10 Key Trends in Spine Surgery for 2013
1. Coverage denials will continue among many payors. This year more than ever, spine surgeons are reporting coverage denials from insurance companies for surgery as well as other procedures and tests.
"The last two years have been extremely challenging," says Neel Anand, MD, director of spine trauma, minimally invasive spine surgery at Cedars-Sinai Spine Center in Los Angeles. "Seemingly, everything is being denied, including MRIs and CT scans. We spend at least 50 percent of our time, compared to two years ago, getting approval for patients and talking to non-medical personnel. Sometimes even then, we aren't able to get clearance for the surgery."
The inability to treat patients quickly and efficiently could lead to health problems in the future, especially for patients with degenerative conditions.
"It really has become a vicious and ineffective cycle that I think will adversely affect patient care," says Dr. Anand. "It is delaying patient care and it's really sending them backwards. There is a very finite window for treatment, and that's become apparent now. If we are able to tackle the problem right away, patients can go back to work and their regular life. On the flip side, if the back pain digresses and they are unable to work for a year or more, patients don't tend to do as well."
Professional societies are responding to payors and advocating in Washington, DC, so patients can receive the care they need without bankrupting the healthcare system.
"I know the North American Spine Society is trying to start a registry to gather evidence," says Jeffrey C. Wang, MD, vice chair of clinical operations in the UCLA department of orthopedic surgery and chief of the orthopedic spine service at the UCLA Comprehensive Spine Center. "Whenever there is a new code or issue, NASS is there to respond and have an evidence-based approach. When payors announce an inappropriate coverage decision, NASS responds."
2. All surgeons must gather data and practice evidence-based medicine. Insurance companies are increasingly implementing coverage guidelines that exclude patients and services from coverage that traditionally would have been approved in the past. The most glaring example in spine surgery is the Milliman guidelines, which have been adopted by insurance companies across the country.
"It's becoming harder and harder to take care of our patients and deal with the payors," says Dr. Wang. "Because of the Milliman guidelines, when we try to authorize surgery for our patients we are getting push back from our payors. We need to advocate on the behalf of the patients and say these guidelines aren't accepted by the medical community."
The Milliman guidelines recommend continued conservative treatment for patients who were considered candidates for spinal fusion in the past, particularly those presenting with just degenerative disc disease. The guidelines are based on hand-picked, outdated studies that many surgeons reject in favor of new, higher quality studies.
"Payors are adding these guidelines and there is very little evidence that they are appropriate," says Dr. Wang. "We as spine surgeons have to collect evidence and outcomes — whether it is from registries or good prospective studies, to show what works and what doesn't. There are some things we can work on and it's incumbent upon the surgeons themselves to gather the evidence for these things and show what will be successful for our patients."
The implementation of EMR and other healthcare IT may make this process easier in the future. "The one good thing coming out of EMR is that it will gather our data and show our treatments work," says Dr. Wang. "I think that's going to result in better outcomes. I think gathering outcomes and doing the surgeries that work is important. It may be harder for people in private practice to do it, but it's more important because private practices are dwindling and more surgeons are becoming hospital employees."
3. Hospital employment will likely increase. Today's tight regulatory environment, coupled with low reimbursements and rising costs for practice management, mean fewer physicians coming out of medical school are choosing to strike out on their own. Instead, they are becoming hospital employees. Established physicians are also selling their practices to hospitals at an alarming rate in search of more flexible hours and high salaries hospitals are willing to pay.
"The trend of hospital employment of spine surgeons is growing and will continue to grow," says Robert Watkins Jr., MD, co-director of the Marina Spine Center at Marina Del Rey (Calif.) Hospital. "The larger hospital networks are gaining control of masses of patients which will make it more difficult for private practice surgeons. The private practice surgeons need to be able to spend adequate time with their patients and provide outstanding service."
When hospitals begin employing specialists it becomes more difficult for private practice surgeons to drive referrals.
"The opportunities are going to become more constricted as more hospitals hire people to be staff members instead of independent contractors," said Donald Corenman, MD, a spine surgeon with The Steadman Clinic in Vail, Colo. "I think it's going to negatively impact care because doctors will become shift workers and that's going to diminish their quality and continuity of care."
Even when surgeons are not employed by hospitals, hospital executives and leaders are dictating clinical measures, such as which types of implants surgeons can use.
4. Care will need to become more cost-effective. All providers will be pushed further toward delivering the most cost-effective care possible as the government and payors pursue ways to lower healthcare spending and cut costs. Additionally, more patients with high deductible plans will shop for the best value and expect spine surgeons to deliver.
"Reimbursements are declining and they will continue to decline," says Dr. Watkins. "Patients expect better care and more time with doctors, but most people don't want to pay for it."
This trend also holds true for spine innovations. "One of the biggest challenges in the medical profession is dealing with the decreased reimbursement and moving toward more cost-effective measures," says Matt Chong, MD, a spine specialist at White Memorial Medical Center in Los Angeles. "How do we make safer, more reliable implants and keep innovation going while minimizing the cost of developing and using this new technology.”
