Minimally invasive spine surgery has been rapidly evolving for decades, and the resurgence of the attempt to perform more appropriately invasive surgical techniques will continue to develop.
Hallett Mathews, MD, MBA, is the Executive Vice President and Chief Medical Officer of New York City-based Paradigm Spine, a non-fusion spinal implant and device technology manufacturer. He is also a board-certified orthopedic spine surgeon and minimally invasive spine surgery pioneer.
Here are Dr. Mathews' three predictions about the future of minimally invasive spine surgery.
1. Reimbursement lines will blur. Spine surgeons performing minimally invasive approaches must satisfy criteria set by coders and insurance payers to prove they can fully see and address pathologies to be properly reimbursed for the procedure.
Lines have also begun to be drawn by coders and payers to distinguish between the surgical and adjunctive pain market. Some pain management interventionalists have been performing surgeries on pathologies to include injections and technologies bordering on what a spine surgeon would have done with open or MIS techniques, and that area is becoming more gray, Dr. Mathews says.
This year, payers decided an open spine decompression can only be coded as such if the physician physically sees the nerve, which Dr. Mathews argues should only be done by a surgeon. While trying to separate between surgery and interventional procedures, payers have given non-surgeons more privileges to do surgery-like procedures, he says. This trend is currently evolving, and it's hard to predict where it will go. The recent coding changes seem to provide more clarity. Innovation will continue to challenge user, indications and best practices.
2. Payers will be more involved. Historically, the difference between a surgeon performing a minimally invasive discectomy and an open discectomy was not within the purview of insurance companies. However, recently payers have started to define endoscopic and MIS in their coding descriptions, Dr. Mathews says. They are catching up with MIS, and the codes are describing more techniques.
"Payers are seeing that minimally invasive is not going away," he says. "This is a good development. This trend supports endorsement; however it may not translate into higher reimbursements."
However, problems arise with surgeon training, which is not standardized within the industry. Some institutions provide thorough MIS training, and other surgeons have to seek out proper training on their own to improve their skill set. Since surgeons do not perform procedures identically and with the exact indications, it will be harder to receive reimbursements for stringently-coded techniques.
3. Spine surgery in general will come under attack. Surgeons initially focused minimally invasive efforts on procedures they could easily perform, such as simple decompressions and discectomies. More recently, surgeons have added more advanced surgical stabilizations with the use of fixations, biologics and fusion, he says, and have gotten more skillful at tackling bigger deformities with less invasive tactics.
However, a crisis of indication is beginning to occur for both MIS and open procedures.
"We have learned to be better surgeons, and now we have payers pushing back on our procedures because there is so little evidence supporting efficacy and cost-effectiveness of minimally or maximally invasive spine surgery," Dr. Mathews says. "The overall surgical specialty of spine surgery and reimbursements for more efficient and less invasive intervention is under attack because of this lack of evidence. Evidence-based medicine will play an increasingly important role in coverage decisions and denials of precertification for surgery."
The lack of evidence with most spine surgery is overshadowing the MIS discussion because all spine procedures are increasingly harder to get reimbursed today. The real discussion is on the assault of surgical solutions for spinal diseases, he says.
"Payers are no more willing to pay for minimally invasive deformity than for open surgical procedures because they are saying, 'We don't want to pay for either of them. Provide the evidence that the safety, efficacy, and risk benefit ratio is favorable to the patient and stakeholder group,'" he says. "That's really challenging for the surgeons."
As this crisis continues, surgeons will have to stay trained and focused, continue to master patient selection and work to limit the inherent morbidity of their surgical approach.
"Incisions create baggage for patients to overcome," Dr. Mathews says. "Incisions bring an element of soft tissue trauma to the healing process. Minimally and appropriately invasive surgery lessens the baggage so the real intent of the surgery can be realized."
The future of MIS will challenge surgeons to collect data, prove efficacy and show that patients have a better of quality of life after spine surgery so payers will understand the necessity.
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