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Confusedmom
04-13-2011, 10:57 PM
From today's Wall Street Journal (online edition)

HEALTH INDUSTRY APRIL 13, 2011.

Hospital Bars Surgeon From Operating Room

Medical Board in Oregon Separately Investigates Doctor Who Stood Out for High Rate of Multiple Spinal Procedures.

By JOHN CARREYROU And TOM MCGINTY

A Portland, Ore., neurosurgeon who performed multiple spinal fusions on the same patients lost his operating privileges at the hospital where he did many of his surgeries and is under investigation by the Oregon Medical Board.

Providence Portland Medical Center revoked Vishal James Makker's surgical privileges last week following a March 29 article in The Wall Street Journal that identified Dr. Makker as having the highest rate of multiple spinal-fusion surgeries among 3,407 surgeons who performed the procedure on 20 or more Medicare patients in 2008 and 2009.

Dr. Makker's rate was nearly 10 times the national average, a Journal analysis of Medicare claims data showed. Dr. Makker, who operated on some of his patients' spines as many as seven times, last month denied wrongdoing and said he acted in the best interest of his patients.

Oregon's medical board has also opened an investigation into Dr. Makker, according to two people familiar with the matter. One of these people was recently interviewed by board representatives and Federal Bureau of Investigation agents as part of the probe. The FBI didn't return a call for comment. Dr. Makker's lawyer declined to comment.

The Oregon board forced Dr. Makker to undergo remedial training in 2006 for what it called unnecessary surgeries and for allegedly billing for procedures he didn't perform, but his status is listed as active on its website. A malpractice lawsuit—the ninth in less than seven years—was filed against Dr. Makker last week.

A spokesman for Providence Portland declined to say why it withdrew his privileges.

The latest developments came as new information emerged about the medical-device distributorship that supplies Dr. Makker with spinal implants. The distributor, Omega Solutions of Fresno, Calif., sometimes pays surgeons to use its products, according to a document reviewed by the Journal that Omega recently sent to surgeons it sought to recruit.

The document says that the company enters into partnerships with surgeons who agree to use its products and pays them "dividends" based on the number of surgeries they perform. Critics say such arrangements are controversial because they can skew medical decision-making.

The document details the cash payments made to one of Omega's partners, an unnamed spine surgeon in Los Angeles. From Jan. 1, 2009, to May 19, 2010, the surgeon received a total of $519,674.35 based on his use of Omega implants in two to three surgeries a week, the document says.

Dr. Makker told colleagues at Providence Portland Medical Center that he was a partner in Omega's business, according to a person familiar with the matter. Through his lawyer, Dr. Makker denied this.

Ted Switzer, the chief executive of Omega, said the company wasn't involved in a partnership with Dr. Makker that paid him to use its products, and declined to answer any other questions. Robert Zendejas, the Omega employee whose name is on the company's marketing document, hung up on a reporter when reached by phone.

Physician-owned distributorships, or PODs, such as the ones outlined in the Omega document have spread through spine-surgery circles. Distributorships act as middlemen between medical-device makers and the hospitals and surgery centers that buy their products. In exchange for marketing the devices and nurturing client relationships, they get a cut of each sale.

For a distributorship, winning the allegiance of surgeons is crucial because surgeons often dictate to their hospitals which devices to buy. By offering surgeons an ownership interest in their operations, distributorships can lock up a hospital's business while allowing the surgeon to profit from each device he uses, according to people familiar with how PODs function.

Critics say such deals have contributed to a jump in spine surgeries. Spinal fusion, which involves fusing together two or more vertebrae with the help of thousands of dollars of hardware, went from costing Medicare $343 million in 1997 to $2.24 billion in 2008, according to a Journal analysis of Medicare claims data.

The Office of Inspector General of the Department of Health and the Centers for Medicare and Medicaid Services have both warned that PODs may violate federal antikickback statutes and laws governing patient referrals.

Mr. Switzer, the Omega Solutions CEO, is listed in California corporate records as a partner in a half-dozen limited liability companies named after letters in the Greek alphabet. Asked whether they are PODs, Mr. Switzer declined to comment.

Dr. Makker's use of Omega implants raised eyebrows at Providence Portland Medical Center because Omega's product representative in Portland, Erin Martinson, is Dr. Makker's girlfriend, according to three people with knowledge of their relationship. Ms. Martinson was often present in the operating room with Dr. Makker to hand him the Omega implants during his surgeries there.