Striking that equilibrium for better products with fewer complications while meeting lower reimbursement needs will make it more difficult to innovate. However, some innovations we are likely to see in the future include robotic guidance for spine surgery because it delivers higher quality of care.
"Technology will continue to make spine surgery safer and more effective," says Dr. Watkins. "Robotic computer navigation will continue to evolve."
5. Spine care is becoming more interdisciplinary. Spine care providers are now integrating more than in the past to provide patients with a one-stop location for all their spine and back pain needs. Spine surgeons are partnering with all types of non-surgical specialists, including physical therapists, pain management, physicians, massage therapists, chiropractors and acupuncturists to bridge the gap in care.
"Spine surgery can be an isolating profession but at its core, our patients require a multidisciplinary approach," says Dr. Chong. "We need to reconnect with primary care physicians and pain management specialists on a multi-modal approach to care."
Practices are also incorporating MRI, behavioral specialists and other ancillary services into their practice for convenience; patients can have multiple services in the same visit and specialists are able to coordinate care better.
"I think the model that a lot of people are interested in is the 'one-stop shop' approach, where through a single practice site you can see a non-operative specialist or a spine surgeon, as well as a physical therapist, and have access to advanced imaging facilities," says Dr. Chong. "Consolidating all of that is an advantage from a financial perspective and enhances good communication."
It will take considerable skill to lead these practices of the future. "To be a leader at a major institution, a spine surgeon needs to become fluent in the politics of the field," says Dr. Watkins. "To be a leader in private practice, the surgeon needs a marketable trait and [needs] to provide outstanding service to patients."
6. Regulations and lower reimbursement threaten the patient/physician relationship. As more regulations are passed, and healthcare providers struggle to implement electronic medical records, surgeons are spending more time doing administrative and paper work than ever before. While they are still spending time with patients, it has become more difficult for them to carve time out of busy schedules.
"It's a challenge for surgeons comply with the rules, institute EMRs and improve patient satisfaction scores," says Dr. Wang. "A lot of the reimbursement in the future will be based on patient satisfaction. We need to figure out how to maintain our practices and profitability while having good relationships with patients and complying with more rules and regulations."
According to a Medscape 2012 report, around one quarter of orthopedists spend 30 to 40 hours per week seeing patients, slightly higher than last year. However, 20 percent of orthopedists reported spending 10 to 14 hours per week on paperwork and administrative activity; another 29 percent reported spending five to nine hours weekly on non-patient visit work. With the uncertainty surrounding healthcare reform implementation, more regulations are possible in the future.
"Right now, we know what we have to do and we think we know what will be required next year, but they could change the rules at any time," says Dr. Wang. "They could have new rules and regulations in a few years, so it's almost like a moving target."
Another threat to the patient/physician relationship is lower reimbursements, which prompt some surgeons to see more patients per day and spend less time with each patient.
"One of the biggest challenges facing spine surgeons over the next five years is being able to afford to spend enough time with patients to make a proper diagnosis and to properly inform patients of their conditions and potential treatments," says Dr. Watkins. "Patients desire to know more information than in the past, and they want their doctor to answer many questions. These are reasonable expectations from the patient with spinal disability, but with decreasing reimbursement the doctor will less be able to afford to do this."
7. More surgeons will jump on the minimally invasive bandwagon. Over the past five to 10 years, the biggest trend in spine surgery technological development has been less invasive surgical technique. "Minimally invasive approaches are really revolutionizing the field," says Dr. Chong. "At times in the past, we were often limited to offering a patient a more invasive procedure. The advancements and increased adoption of minimally invasive techniques are resulting in shorter hospital stays, less post-operative pain and a reduction in traditional complications."
While most surgeons were initially skeptical of these developments, solid evidence have shown certain techniques and procedures — performed with the same goal as open surgery — have good outcomes while minimizing comorbidities such as pain and blood loss.
"Minimally invasive spine surgery should play a role in the practice of every spine surgeon," says Dr. Watkins. "Surgeons should perform less invasive surgery when they feel confident that it will treat patients' conditions as safely as more invasive surgery. Surgery may be performed as an outpatient [procedure] if the safety is not compromised."
In time, the procedures that don't show clinical and cost improvements will fall out of favor and those with clear, proven benefits will continue to grow.
"There are some procedures that are good and we know work well, but even among these procedures there will be innovation," says Dr. Chong. "We'll want to reduce the rate of revision surgery and maximize long term patient satisfaction. We're also looking for new technology that will make us more accurate and expose surgeons to less radiation."
New developments in minimally invasive procedures for more complex surgeries, such as spinal deformities, are on the horizon and pioneers in the field are already using them.
"I think the minimally invasive correction of spinal deformity is a massive move forward," says Dr. Anand. "It represents a huge paradigm shift in performing major spine surgery. I see that continuing in the future because many centers are adopting it, societies are accepting it and courses are teaching it. A big operation being done through minimally invasive techniques is showing equivalent to better outcomes; we have five and seven year outcomes data proving it works."
