How the Supreme Court's Decision on Healthcare Reform Impacts Spine Surgery: 5 Surgeons Weigh In FeaturedWritten by Laura Miller | July 02, 2012
Last week the Supreme Court upheld the Patient Protection and Affordable Care Act and its individual mandate, which requires all Americans to purchase insurance by 2014. At the same time, the Court struck down the ACA's Medicaid expansion for individual states. The implications of the Supreme Court's ruling vary depending on the perspective of different stakeholders going forward.
Here, five spine surgeons offering responses to the ruling and discuss how it will impact the field of spine surgery in the future.
Ara Deukmedjian, MD, Founder & CEO of Deuk Spine Institute (Melbourne, Fla.): I believe that PPACA will be good for the vast majority of Americans because it imposes health insurance reform that will result in more health related spending on actual patient care and less in profits to insurance companies. Everyone talks about how America spends 18 percent of its GDP on healthcare but this is a very misleading statistic because the vast majority of that money actually ends up in the pockets of executives and other stock holders of our nation's public and private insurance companies. Somehow health insurers have managed to hide the true medical loss ratio (portion of premium dollars spent on actual patient care) from public attention for decades as a result of very sophisticated "nut shell" game. In my years of experience and negotiating health insurance company contracts through third party administrators I have become aware of the true medical loss ratios for insurers and they are typically around 50 percent of the premium dollars they collect. Simply put, 50 cents of every dollar they collect is paid out in claims. One of the most important requirements of the PPACA is to mandate 80-85 percent of every premium dollar is spent on patient care or quality improvement (ambiguous). This is certainly a change for the better for Americans and I support it. See this site for more details http://www.healthcare.gov/news/factsheets/2010/11/medical-loss-ratio.html
In addition to the reform on health insurance company pilfering, the PPACA will attempt to enlarge the insurance risk pools to include coverage of the healthy, low risk population which should make insurance for the high risk, sick and elderly more affordable by spreading the cost of healthcare over a larger population of premium paying beneficiaries. I believe everyone deserves exceptional healthcare as a basic human right and I believe that is also how the President saw it when his administration drafted this legislation. By restoring and preserving health to all Americans we as a nation can focus on working together to bring our nation back to its greatness in the eyes of our countrymen and other nations.
Back and neck pain are the most common disorders affecting the spine. Spine surgeons play a key role is shaping the care of patients suffering with degenerative and traumatic spinal conditions including chronic back and neck pain. If the correct diagnoses are made as to the cause of the pain and a properly executed treatment is rendered, 90 percent-plus of back and neck pain can be cured. Yes, I said cured. Chronic back and neck pain patients live tortured lives and if they are not fortunate enough to "find" a physician that understands the causes of their pain as well as how to cure it, their suffering will endure...needlessly. The only other significant barrier to curing chronic back and neck pain aside from an incorrect diagnosis or an improperly executed "correct treatment" is denial of care by the patient's health insurer. Unfortunately, the PPACA does nothing to stop the insurers from adding more tests, medications or treatments to their lists of "medically unnecessary" or "experimental" care. Every doctor has encountered these denials on a daily basis in their practice and the insurers have successfully driven a massive wedge between the doctor patient relationship, effectively destroying it. Insurers have exploited this avenue of cost savings that goes unchecked and unregulated while doctors are powerless to fight for their patients rights without engaging in an elaborate, complex and usually futile scheme called the "appeals process". I only hope future legislation will be enacted to return the control of medical care back to the patient and their physician.
Stephen Hochschuler, MD, Co-Founder of Texas Back Institute (Plano): The purpose and priority of Texas Back Institute remains the same — the most advanced, most effective and safest treatment of patients. Our complete compliance with the legal and constitutional requirements handed down by state and federal authorities will not change. However, medical decisions regarding the diagnosis and treatment of patients should be left to medical professionals, not politicians. Any ruling that limits or confines the decision-making authority of surgeons and other medical professionals is not in the best interest of patients and is not endorsed by Texas Back Institute.
