7 Top Concerns for Spine Surgeons in 2012

Four spine surgeons discuss the topics weighing most heavily on them and their practices heading into 2012. 1. Treating Medicare patients. The sustainable growth rate for Medicare reimbursement is a problem — particularly if Congress allows for the 27 percent cut in physician rates scheduled to occur in March. These cuts have been avoided so far, but an uncertain political future makes it difficult to determine exactly what will come next.

"As legislators are looking at healthcare, they should to be cognizant that we have to take care of patients who are in the growing Medicare population," says Purnendu Gupta, MD, medical director of the Chicago Spine Center at Weiss Memorial Hospital and associate professor of surgery in orthopedics and rehabilitation at the University of Chicago. "Economically, the SGR is the big looming question; it has gone through the House and will be debated in the Senate. That will have a huge impact on access to spine care for those patients."

How lawmakers choose to legislate payments to insurance companies could make an impact on reimbursement in the future. "From a legislative and policy perspective, we have to look at how the insurance company is spending their dollars because it looks like they aren't being spent on healthcare," says Sheeraz Qureshi, MD, MBA, a spine surgeon at Mount Sinai Medical Center in New York City.

Another frustration Dr. Gupta sees, as a tertiary care specialist, is that the level of reimbursement does not reflect the level of care provided. "Many times when we do major revision operations, the reimbursement doesn’t reflect that," he says. "On the hospital side, there is a loss of revenue because it was a more expensive procedure and the current policy does not reimburse the hospital high enough either. This is ultimately may cause limitations in our ability to take care of patients with complicated problems."

2. Insurance company coverage for spinal procedures.
Over the past few years, insurance companies have become less willing to approve spine surgery for patients in non-emergency situations with the surgeon's diagnosis alone. As of Jan. 1, 2011, the Blue Cross Blue Shield of North Carolina stopped covering spinal fusions for patients with degenerative disc disease as the only indication, and throughout the year other payors have explored similar measures. Many insurance companies institute coverage guidelines requiring patients to undergo a specific treatment pathway before approving surgery, if they are willing to approve the procedure at all.

"Insurance companies are trying to prevent advances in spine surgery by ratcheting down their rates and our ability to provide care," says David Schwartz, MD, a spine surgeon at OrthoIndy in Indianapolis. "It's financially motivated. They set guidelines and we can discuss exceptions in peer-to-peer reviews with insurance company physicians, but it's really a formality because they have to deny it."

Now, beginning Jan. 2012, Minnesota-based insurance company HealthPartners requires its clients to see a company-approved "designated spine specialist" who promotes non-surgical options before having the chance to see a spine surgeon. However, seeing a spine surgeon doesn't guarantee coverage for eventual surgery.

"Not only is there a significant change in reimbursements, but insurance companies are also increasingly dictating the types of treatments physicians can provide," says Dr. Qureshi. "Lumbar fusion for degenerative disc disease is one such example. Although not every patient with DDD is going to require a lumbar fusion, clearly there are patients who fail other options that will benefit from surgical intervention. In the end, patients are paying higher premiums and deductibles for less and less coverage."

3. Proving spine surgery is effective in the literature.
Evidence-based medicine has been on the tongue of many healthcare providers, as coverage may soon depend more on what the literature says about each individual treatment. While many specialties have been focused on reporting outcomes and building up a database of randomized, double-blind, controlled studies, spine research has primarily focused on lower level data. Now spine surgeons most focus on strong studies to prove in the literature that surgical procedures are effective.

"We are paying greater attention to patient outcomes and research now than we have in the past," says Dr. Gupta. "That is one of the best developments occurring in spine surgery today — it will help us survive through this tough economic environment we are experiencing in healthcare and healthcare administration."

Many in the spine industry were hopeful that the Spine Patient Outcomes Research Trial would be revolutionary in terms of the impact it would have on the practice of spine surgery, but many conclusions its authors drew served to reinforce existing treatment guidelines for conservative care, says Dr. Gupta. The studies generally promoted conservative treatment for pathology such as disc herniation and spinal stenosis. Despite the SPORT outcomes, spine literature is still needs further rigorous outcome studies.

