Big changes are coming in healthcare, and not all of them are positive. "There is an understanding changes are coming from ObamaCare, and spine surgeons have to find creative strategies to solve these new issues," says Bryan Oh, MD, a neurosurgeon who focuses on spine surgery with BASIC Spine in Orange, Calif. "There might be ideas that they hadn't thought of in the past and having the framework to present these strategies to carriers as well as execute them successfully would benefit spine surgeons going forward."
Here are five threats to spine care and how surgeons can effectively overcome them.
1. Transition to pay for performance. The traditional fee-for-service model is changing to compensate more for quality than quantity. Spine surgeons aren't paid as well today as they were a few years ago for the same amount of work as each unit of work receives smaller payment.
"If you want to keep the same level of income, you have to work harder," says Dr. Oh. "The other part of pay for performance is that if there are complications, you'll be paid less than if the case went perfectly. This hasn't happened yet but it's coming in the future."
Even if the complication isn't directly attributable to the surgeon, insurance reimbursement will still take a hit. Spine surgeons will heighten oversight on all aspects of patient care to ensure full compensation.
"Surgeons may have to become an overall better 'doctor' by making sure everyone from the internist to the anesthesiologist to the rehabilitation specialist is doing the right thing," says Dr. Oh. "They'll take on a leadership role in taking care of the patient."
2. Medicare payment cuts. Even though the 27.5 percent reduction in Medicare payment to physicians was once again avoided at the beginning of this year, spine surgeons should expect to see cuts in the near future.
"There is always a threat that Medicare payments are going to get cut, especially with upcoming budget talks," says Dr. Oh. "When Medicare is cut, everything else will be cut because private insurers base their rates on the Medicare fee schedule. This hasn't happened yet, but it's out there."
Without knowing for sure when or how Medicare reimbursement will be cut, specialists will be forced to delay big purchases and other growth plans until they understand how their practice will be impacted. In the meantime, surgeons can seek other revenue and compensation opportunities, such as ancillary services.
3. Bundling codes. Insurance companies are now bundling codes to squeeze less reimbursement into larger overall payment for services. This can have a big impact on a spine surgeon's bottom line.
"Now CPT codes are getting bundled and again we are paid less for the same amount of work," says Dr. Oh. "We'll need to bring more cases into the practice and surgery center. I think having a good physician extender is going to be key in the future."
If spine surgeons aren't routinely running more than one operating room at one time, the PA can open and close the cases. This allows surgeons to work the same number of hours but see increased patient flow.
"Obviously spine surgeons still need to be mindful of not cutting corners in the OR and have the same attention to detail as in the past," says Dr. Oh. "But this strategy should allow for increased efficiency and revenue."
4. Reimbursement decline. As payment from all payor sources continues to decrease, and the cost of keeping a practice open increases, physician groups have the opportunity to capture ancillary income. Ancillary services can add revenue flow to the practice and improve the bottom line.
"Imaging is one service many spine practices can bring in, although they are more tightly regulated today," says Dr. Oh. "Providing a physical therapy component to your spine program or partnering with a hospital to provide call are other opportunities for spine surgeons."
Make sure you understand local and national regulatory requirements for adding new services or contracting with the hospital.
"There are some gray areas, but I think in a very careful setting there are good options for generating ancillary income legally," says Dr. Oh. "Some physicians have looked at ancillary revenue streams negatively in the past, but these services can add value to the practice as well. Spine surgeons have to demonstrate how ancillary services enhance patient care by better communication between specialists, easier scheduling and less travel and waiting time for patients."
5. Accountable care organizations and global payments. New payment models such as accountable care organizations and bundled payments are forcing providers to take more risk for patient care than in the past. Insurance companies are passing the risk by negotiating a single pay rate for global coverage, including conservative care, spine surgery and postoperative rehabilitation.
"Our practice has spine surgeons, physical medicine and rehabilitation, physiatry, pain management, pain psychology and chiropractic care," says Dr. Oh. "This is the beginning of a spine care ACO model. In the future we could go to big carriers and offer to handle all spine care for their customers. We haven't executed any contracts yet, but they are in the works."
Under these agreements, if there were complications insurance companies wouldn't pay more to cover them. "However, if the providers execute quality care, they can actually stand to increase their revenue," says Dr. Oh.
Dr. Bryan Oh is board certified in Neurological Surgery and received his medical training at Stanford University with a residency in neurosurgery and fellowship in spine surgery at the University of Southern California. Dr. Oh was a faculty member at the University of Texas at Houston Medical School and was Director of Neurotrauma for the busiest Level One Trauma Center in the United States. He is a reviewer for the journals Neurosurgery and World Neurosurgery as well as a member of several prestigious societies, including the Congress of Neurological Surgeons and the American Association of Neurological Surgeons.
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