Jeff Lobosky, MD, Associate Clinical Professor of Neurological Surgery at the University of California San Francisco: I must admit I was a bit surprised by the ruling. After listening to the oral arguments and the Justices' responses, I anticipated the Court would strike down the individual mandate provision yet let stand the mandatory expansion of Medicaid. They actually did the opposite although Chief Justice Roberts' explanation of his support of the law seemed quite convoluted. As it now stands, I think the Court paves the way for healthcare reform to move forward. Personally, I look at the ACA as a step in the right direction but it is destined to fail if we don't do a better job of securing access for patients and controlling costs. What the Supreme Court has done is leave us with scaffolding on which to build a truly better healthcare system. This decision is sure to spark more rancor and bile among the partisan debaters but at least it allows us the opportunity to move forward.
As to the question of how the ruling will affect surgeons…the impact remains to be seen. Two of the big issues in reform are how to provide everyone with access to care and how to pay for it. One of the major flaws in the new law is the fact that the majority of newly insured patients will receive their coverage through the Medicaid program. In most states, reimbursement for Medicaid is dismal and thus it won't address the concerns of surgeons who see their incomes declining nor of patients who lack access because so many physicians have had to limit the number of Medicaid patients in their practice. If the plan remains to pay for this expansion of care by reducing reimbursement to physicians and to hospitals by the Medicare program we will soon see our senior citizens finding access just as difficult as it is for the Medicaid population.
Two other burning issues that relate to surgeons is the Independent Payment Advisory Board which is given the power to slash reimbursement with only a modest physician influence and malpractice reform. Almost all physicians' organizations and most Republican lawmakers strongly oppose the current make-up of the IPAB and are working to repeal it. Tort reform has been given nothing but lip service by the current administration yet is a major concern to most surgeons. We'll have to wait and see if there is any movement on these two important issues.
At the end of the day, I think we surgeons and all physicians have done a rather poor job of assuring a prominent seat at the table of healthcare reform. It is absolutely imperative that we be the ones who step forward with innovative ideas which address the myriad of problems currently plaguing the delivery of healthcare in America. We need to LEAD the battle of reform and quit simply REACTING to it. We need to admit our role in the dysfunction the current system and craft solutions that address not only our own self interests but those of our patients as well as those who foot the $2.6 trillion bill. If we do nothing more than put up fences and circle the wagons we are going to find ourselves once again at the mercy of those with less expertise in medical care.
It is time that we as a nation unite and put partisan politics and bickering aside. If we don't solve the problem of American healthcare it will soon be the financial ruin of us all. If we allow healthcare to continue to consume 17, 18 or 23 percent of our GDP as is predicted for the near future it is sure to cannibalize the necessary resources to support our infrastructure, our schools, Social Security and national defense. Time is running out and thus it is essential that our elected leaders in Washington, our elected leaders of organized medicine and the American public as a whole unite as one and work together to create solutions that assure all Americans will be able to enjoy the benefits that American healthcare can provide for generations to come.
Thomas Schuler, MD, Founder and President of Virginia Spine Institute (Reston): I believe that ObamaCare is a disaster for Americans! It will lead to increased denial of services. Insurance companies and the government are being asked to cover more people with the same amount of money. This can only mean one thing, access to specific treatments will be limited which equates to rationing of healthcare. Currently, to control expenses, insurance companies are increasing the number and frequency of denials for many spinal treatments. Suffering patients are no longer able to get many operative and non operative treatments because insurance companies are selectively interpreting available research to support their denial of coverage. This is the fallacy of comparative effectiveness: there is no accepted standard guiding insurance companies and the government to define which evidence based medicine is optimal. Furthermore, even quality literature does not help the atypical patient. This means as government oversight becomes amplified individual patients who are outliers will be unable to receive necessary treatment. Evidence based medicine is not designed to identify all treatments just the ones that are for the most common scenarios. In the end, evidence based medicine is not being implement by the government to identify the best treatment; it's being done to control cost. Cost containment with this new law is essential to meet the goal of covering more people for the same budget.
