As the New Year draws nearer, it will bring new challenges for spine surgeons and industry innovators. Several experts weigh in on six pressing spine challenges and how professionals can cope with these challenges. 1. 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."
2. Improving quality while lowering cost of care. In today's healthcare environment, the 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 Andrew Cordover, MD, a spine surgeon with Andrews Sports Medicine and Orthopaedic Center in Birmingham, Ala. "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," Dr. Cordover said. "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."
3. Dealing with regional differences in spine care. The perception of too much spine surgery has been propagated by several sources, including statistics showing rates of spine surgery are higher in some parts of the country than others. Frank Cammisa, MD, is chief of spine service at the Hospital for Special Surgery in New York City. He said there are several factors contributing to this difference, including:
• How quickly new procedures are introduced
• When spine surgeons are willing to adopt new procedures
• Demographics — percentage of the population who are likely candidates for spine surgery
"It may be that one area is treating spinal conditions more aggressively, but another area might not have the resources available to perform the same procedures on their patients," Dr. Cammisa said. "There may be just as many patients needing surgery in both areas in terms of population percentage, but the care isn't as advanced. From the statistics, it's hard to tell whether surgery is being overused or underused in different regions of the country."
4. Adjusting to the medical device tax. Beginning in January, a 2.3 percent tax will go into effect for gross medical device sales, which equates to a 15 percent tax on profits from medical devices. The tax was put into place because government officials believed the Patient Protection and Affordable Care Act would create an influx of new patients which would offset the tax's burden to companies while creating additional federal revenue, said Payal Keshvani, an associate with McGuireWoods LLP law firm in Chicago.
However, it could potentially be a barrier to device companies, particularly start-ups, because even an increase in patient volume would leave companies struggling to comply with such a high tax rate.
This new source of government income is being challenged by lawmakers from both parties who don't believe the theory of untapped volume of customers will hold up in practice.
Device tax implementation also creates an uncalculated transaction cost of understanding what the tax means for the entire industry, said McGuireWoods Associate Katherine Lin. The language of the law is very broad and does not make it clear exactly to whom or what the tax will be applied.
"A company may not have somebody in house exclusively to deal with cutting edge regulatory problems," she said. "It's an additional cost that maybe the people who supported the law didn't account for."
5. Dealing with Medicaid expansions and retractions. Earlier this year, 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. 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. Providing access to care for the older population. As baby boomers age, spine surgeons are seeing an influx of patients with back pain. Caring for these patients has become even harder as the number of young surgeons hasn't kept up with the number of surgeons retiring.
"There is a challenge we'll need to define with the aging population because as technology advances, we are able to treat them, but they may not have access to care or the ability to pay for their care," Dr. Cordover said. "With more educated patients, the demands on the system are going to reach new heights. New technologies and the cost of research and development will add additional strains. We are going to have to make some tough decisions with regard to how many resources we want to put into healthcare as a country."
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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."
2. Improving quality while lowering cost of care. In today's healthcare environment, the 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 Andrew Cordover, MD, a spine surgeon with Andrews Sports Medicine and Orthopaedic Center in Birmingham, Ala. "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," Dr. Cordover said. "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."
3. Dealing with regional differences in spine care. The perception of too much spine surgery has been propagated by several sources, including statistics showing rates of spine surgery are higher in some parts of the country than others. Frank Cammisa, MD, is chief of spine service at the Hospital for Special Surgery in New York City. He said there are several factors contributing to this difference, including:
• How quickly new procedures are introduced
• When spine surgeons are willing to adopt new procedures
• Demographics — percentage of the population who are likely candidates for spine surgery
"It may be that one area is treating spinal conditions more aggressively, but another area might not have the resources available to perform the same procedures on their patients," Dr. Cammisa said. "There may be just as many patients needing surgery in both areas in terms of population percentage, but the care isn't as advanced. From the statistics, it's hard to tell whether surgery is being overused or underused in different regions of the country."
4. Adjusting to the medical device tax. Beginning in January, a 2.3 percent tax will go into effect for gross medical device sales, which equates to a 15 percent tax on profits from medical devices. The tax was put into place because government officials believed the Patient Protection and Affordable Care Act would create an influx of new patients which would offset the tax's burden to companies while creating additional federal revenue, said Payal Keshvani, an associate with McGuireWoods LLP law firm in Chicago.
However, it could potentially be a barrier to device companies, particularly start-ups, because even an increase in patient volume would leave companies struggling to comply with such a high tax rate.
This new source of government income is being challenged by lawmakers from both parties who don't believe the theory of untapped volume of customers will hold up in practice.
Device tax implementation also creates an uncalculated transaction cost of understanding what the tax means for the entire industry, said McGuireWoods Associate Katherine Lin. The language of the law is very broad and does not make it clear exactly to whom or what the tax will be applied.
"A company may not have somebody in house exclusively to deal with cutting edge regulatory problems," she said. "It's an additional cost that maybe the people who supported the law didn't account for."
5. Dealing with Medicaid expansions and retractions. Earlier this year, 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. 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. Providing access to care for the older population. As baby boomers age, spine surgeons are seeing an influx of patients with back pain. Caring for these patients has become even harder as the number of young surgeons hasn't kept up with the number of surgeons retiring.
"There is a challenge we'll need to define with the aging population because as technology advances, we are able to treat them, but they may not have access to care or the ability to pay for their care," Dr. Cordover said. "With more educated patients, the demands on the system are going to reach new heights. New technologies and the cost of research and development will add additional strains. We are going to have to make some tough decisions with regard to how many resources we want to put into healthcare as a country."
More Articles on Spine Surgery:
8 Steps to Optimize Spine Practice Revenue in 2013
NASS Honors Outstanding Paper Award Winners
8 Experts on Most Important Areas for Spine Research