Q: Have you ever considered offering spine surgery for cash-pay patients?
Dennis Crandall, MD, Founder and Medical Director of Sonoran Spine Center, Mesa, Ariz.: Canadians are our most frequent cash customers. For those Canadians who do not want to wait for their single payor system to get around to them, we work out deals with our hospitals to accommodate.
Walter Eckman, MD, Founder, Aurora Spine Center, Tupelu, Miss.: Yes.
Brian R. Gantwerker, MD, Spine Surgeon, The Craniospinal Center of Los Angeles: Yes, in select cases. The cash price is designed to offset costs of follow-up and for possible loss to follow-up. We always take a reasonable deposit and work within every patient's budget in terms of the remainder of the balance. We never refuse surgery for anyone who needs it, regardless of their ability to pay.
J. Brian Gill, MD, Spine Surgeon, Nebraska Spine Center, Omaha: Yes, I currently do offer cash payment plans for these patients who pay for their medical care out of pocket.
Richard Kube, MD, Founder & CEO, Prairie Spine and Pain Institute, Peoria, Ill.: Yes, we have. There are procedures that we offer that are cutting edge and often insurance carriers do not cover these items. Offering treatments on a cash basis helps us to provide those services when we would otherwise have few options. Also, as the insurance companies continue to decrease the number and variety of indications for spine surgery, there is the potential for an increasing need for patients to have a cash provider in order to attain certain treatments.
Paul Slosar, MD, President, SpineCare Medical Group, San Francisco Spine Institute: It is already happening in some markets but only a few patients can afford the expense. Specialty (tourism) hospitals are growing outside U.S., staffed by U.S. spine surgeons, which allow patients to receive surgery for cash.
Jack Zigler, MD, Spine Surgeon, Texas Back Institute, Plano: In this era of healthcare decision-making by both government and insurance companies, internet-informed patients with financial ability are increasingly exploring healthcare options that are not available to them through their health insurer. Frustrated by policies that independently determine that a particular proposed treatment is "experimental and investigational," and by FDA labeling that indirectly restricts insurance payment for procedures that are readily available outside the U.S., more patients are considering going abroad to pay cash for surgical procedures on their spine.
At the Texas Back Institute, we have a culture of participation in many FDA studies that has made us very familiar, comfortable, and technically proficient in procedures that are not yet FDA-approved, and are often not covered by specific insurance company policies. Yet we have patients who want those procedures, and are indeed excellent candidates for them. To solve this dilemma, we have partnered with our local physician-owned hospital to establish cash pricing that makes a complete package for the surgical experience which is clearly understood by, and competitively affordable to, the patient.
In order to offer a complete package, the surgeons must obviously have good data on their outcomes and postoperative experience. They must be able to work with their hospital administrator to be sure that all of the "moving parts" are in synch, including the anesthesiologist, radiologist, monitoring component, implant supplier, and inpatient hospitalist, and that the hospital can still be profitable even with significant cost reduction for pre-payment by the patient. All of these key components must work in harmony, with constant monitoring to ensure that the quality of service provided by the admissions staff, surgical staff, and floor nursing staff continues at an excellent level. Patient feedback in physician-owned hospitals in Texas has consistently remained at the top of the chart, year after year.
Denial of patient access to spine arthroplasty, which continues to experience a difficult road to insurance approval despite outstanding data metrics, served as the impetus for establishing this process. It has allowed spine surgeons at TBI to offer patients an option to medical tourism. In 2013, with the specter of newer draconian insurance guidelines limiting the ability of patients with disabling degenerative disc disease to be allowed a surgical fusion, this mechanism of cash pay may ultimately appeal to an even larger number of patients who prefer a surgical solution to the alternative of pain management and drastic lifestyle changes.
Patients who pay cash for their spine surgery are, in general, highly motivated. They have done their homework and have made the positive decision to find a top facility and surgeon, have "skin in the game" because they are directly paying for their healthcare, and tend to have better outcomes than other patient groups who may have less motivation to work hard postoperatively to resume their highest level of function.
Successfully managing spine surgery for cash-pay patients certainly requires extra work to set up and maintain a system that works for all parties. It serves as a good model which not only dovetails with governmental desires for coordinated care, but also provides less restricted access for our patients to newer technology streams.
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