More Americans may have access to insurance but the covered services will be less with ObamaCare. This is simple math you cannot cover more people with the same amount of money and expect everyone to maintain the same high level of care that exists today. Denial of service is worsening and will continue to worsen under this new government edict. Furthermore, there is a paradigm shift from covering what is best for the patient to what is best for society. The physician will not be allowed to provide what he or she knows is in the best interest of the patient and their specific condition. Patients will suffer! This paradigm shift is a direct violation of the Hippocratic Oath and will alter the physician-patient relationship.
I have 20 years of experience in treating patients as individuals with the best customized care plan. This is about to change. Our government and insurance companies do not care about individuals. All they care about is containing cost. Many of us are already experiencing an in increasing frequency of denials of medically necessary treatments for our patients. In the future there will be a greater rationing of services and a greater denial of treatments. The overall quality of healthcare available to Americans especially those with spinal conditions will deteriorate. The real problem is going to be the severe impact in patients suffering from spinal conditions who will be unable to be active parts of their family, workplace and society because of denied treatment. This will lead to lost self esteem, lost income, lost tax revenue and an increase in individuals applying for disability. The real crisis arising from this law will be the severe decrease in the quality of life for the individual.
Hopefully Congress wakes up and rewrites the law!
Nick Shamie, MD, Co-Director of UCLA Comprehensive Spine Center: We can't know exactly how things are going to be affected by this law until some time passes and the changes take effect. The good news is that the uninsured will be covered by some form of insurance, the pre-existing conditions cannot be used as a basis for the insurance companies to deny care, and lifetime coverage caps will be banned. But how will we pay for all the additional benefits and for the expanded number of insured individuals? That is a question that is most difficult to answer…specially in the current economic environment that we are faced with. My impression is that we will see a limit to the healthcare services that Americans have come to expect from their healthcare payors, unless they pay for these services themselves. There are over 32 million uninsured Americans and they are currently coming to emergency rooms or seeing urgent care when catastrophe hits medical care. Now they will have some type of insurance, whether that's a government or private healthcare company.
If we use the analogy of a pie as the delivery of healthcare, we are putting more people in the pie dish and naturally have to make the pie dish bigger. One can make the pie dish bigger by putting more money into it, whether that be government insurers or private insurers. This is achieved either by the government or private insurance companies spending more money on healthcare; so the government will either have to expand its budget for healthcare — which I don't see happening — or patients will have to pay more for their care. The insurance company can make the dish bigger by charging each insured individual more on premiums or deductibles would go higher. The other option is to force insurance companies to make less profit and that would be hard to enforce. In addition mandates in the law that force insurance companies to take everyone regardless of their preexisting conditions, forces them to take high risk people and this cuts into their profit. I think our healthcare dish size will remain the same, but we are pouring 32 million more Americans into that dish, which means everyone gets a smaller portion of the pie.
Elected surgeries are going to be affected because patients will have to stand in line longer or not be covered. Much of what we do in spine is not life threatening; it's to improve quality of life. Taking care of life threatening conditions, making sure the heart is working well and providing diabetes and cancer care will all take precedence over elective care. We will have to ration the care we provide such that people in the limited pie dish can have as much healthcare as possible and to divide the resources efficiently and fairly with the most proven quality of life improvement for the society as a whole. As a result, I think patients who want to get specialty and elective care will have higher premiums or pay for their care themselves. There are some procedures that aren't covered by government or insurance companies, so patients who want those procedures will have to pay out of their own pockets. We have a multi-tiered healthcare system in the country already, but this will make it more apparent because in the past specialty care was mostly covered.
More Articles on Spinal Surgery:
The Most Important Issues Facing Spine Surgeons: Q&A With ISASS President Dr. Steven Garfin
20 Spine Surgeon Leaders in Advocacy Efforts
Healthcare Reform Upheld: AAOS President Dr. John Tongue Responds
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