6 Obstacles All Spine Surgeons Must Overcome

Here are six obstacles to a successful practice spine surgeons must face.   1. Fighting for coverage and better reimbursement rates. Spine has traditionally received high reimbursements and been considered an expensive procedure. As a result, payors are limiting their guidelines for coverage and providers must spend more time advocating for their patients.

"The approval process seems to be more arduous with each year of practice with regard to performing procedures," said Andrew Cordover, MD, a spine surgeon with Andrews Sports Medicine and Orthopaedic Center in Birmingham, Ala. "My employees have to spend a disproportionate amount of time addressing coverage issues with insurance companies. Andrews Sports Medicine has had to hire additional employees to assist with these issues."

Insurance companies have successfully implemented these stricter guidelines to limit the number of expensive procedures they cover, and have a continued presence in Washington, D.C.

For the cases that are approved, reimbursement rates have dropped and in some cases declining reimbursements have forced private practices to sell to the hospital. "It's a challenge for us as well as everyone in the industry," said Dr. Cordover. "We need to practice more efficiently than ever. I am concerned that there are going to be some practitioners that will find it a challenge to survive over the next decade."

2. Relationship with insurance companies. The individuals at insurance companies responsible for denying or approving claims and authorizing procedures often don't have a clinical background. These individuals are rarely spine surgeons. Their decisions are based on lists and data that are decades out of date and in contradiction with criteria released by physician-led organizations such as the North American Spine Society. "We have exhausted all other alternatives by the time we arrive at the decision to proceed with surgery. It is frustrating for patients to be denied coverage for a surgery their physicians have decided they need," said Tiffany Rogers, MD, MPT, an orthopedic spine surgeon at Torrance Orthopaedic & Sports Medicine Group.

While reining in insurance companies remains a daunting task with a path stretching far ahead, spine surgeons have begun to take the first steps. "Insurance companies are not being held accountable for delaying patient care. The biggest thing we need to do is regulate health insurance, not healthcare," said Neel Anand, MD, clinical professor of surgery and director of spine trauma at Cedars-Sinai Spine Center in Los Angeles. He stresses the importance of lobbying efforts and massive legislative change, though he acknowledges the enormity of the task ahead.

3. Obstacles standing in the way of innovation. The field of spine has a remarkable wealth of new technology, but there are a number of stumbling blocks standing between an innovative idea and the operating room. The first obstacle is the approval process. Studies of a new device or technology can cost $30 million to $40 million prior to approval. "It has made companies shy of financing new technologies and in turn companies are becoming shy of studying new technology," said Dr. Anand. Innovations are making the arduous journey through the approval process, but this is not the final frontier.

Prospective randomized studies are being done and devices are receiving the required FDA approval, but failing to receive reimbursement from insurance companies. "The biggest attraction U.S. medicine has is the ability to innovate and we are losing our biggest claim," said Dr. Anand. The potential for innovation will always be there. Minimally invasive surgery and biologics continue to advance in the field. The key for the future will be in finding the resources and funding to take technology from an idea to a reality.

4. Providing appropriate care. Jeffrey A. Goldstein, MD, is a clinical professor and director of spine service, Department of Orthopaedic Surgery at NYU Langone Medical Center and sits on the Board of Directors for the International Society for the Advancement of Spine Surgery.

He believes one of the biggest challenges next year will be to provide the right treatments for patients, based on appropriate guidelines and protocols. Transparency with patients will be crucial.

"The onus is on the spine surgeon to maintain an open and honest relationship with the patient to include them in the decision process and develop the best treatment for that particular patient," he said. "These decisions need to be based on what we as surgeons know, and not on what we believe. While our knowledge comes from the sum total of our experience combined with the evidence, which includes understanding the lifestyle and goals of the patient as well, surgeons continue to be challenged by limitations of resources which are real in addition to those limits placed by payors."

5. Dealing with Medicaid expansions and retractions. Ever since the Supreme Court upheld the Patient Protection and Affordable Care Act but struck down its Medicaid expansion in favor of allowing each state to provide Medicaid individually, states have been opting in or out to the expansion. For some states, this will still mean including more people in Medicaid while others will lead to fewer enrollees. Either way, surgeons who provide care for Medicaid patients will receive very little reimbursement.

"In Illinois, the problem is that Medicaid pays a third of Medicare rates, and often takes 180 days to send payment," said Anthony Rinella, MD, a spine surgeon with Illinois Spine & Scoliosis Center in Homer Glen and co-founder of SpineHope. "No industry can survive receiving 10 percent of billed charges six months after a service is provided."

He also noted a disproportionate payment model between hospitals and independent professionals. Hospitals receive substantially higher rates than physicians, and eliminating that discrepancy could lead to a more synchronistic system, he said.

"Raising Medicaid to Medicare reimbursement rates would make Medicaid expansion more viable," he said. "When the government pays hospitals very well for Medicaid services and pays surgeons very poorly, the hospital endorsement of Medicaid expansion creates a financial disaster for physicians. If we balance the physician and hospital payment formulas at a reasonable level, and adjust each side of the equation equally over time, we could align our interests and balance the overall federal healthcare initiative."

6. Improving quality while lowering cost of care. In today's healthcare environment, emphasis is placed on providing high quality care for the lowest cost possible. Providers are incentivized to improve efficiencies and cut costs to lower the overall price for care as payors lower reimbursement rates and direct their members to providers with the highest quality reports.

"Spine surgeons have the challenges of improving quality, lowering cost and providing access to the older population," said Dr. Cordover. "There will be changing technology in the coming years and we have to implement it in our practice."

In some cases, payors have stopped covering previously approved procedures, citing a lack of data supporting its effectiveness. As a result, spine surgeons and researchers are engaging in high-level studies to show surgery's effectiveness among appropriately selected patients.

"It's important for me as a spine surgeon to stay involved with the continued development of outcomes measures that are appropriate for our specialty," said Dr. Cordover. "We also must have a voice in new technology because if it doesn't improve quality, limits will be placed on us due to cost cutting measures."