Ms. Martinson didn't return phone calls. In an email last month, Dr. Makker denied having a romantic relationship with Ms. Martinson, saying she was merely a friend.

Write to John Carreyrou at john.carreyrou@wsj.com and Tom McGinty at tom.mcginty@wsj.com

Copyright 2011 Dow Jones & Company, Inc.

Pooka1
04-14-2011, 06:36 AM
There is a known problem with overuse of spinal fusion surgery for non-scoliosis conditions. This is almost certainly what is going on with Makker.

This doesn't apply to fusion for scoliosis. People with scoliosis who need surgery get it and people who don't don't. This is largely true for adults and nearly completely true for kids. There is no unnecessary fusion for scoliosis so the issue with Makker is interesting though irrelevant here.

Whether a surgeon uses instrumentation A versus instrumentation B is not a pertinent question if the patient needs instrumentation and both instrumentation sets solve the problem.

The fact that some surgeons might make money on certain instrumentation doesn't majick away the need of the patient for the fusion for scoliosis.

Elisa
04-14-2011, 10:09 AM
I clicked on the article, read 'hospital bans surgeon from operating room' 'scoliosis' 'Portland Oregon' and my heart sank. Never read an article so fast in my life, lol.

Pooka1
04-14-2011, 11:14 AM
I clicked on the article, read 'hospital bans surgeon from operating room' 'scoliosis' 'Portland Oregon' and my heart sank. Never read an article so fast in my life, lol.

I'm confused.

What did you click? The only clickable thing in the OP was the authors email addies.

Where do you see the word, "scoliosis" anywhere in this article? This article is NOT about scoliosis fusions and in fact is not relevant to them.

Elisa
04-14-2011, 11:19 AM
You're right Pooka, no mention of scoliosis, it was "spinal fusion" that caught my eye as well as "Hospital Bars Surgeon From Operating Room" and "Portland, Oregon".

Pooka1
04-14-2011, 11:29 AM
You're right Pooka, no mention of scoliosis, it was "spinal fusion" that caught my eye as well as "Hospital Bars Surgeon From Operating Room" and "Portland, Oregon".

Linda can correct me if I'm wrong but I think the vast majority of spinal fusions are done for back pain or other orthopedic issues not to include scoliosis. They are NOT done for scoliosis.

The main problem is that, as I understand it, this majority of spinal fusions done for back pain apart from scoliosis cases do NOT result in less pain afterwards. So it's a boondoogle basically and ripe for moral turpitude like that in the article.

This is exactly the opposite situation for spinal fusions for scoliosis where most people end up with less pain afterwards. Many end up with no pain.

That's why this article is irrelevant to scoliosis. If a person needs fusion to treat scoliosis, it is simply irrelevant if the surgeon is making little or lots of money using one set of instrumentation instead of another assuming both sets will treat the patient equally well. That's a matter for the insurance companies to hash out, not the patients who need the fusions.

The bottom line is there is no evidence that people with scoliosis get unnecessary fusions. Rather it is the opposite... some people who could be helped by fusion don't avail themselves of it. The number of cases of diagnosed kids who need fusion for AIS who DON'T get it are vanishing and largely limited to folks with no access to medical care I imagine.

Elisa
04-14-2011, 11:39 AM
When I fist skimmed the article and saw that a surgeon who did spinal fusions in Portland, Oregon was banned from a hospital my heart did give a skip b/c obviously I am here in Portland waiting for my son to have spinal surgery on Tuesday so I'm a bit jumpy and certainly didn't want to see Dr. K's name on there, heh.

Okay, now that hdugger has brought up the price of screws, I have been very curious to know just how much do you guys figure these rods and screws etc. actually cost. I have read on other posts that they are VERY expensive but would like more of a ballpark figure as to what they actually cost: $500? 5K? more?

Pooka1
04-14-2011, 11:41 AM
When I fist skimmed the article and saw that a surgeon who did spinal fusions in Portland, Oregon was banned from a hospital my heart did give a skip b/c obviously I am here in Portland waiting for my son to have spinal surgery on Tuesday so I'm a bit jumpy and certainly didn't want to see Dr. K's name on there, heh.

Okay, now that hdugger has brought up the price of screws, I have been very curious to know just how much do you guys figure these rods and screws etc. actually cost. I have read on other posts that they are VERY expensive but would like more of a ballpark figure as to what they actually cost: $500? 5K? more?

