Marcy Rogers, president and CEO of SpineMark, has worked in the spine field for many years and seen the industry evolve.
She's at the forefront of creating spine-focused, physician-owned practices, destination centers, and ambulatory care complexes. As reimbursement becomes more challenging and technology evolves, there are new opportunities for surgeons to provide additional ancillary services.
The big services Ms. Rogers sees spine practices add on today include:
• Pharmacy
• Imaging
• Toxicology
• Lab services
• Urgent care
• Genetic testing
"The challenge is we are living in a world where when surgeons try to implement a new service, someone launches a review of payments or looks at physician ownership arrangements for Stark Law violations," says Ms. Rogers. "The most important person to have on your team is a lawyer to make sure you are compliant. If you can remain compliant, there are great opportunities to expand services."
Genetic testing is a relatively new field, but could have a significant impact on the quality of care for back pain patients. Surgeons can incorporate genetic testing into their practice to identify the reaction patients could have to pain medications and other prescribed drugs.
"Instead of physicians just prescribing an opioid pain medicine, you can identify in advance what drugs will work," says Ms. Rogers. "That transforms the paradigm because if you're prescribing codeine and it doesn't work for a patient because of their physiological and chemical make-up, that prescription is a waste of time and money. With genetic testing, you can identify what works and what does not."
Ms. Rogers advises organizations to partner with outside companies to obtain genetic testing materials. The company Ms. Rogers partners with bills the insurance and negotiates rates for the testing. "This provides you with valuable information about the medical management of patients — and without the challenges associated with billing for the testing," she says. "A year on the wrong medical treatment paradigm is costly; genetic testing can put patients on the right track from the beginning."
She says genetic testing can ultimately become part of the patient's regular work-up along with diagnostics, MRI/CT, urine drug screening and toxicology studies and works with Dr. Daniel Schwarz, chief medical officer of JAS Genetics and other companies to provide these services.
Currently, genetic testing is limited in pain management because the more common testing has focused on the pharmacokinetics (absorption, distribution, metabolism, etc.) of the medication, rather than the pharmacodynamics (affect, response) of the prescription pain medicine. In fact, according to Dr. Schwarz while 99 percent of medications are broken down by the liver, less than 1 percent are activated by the liver. Codeine is one of the rare opioids that is inactive until the liver converts it into morphine by enzyme CYP2D6. "Although, in our field, neuropathic pain is a key component which requires a non-opioid solution, and, like codeine depends, on genetic variations of the same enzyme," says Dr. Schwarz.
In addition, a more practical genetic test exists that objectively determines a patient's response to pain, or pain sensitivity. Dr. Schwarz reviewed studies from 2004 that described an enzyme in the brain that breaks down dopamine, called COMT. Four variations of the DNA combine to form three types of patients' pain perception.
Knowing this genetic make-up would make a significant change in the type of treatment, including medicine, therapy and even counseling. Ms. Rogers and Dr. Schwarz feel this objective genetic information, along with other validated questionnaires to assess the anxiety/depression components of pain and rigid adherence to monthly assessments of activities of daily living to show improvement provide better outcomes by letting experts intervene sooner, as needed to restore pre-pathological status.
Ms. Rogers also advocates incorporating traditional services into the practice, including imaging, radiology, urgent care centers, and pharmacy. Surgeons must obtain informed consent from patients before referring them to these practice-owned services, educating the patients about ownership.
"Many times patients do not have an issue with the fact that the physicians have ownership; they just want their pain relieved," says Ms. Rogers. "You are dealing with complex patients, and it often takes several specialists to figure out what is the root causes of problems. That is why it's helpful to have all the services coordinated in one place."
Related medical fields such as interventional pain and psychology can help identify other factors contributing to the patient's pain. In some regions, practices may also offer physical therapy services or partner closely with physical therapy providers for their patients.
"Physical therapy has become very scrutinized as a service," says Ms. Rogers. "In many cases, the only way for a medical practice to offer physical therapy is for the physician to have an employee run it under the practice."
New spine-focused practices are developing in a campus-like atmosphere that includes the traditional practice and ambulatory surgery center, but also often includes space for imaging and the ability to run a toxicology lab. Practices need dedicated space to run blood cultures and hormone tests for toxicology services.
Physicians with existing practices looking to add these ancillaries often need to add 10,000 to 20,000 square feet of space as well as a retail outlet for patients to pick up their medications while they're at the practice.
"This is an ever-changing, fluctuating healthcare environment. I am a big advocate of being proactive to make sure surgeons are able to stay independent," says Ms. Rogers. "At the end of the day, the most important aspect of providing these services is the patient. Make sure your focus is providing patient-centric care."