8. Artificial discs and lateral fusion research is coming due. For years, spine surgeons and medical device companies have collaborated on artificial disc replacements and lateral fusions with mixed results for coverage. Lateral procedures, initially developed by NuVasive with the eXtreme Lateral Interbody Fusion, are now becoming a standard approach from device companies across the board.
"Compared to many other spine procedures, direct lateral interbodies are relatively new," says Dr. Chong, "but within the next decade we will have long-term feedback to help us determine what techniques work and where we need further development."
Insurance companies are covering these procedures more readily than artificial disc replacements, which still have some room for development.
"There are trends right now that are going in the direction that will try to maintain mobility but they haven't been completely successful yet," said Dr. Corenman. "The problem with current artificial discs — and it may be resolved in the next generation — is impact absorption. There are a few discs out of Europe that may show some promise in fixing this problem."
One of the road blocks facing many artificial discs is payor coverage. A few discs have gained 510(k) clearance, but even after that insurance companies often continue to deny coverage, citing lack of evidence for clinical efficacy.
"There are new technologies out there that are being hampered by coding and regulations in that they are put forward as experimental and insurance companies won't pay for it," says Dr. Anand. "These issues will determine whether new technology moves forward and whether it will become more ubiquitous."
Current research in these fields is promising and coverage could be expanded in the future, if cost- and quality-effectiveness are shown.
"One way to influence the decision by insurance companies on whether to provide coverage for this procedure," says Dr. Chong, "is to conduct studies designed for superiority to determine if artificial disc replacements are better than traditional fusion in long term follow up."
9. Online marketing and patient education becomes a must. There is a huge opportunity for spine surgeons to market themselves and their practice to patients online. Beyond the standard practice website, spine surgeons must engage the online community with patient education platforms, videos and blogs related to spine conditions.
"I think the internet is going to be the next wave for spine care," says Dr. Corenman. "Patients are coming into the office having significant fear and not understanding anything about spine surgery, and they are hungry for knowledge. Unfortunately, there is not a lot of education in typical spine offices, and that's where I think the internet is really going to shine."
Dr. Corenman has a website that includes a forum where anyone can ask general questions about spinal conditions and he answers to the best of his ability. One common problem is patients receiving different diagnoses and treatment recommendations from multiple spine surgeons and specialists; he tries to help patients sort through this information and find the right pathway to care.
"There is a significant lack of continuity for different problems," says Dr. Corenman. "When I'm interacting with them online, I'm not practicing medicine, it's purely education. When you can gain accurate and succinct education, it makes patients more confident and empowers them in their own decisions."
Dr. Corenman receives two to seven questions per day on his forum and spends around an hour answer the questions daily. He also writes articles for the website and uploads videos of procedures. He has nearly 40 videos on his YouTube site, which receives about 100,000 hits per month. While the website has gained traction, it takes significant time and effort to maintain.
"It's still uncommon for surgeons to have a vast online presence," says Dr. Corenman. "The problem is that it takes a tremendous amount of time to write these things and an understanding of how patients think so you can write in a way they will understand. Even though there are a lot of plug in sites where you can purchase information and publish it on your webpage, it might not be accurate or accessible to patients. It behooves you to write that information yourself."
10. Physician ratings and online reputation management won't go away. Over the past five years, several physician rating websites have sprung up from various organizations, allowing patients to "rate" their physician and leave comments.
"The most difficult part of the internet will be how to rate doctors," says Dr. Corenman. "Now a patient can go on the internet and there are a number of different rating sites. They can express their opinions and you don't know how accurate it is. That's one of the dangers of the internet, and it's relatively new territory."
While a vast majority of these websites are underutilized, they are gaining traction as patients are continuously encouraged to take more responsibility for their care. Unfortunately, the most avid contributors to these pages are often those with negative experiences.
"It's a double-edged sword," says Dr. Anand. "You can have one disgruntled patient for any reason who could post a very negative review that is an inaccurate misrepresentation of the physician and his clinical skills. On the flip side, you can also have patients posting extremely positive results. At the end of the day, I advise people to look at these comments very carefully, conduct extensive research about the surgeon they are considering, and assess their decision based on more than just one review whether it is positive or negative."
If someone publishes false damaging information, physicians may be able to take action based on libel or slander. However, wrongdoing may be difficult to prove and removing the information could be a time-consuming process. Instead, physicians should work on getting ahead of a negative reputation by creating a positive one.
"The internet is going to make decisions for us," says Dr. Corenman. "If physicians don't take part in the discussions regarding the internet, you are going to have the decisions make for you by the general public."
Beyond using the internet, Dr. Anand suggests connecting patients via phone. With permission, connect a previous patient with a future surgical candidate so they can discuss the process and what to expect in the future. "I think that's the most effective way for patients to be comfortable about who the surgeon is and what the surgeon is capable of clinically and surgically," he says.
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