Linda will know but I think it's on the order of $30K or more for a "typical" scoli fusion.

Elisa
04-14-2011, 11:47 AM
Linda will know but I think it's on the order of $30K or more for a "typical" scoli fusion.
That is about the number that I read a while back. I was talking to my sister the other day on the phone and I was telling her about how expensive the surgery was as well as how expensive the hardware was and she joking said: "Well I guess that's why they never took Elias on at BC Children's".

So, if he has 8 screws in him so far... he has a pretty expensive back already. ;-)

Pooka1
04-14-2011, 11:56 AM
That is about the number that I read a while back. I was talking to my sister the other day on the phone and I was telling her about how expensive the surgery was as well as how expensive the hardware was and she joking said: "Well I guess that's why they never took Elias on at BC Children's".

So, if he has 8 screws in him so far... he has a pretty expensive back already. ;-)

Both my kids have a 10 level fusion with about 15 screws and about 2 hooks iirc. There is at least one cross member on each construct. It's been a while but I seem to recall the instrumentation cost on the first kid (March 2008) as being about $18K. I could be wrong. The entire thing including instrumentation came to about $75K for the first kid. I am guessing it was the same for the second.

LindaRacine
04-14-2011, 12:53 PM
Linda can correct me if I'm wrong but I think the vast majority of spinal fusions are done for back pain or other orthopedic issues not to include scoliosis. They are NOT done for scoliosis.

The main problem is that, as I understand it, this majority of spinal fusions done for back pain apart from scoliosis cases do NOT result in less pain afterwards. So it's a boondoogle basically and ripe for moral turpitude like that in the article.

This is exactly the opposite situation for spinal fusions for scoliosis where most people end up with less pain afterwards. Many end up with no pain.

That's why this article is irrelevant to scoliosis. If a person needs fusion to treat scoliosis, it is simply irrelevant if the surgeon is making little or lots of money using one set of instrumentation instead of another assuming both sets will treat the patient equally well. That's a matter for the insurance companies to hash out, not the patients who need the fusions.

The bottom line is there is no evidence that people with scoliosis get unnecessary fusions. Rather it is the opposite... some people who could be helped by fusion don't avail themselves of it. The number of cases of diagnosed kids who need fusion for AIS who DON'T get it are vanishing and largely limited to folks with no access to medical care I imagine.
Since my involvement has always been with spinal deformity surgeons, my only experience with these other surgeons is from what I read. My understanding is that there are a lot of surgeons who take almost every back pain patient to fusion surgery. It's a highly effective surgery, but is unneeded in a large percentage of patients who see this type of surgeon. And, if the surgeon is using an implant for which s/he receives some sort of royalty, the profit can be huge.

On the subject of surgeons designing and manufacturing implants, the debate isn't an easy one. If we had to depend on non-surgeons to design implants, we would not be nearly as far along in terms of the technology of spinal surgery, especially in terms of spinal deformities. I really hate insurance companies, but this is one time where they have the potential to do a lot of good. I can't imagine how they let Makker get away with what he did.

I don't know much about the cost of the implants any more, but $5,000 per screw (especially if it's titanium or one of the other more recent technology metals), sounds about right.

Regards,
Linda

Ballet Mom
04-14-2011, 01:00 PM
Here's a recent study regarding AIS patients (includes total cost, not just instrumentation). Adult and revision surgeries would probably be much more expensive.


Cost Varies by Region in Spinal Fusion for Scoliosis

Per-patient average charge ranges from $103,256 to $152,637; length of stay also varies

Scott D. Daffner, M.D., of West Virginia University in Morgantown, and colleagues extracted records from a national insurance billing database on 76,741 idiopathic scoliosis patients (aged 10 to 24), 955 of whom underwent fusion surgery during 2004 to 2006.

Overall, the researchers found that the per-patient average charge (PPAC) for the procedure was $113,303 with an average LOS of 5.6 days. PPAC varied by region, with the West highest at $152,637 and the South lowest at $103,256. LOS was lowest in the South (5.2 days) and highest in the Midwest (6.5 days).

http://www.modernmedicine.com/modernmedicine/Family+Medicine/Cost-Varies-by-Region-in-Spinal-Fusion-for-Scolios/ArticleNewsFeed/Article/detail/672724

LindaRacine
04-14-2011, 01:13 PM
Here's a recent study regarding AIS patients (includes total cost, not just instrumentation). Adult and revision surgeries would probably be much more expensive.