"People need to gather data and publish this data so insurers and the world can see what their good outcomes are," says Robert S. Bray, MD, a neurosurgeon and founder of DISC Sports & Spine Center in Marina del Rey, Calif. "These studies have to be quality studies. We can't just rely on academics and our fellows — we have to organize strong prospective studies for outcomes analysis."

Spine groups can implement electronic medical records to help mine data from their practice. The EMRs should be able to perform data analysis — not just billing and scheduling functions — to give you a clear concept of how your outcomes are trending. They can also ensure you include every patient with a specific diagnosis in retrospective studies.

"I can pull data to look at ever person I've performed minimally invasive spine surgery on when I need it," says Dr. Bray. "We need to share that data with insurance companies to control where spine goes. If we as spine surgeons don't step up to the plate and show the outcomes for our procedures, we'll be in trouble. People who are fortunate enough to have big practices need to collect data, put it together in a quality fashion and publish it. We need to know what is really happening with our procedures."

Professional societies, such as the North American Spine Society, are also promoting the organization of strong evidence-based literature. At the annual meetings, surgeons are invited to share the results of strong studies and discuss their merits in clinical care. "We want to show the benefits of what we do for ourselves, patients and payors," says Dr. Qureshi. "Sometimes there isn't as much benefit as we thought, but other times we find there is. We are organizing as a group and pushing for more evidence-based outcomes in the literature to support the things we do."

4. Contracting at outpatient surgery centers. While spine surgeons across the country find receiving reimbursement challenging, spine surgeons seeking approval for performing cases in an outpatient ambulatory surgery center have an even more difficult task. As of today, Medicare doesn't have a code for performing spine cases at an outpatient ASC — which means Medicare patients must pay out-of-pocket or have their surgery done at a hospital.

When surgery centers first begin considering spine surgery, they perform procedures out-of-network and then slowly move in-network. This was the process Dr. Bray took when he established his ASC and began performing TLIFs, XLIFs, ALIFs and anterior cervical discectomies. It took some convincing for the insurance companies to see he could achieve good outcomes at a lower price in ASCs than in hospitals.

"We started completely out-of-network and moved progressively in-network with major providers, but we made sure the contract was reasonable and a win-win for us and the insurance companies," says Dr. Bray. "It wasn't easy to do — we had to collect data on our cases and do enough damage to the insurance companies out-of-network to show that we would be better for them to contract with us."

During in-network discussions, Dr. Bray offered the insurance company a deal — the surgery center would discount procedures down, but the insurance company had to provide a good, solid contract for surgeons to work with. "We have contracts with a few payors now," he says. "The problem has been to create a field of outpatient spine by showing insurers what we can do."

5. Spine surgeons are trending toward hospital employment.
As in most specialties, spine surgeons are now becoming employed by hospitals at a higher rate than ever before, which could have a big impact on the way they practice medicine. Surgeons in private practice have more control over their business and autonomy with patients, but hospital-employed surgeons have the benefit of a regular salary and work schedule. Alternatively, surgeons can also work for universities or facilities like Kaiser Permanente. However, almost every institution is financially strapped.

"Becoming employed by a hospital is might seem safe, but extra profit doesn't go to the surgeon," says Dr. Bray. "The hospital-employed surgeon might have a good work schedule and retirement benefits, but they don't have a big upside. In founding our large multidisciplinary center, my concept was to create another vehicle to deliver medicine. We consolidated our providers so we could afford marketing efforts, human resources and other business contracts small private practices can't support."

There are currently eight spine-focused surgeon partners at Dr. Bray's practice that perform microsurgery and minimally invasive procedures. They are able to grow along with modern technique because of the flexibility their center affords. "We created an environment where we can all work and have the power to grow our practice as we please," says Dr. Bray. "Multispecialty groups where everyone is working together for a full-service center is the future."

