in the case of two equally effective treatments, the more costly alternative may not be recommended for coverage.”—DB

Patient Selection Criteria for ESS

  1. All patients received a full otolaryngic history, physical exam, nasal endoscopy, and computed tomography scan of the paranasal sinuses to ensure accurate diagnosis of CRS based on the American Academy of Otolaryngology-Head and Neck Surgery Adult Sinusitis Clinical Practice Guideline.
  2. All of the patients were deemed to have persistent symptoms of CRS despite the following treatment protocol:
    • A minimum of three months topical steroid therapy;
    • A minimum of seven days of systemic corticosteroid therapy; and
    • A minimum of 14 days of broad-spectrum systemic antibiotic therapy.

Source: Laryngoscope. Published online ahead of print September 3, 2014. doi: 10.1002/lary.24916