Cost Varies by Region in Spinal Fusion for Scoliosis

Per-patient average charge ranges from $103,256 to $152,637; length of stay also varies

Scott D. Daffner, M.D., of West Virginia University in Morgantown, and colleagues extracted records from a national insurance billing database on 76,741 idiopathic scoliosis patients (aged 10 to 24), 955 of whom underwent fusion surgery during 2004 to 2006.

Overall, the researchers found that the per-patient average charge (PPAC) for the procedure was $113,303 with an average LOS of 5.6 days. PPAC varied by region, with the West highest at $152,637 and the South lowest at $103,256. LOS was lowest in the South (5.2 days) and highest in the Midwest (6.5 days).

http://www.modernmedicine.com/modernmedicine/Family+Medicine/Cost-Varies-by-Region-in-Spinal-Fusion-for-Scolios/ArticleNewsFeed/Article/detail/672724

These numbers include hospitalization and surgeon fees, so there's no way to know what the cost of the implants is.

Ballet Mom
04-14-2011, 01:22 PM
That is about the number that I read a while back. I was talking to my sister the other day on the phone and I was telling her about how expensive the surgery was as well as how expensive the hardware was and she joking said: "Well I guess that's why they never took Elias on at BC Children's".

So, if he has 8 screws in him so far... he has a pretty expensive back already. ;-)

I'm sure the cost of your son's stay is much greater than the average scoliosis surgery due to the halo treatment and length of stay. Your son is receiving donated care that most kids with those size curves do not receive. The girl water polo player that I mentioned that had a 112+ degree curve after waiting to play in her state finals had just a regular scoliosis surgery, with no halo treatment, etc. The surgeon recalls the surgery as "very difficult" as he had to move that large curve in one big session. Kids from this country do not receive insurance payments to stay for weeks at the hospital with a halo on. That seems to be a Shriners feature.

I'm sure that's why you received the response you did from the surgeon you don't care for. It's not like you're going to be given a choice of instrumentation should you not like the set being provided.

I'm just glad there are kind old men willing to provide money for the wonderful treatment these kids receive with these conditions, without knowing them, and from countries that like to say they have universal care. God bless them.

Ballet Mom
04-14-2011, 01:23 PM
These numbers include hospitalization and surgeon fees, so there's no way to know what the cost of the implants is.

Yes, I deliberately stated that the study included total costs, not just instrumentation. People were quoting total costs, so I added to the conversation.

Elisa
04-14-2011, 01:28 PM
Interesting article though. Still, at about $150K for scoliosis surgery for an average stay of 5 days in the hospital compared to: $150K for scoliosis surgery + posterior release surgery with halo application + 5 weeks stay in hospital (with parent) + 24 hr. nursing care + physio care + school teachers + transportation to and from hometown to Portland + hotels & meals + some other stuff I probably don't even know about. WOW, I can only imagine what the grand total of all this is going to be. I think I need to buy a LOT of Shriners raffle tickets when I get back home.

Edit: Ballet Mom, I typed out my response before I read your last one and agree with everything you said. If my son had been seen in a timely manner in BC then we would not have been forced into this extremely expensive route. Don't agree with your statement about the other surgeon though as he should NEVER answer anyone by saying: "Why do you care?" Just wrong. All around wrong, tasteless and rude. No excuse. It wasn't about me "refusing" a certain type of metal, I was just curious what they were planning on using.

Elisa
04-14-2011, 02:02 PM
Your son is receiving donated care that most kids with those size curves do not receive. The girl water polo player that I mentioned that had a 112+ degree curve after waiting to play in her state finals had just a regular scoliosis surgery, with no halo treatment, etc. The surgeon recalls the surgery as "very difficult" as he had to move that large curve in one big session. Kids from this country do not receive insurance payments to stay for weeks at the hospital with a halo on. That seems to be a Shriners feature.


I'm not familiar with the 'water polo girl' that you're referring to but according to Dr. K surgeons rarely see kids with massive curves b/c they are corrected much sooner. I'm sure regular medical insurance allows kids in the US who have been diagnosed with scoliosis to see a specialist relatively quickly if they have been referred? That's the feedback I'm getting while down here. Let's just look at this hospital we're in right now, there's 3 spinal surgeons who practice here. There are 2 spinal surgeons who deal with kids in the entire province of BC which has 1 million kids. The kids with the big curves they see here and mainly from Canada. Sad but true. I am just thankful that the BC Shriners are still active in our community otherwise... I can't even go there b/c it's too scary and gives me nightmares and anxiety attacks. That's why I recently joined a 'cause' on facebook to fix this particular mess and I hope it does make a difference soon for other kids and their parents who are going through this very thing.