Dr. Gupta has been with an academic medical center for his entire career, and enjoyed that environment. "I've always been a salaried surgeon in a medical school type of environment," he says. "I have enjoyed my time there because my decisions are always patient-centered and patient-focused. In addition to that, my other mission is to teach residents and others involved in healthcare at our medical center. I enjoy this tremendously because it allows me to take care of patients with complicated spinal disorders."

In the future, Dr. Gupta sees more surgeons being employed by hospitals because of the financially difficult healthcare environment we see today. "As the method of payments changes in healthcare, perhaps the majority of payments will be given to the hospital for an episode of care and the physicians will be paid by the hospital," he says. "Changes in SGR and reimbursement are all driving this trend toward employment."

6. Technology costs and benefits. Spine surgery has been a booming field for growth and innovation over the past decade. New techniques and devices allow for minimal disruption in many surgeries that were once performed as big, open procedures. Surgeons can now approach the spine from several different angles and use computer or robotic assistance for more precise implant placement.

"New advances in spine care, such as the XLIF procedure, continues to provide new ways for patient reconstruction and the quicker minimally invasive approach allows them to have faster recovery and better outcomes," says Dr. Schwartz. "There is still a push by physicians for cervical disc arthroplasty, and we are seeing that start to take hold. We are seeing at least equal outcomes and long term benefits for patients when compared with fusion procedures."

However, with downward cost pressure on the healthcare industry, surgeons may have trouble accessing this technology and further development could be pushed aside.

"Unfortunately, cost is a huge issue right now, even for the technology we currently have," says Dr. Gupta. "We are just at the point where the development of current technology may be stunted going into the future."

Dr. Gupta has been asked to participate in a study for robotic guidance, which he thinks could be a promising technology down the road. "One of the things that limited robotics in the past was image guidance," he says. "Now, technology has advanced so we are seeing additional benefits in our procedures. I think there will be some advantage to robotics for spine surgery in the future, but I don't know exactly where the impact will be or if it will add the same value as it has in other specialties, such as cardiology."

This is one of the ongoing struggles for spine surgeons — to identify whether a product will add value, or just cost, to their procedures. "We look at the new things coming out from device companies right now and they are released with marketing information but no human data," says Dr. Bray. "There is sometimes very little data showing what works, which can be problematic."

7. How biologics will be incorporated into future spine care.
Spine surgeons and researchers are exploring the use of several biologic agents to promote fusion and disc regeneration for patients with spinal conditions. "We are seeing more of a push toward biologic treatment for fusion enhancement," says Dr. Qureshi. "We are also looking for biologics and injectable that can be placed in the disc space to prevent further degeneration and collapse. Biologics is really starting to pick up steam and we are making significant headway in terms of spine care delivery."

One of the most commonly-used biologic agents is bone morphogenic protein, and recombinant bone morphogenic progein-2 is the only BMP currently approved by the Food and Drug Administration. Medtronic holds the patent for Infuse, an rhBMP-2 product, which has caused some controversy this year. While some studies suggest rhBMP-2 has a higher rate of complications than previously noted, others show it is beneficial for several properly-selected patients in appropriate situations.

"I am hopeful that we will get better data on BMP and a greater consensus on the use of BMP because I do feel it is valuable in patients who have significant comorbidities, such diabetes and smoking, patients who are having long fusions or other complex surgery, and patients with pseudarthrosis from prior surgery" says Dr. Gupta. "I'm hopeful that as we look at the data we have, analyze what we had in the past and look at it prospectively, we will obtain a better answer as to the value and use of BMP in the future."

Other surgeons and researchers are using biologics for disc generation and regeneration, which will be big over the next few years. "Hopefully we can use gene therapy and will have regenerated discs within the next five years," says Dr. Schwartz. We are also continuing gene therapy treatment for patients with spinal cord injuries, which is a new frontier."

Related Articles on Spine Surgery:

Challenges and Opportunities in Complex Spinal Correction: Q&A With Dr. Krzysztof Siemionow

10 Spine Surgeons for Professional Hockey Teams

Spine Surgeons: Is An ACO in Your Future?

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