Elisa
04-14-2011, 02:19 PM
While I'm on my BC rant, check out this article. Looks like they're spending a boatload of money to build a new kids hospital. Is this really going to cut down the wait times for kids' surgeries? Why aren't they spending money to bring in surgeons to help out with the workload burdened on those TWO they already have? Yeah, we'll have a brand new gorgeous kids hospital to awe at but you'll still have to wait until your kid turns into a pretzel and can't breathe... and you still don't get an appointment. I left a comment but I doubt very much it will ever get posted.


these donations will ensure that BC’s one million children will have access to the finest medical care our hospital can provide.
^^ This is such an oxymoron. Yes, the kids will get the finest medical care the hospital can provide... with those 2 surgeons available for 1 million kids, LOL

http://www.bcchf.ca/blog/?p=1438

Ballet Mom
04-14-2011, 02:21 PM
Edit: Ballet Mom, I typed out my response before I read your last one and agree with everything you said. If my son had been seen in a timely manner in BC then we would not have been forced into this extremely expensive route. Don't agree with your statement about the other surgeon though as he should NEVER answer anyone by saying: "Why do you care?" Just wrong. All around wrong, tasteless and rude. No excuse. It wasn't about me "refusing" a certain type of metal, I was just curious what they were planning on using.

Surgeons are known for their surgical skills, not necessarily known for their bedside manner. All doctors get tired of answering questions from patients with a little dangerous knowledge learned off of the internet. My sister even complains about it (a doctor). Doctors and surgeons have very limited time to spend with the patient to answer questions, I'm sure he doesn't want to start a conversation about the metallurgical properties of different implant systems with you.

I personally find it "wrong, tasteless and rude" to be trashing a well-regarded surgeon on the internet for the world to see, when your son is receiving outstanding care. Just my opinion.

Elisa
04-14-2011, 02:30 PM
I asked what kind of rods they were planning to use. All he had to say was: cobalt-chromium-molybdenum. I had a pen in hand to write it down and Google it. He is not caring for my son, Dr. Krajbich is. You are entitled to your opinion which you express freely and often. I am entitled to mine. End of story.

Ballet Mom
04-14-2011, 02:56 PM
I've been trying to figure out the role of insurance companies recently. It would seem as if it would be to their advantage to vigorously investigate medical fraud and overcharges, but that doesn't seem to be the case. I've wondered if maybe they're afraid of having an antagonistic relationship with doctors for fear that doctors will no longer accept their insurance.


The insurance companies have started to clamp down on some spine surgeries:


"A collection of nine medical associations is arguing against new restrictions on spinal-fusion surgery set by a health insurer in North Carolina amid concerns such restrictions could limit patient care and spread to other states.

Whether the groups can alter the new rules from Blue Cross and Blue Shield of North Carolina, which go into effect Jan. 1, remains to be seen. But the response is evidence doctors are joining forces to battle ongoing insurance pressure on the spinal-fusion market. Several spinal device-makers, most recently NuVasive Inc. (NUVA), have cited signs insurers are raising barriers to such procedures amid concerns they're over-utilized.

Doctors worry the new policy in North Carolina, which is seen as particularly restrictive, could further dampen an already slowed market if it spreads elsewhere.

"We certainly see that once even a local area starts coming up with these policies, others may start adopting it," said Joseph Cheng, who directs the neurosurgery spine program at Vanderbilt University Medical Center in Nashville, Tenn. He also serves on the coding and reimbursement team for the American Association of Neurological Surgeons, which co-signed the letter.

The letter was sent last week and also signed by the American Association of Orthopaedic Surgeons, the Scoliosis Research Society and the North American Spine Society, among other groups. They said they "have concerns regarding the criteria and guidelines" in the new coverage policy, and they proposed less restrictive language.

That policy includes detailed descriptions of conditions for which fusion surgery in the lower back should and shouldn't be covered. In one case, the new policy denies coverage for patients with degenerative disc disease. There is also new requirement for prior authorization before patients get surgery.

http://online.wsj.com/article/BT-CO-20101222-712475.html

LindaRacine
04-18-2011, 10:39 PM
I got my insurance company explanation of benefits for my January surgery today. The cost of the implants was $45,213 (of which BC allowed $22,607, exactly half). My implants included 3 cages, 2 SS rods (L2-S1), 10 SS pedicle screws, one iliac bolt, and 2 connectors (connecting the new implants to the old). I didn't receive any detailed invoice from the hospital, so I don't know how much each screw was, but obviously, they were pretty expensive.

The overall hospital bill for the OR, implants, and 5 days in the hospital was $261,125, which does not include the professional fees.

--Linda

jrnyc
04-18-2011, 11:35 PM
i agree, Elisa, that the reply was snotty! i don't know if the guy meant it to be snotty, but it was! and...no doctor of any kind should ever ask a parent why they care about something concerning their child!! he could have said a lot of other things...like "there is only one form of instrumentation we can use" or "there is only one appropriate to his needs, and the name of it is_____" or whatever....what he said was so obnoxious, i would have been yelling at him as soon as i closed my mouth from being open in shock!

something appropriate to say a thank you that is almost impossible to put into words...saving Elias' life....is hard to think of....
perhaps a really beautiful letter to the President of the hospital...praising Elias' surgeon, and also naming and praising whomever on the staff have been sweet to him....most all people in all kinds of work like to be praised by name....i found that to be true in department stores and in medical offices, so i bet it is true in hospitals as well....plus of course you could include a big thank you to Shriners itself...

thinking of Elias, and you, for the surgery and after...
jess

LindaRacine
05-07-2011, 02:01 PM
Recent publication quoting implant cost. Note that 1) this is from Europe (which could make a huge difference), and it's hard to know whether "cost" refers to the cost to the patient/insurance, the cost approved by insurance companies/Medicare, etc., or whatever.

Eur Spine J. 2011 Apr 26. [Epub ahead of print]
Right adolescent idiopathic thoracic curve (Lenke 1 A and B): does cost of instrumentation and implant density improve radiographic and cosmetic parameters?
Yang S, Jones-Quaidoo SM, Eager M, Griffin JW, Reddi V, Novicoff W, Shilt J, Bersusky E, Defino H, Ouellet J, Arlet V.
Source

Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive Suite 330, Charlottesville, VA, 22903, USA.
Abstract

In adolescent idiopathic scoliosis (AIS) there has been a shift towards increasing the number of implants and pedicle screws, which has not been proven to improve cosmetic correction. To evaluate if increasing cost of instrumentation correlates with cosmetic correction using clinical photographs. 58 Lenke 1A and B cases from a multicenter AIS database with at least 3 months follow-up of clinical photographs were used for analysis. Cosmetic parameters on PA and forward bending photographs included angular measurements of trunk shift, shoulder balance, rib hump, and ratio measurements of waist line asymmetry. Pre-op and follow-up X-rays were measured for coronal and sagittal deformity parameters. Cost density was calculated by dividing the total cost of instrumentation by the number of vertebrae being fused. Linear regression and spearman's correlation were used to correlate cost density to X-ray and photo outcomes. Three independent observers verified radiographic and cosmetic parameters for inter/interobserver variability analysis. Average pre-op Cobb angle and instrumented correction were 54° (SD 12.5) and 59% (SD 25) respectively. The average number of vertebrae fused was 10 (SD 1.9). The total cost of spinal instrumentation ranged from $6,769 to $21,274 (Mean $12,662, SD $3,858). There was a weak positive and statistically significant correlation between Cobb angle correction and cost density (r = 0.33, p = 0.01), and no correlation between Cobb angle correction of the uninstrumented lumbar spine and cost density (r = 0.15, p = 0.26). There was no significant correlation between all sagittal X-ray measurements or any of the photo parameters and cost density. There was good to excellent inter/intraobserver variability of all photographic parameters based on the intraclass correlation coefficient (ICC 0.74-0.98). Our method used to measure cosmesis had good to excellent inter/intraobserver variability, and may be an effective tool to objectively assess cosmesis from photographs. Since increasing cost density only improves mildly the Cobb angle correction of the main thoracic curve and not the correction of the uninstrumented spine or any of the cosmetic parameters, one should consider the cost of increasing implant density in Lenke 1A and B curves. In the area of rationalization of health care expenses, this study demonstrates that increasing the number of implants does not improve any relevant cosmetic or radiographic outcomes.