Christopher Kauffman, MD, is an orthopedic and spine surgeon who serves as the chair of the North American Spine Society's professional, economic and regulatory committee. Dr. Kauffman and his committee review payer policies, coverage and availability and make recommendations rooted in evidence-based spinal medicine.
Dr. Kauffman is currently in private practice at Premier Orthopaedics in Nashville, Tenn. Prior to going into private practice, he was in fulltime academic practice at the University of California San Diego teaching residents and spine fellows. He received his fellowship training in spinal surgery at UCSD.
He previously served on NASS' surgical coding committee and is the organization's representative to the American Academy of Orthopaedic Surgeons' coding, coverage and reimbursement committee.
Here Dr. Kauffman discusses coding and reimbursement obstacles for spine surgeons and how ICD-10 will come into play.
Question: Why did you choose to subspecialize in spine?
Dr. Christopher Kauffman: I chose to specialize in spine surgery during medical school because of the influences and mentorship of a physician who I spent extensive time with in the clinic and in the operating room. My mentor was Thomas Haher, MD. I started an elective with Dr. Haher and was inspired by his passion and compassion in treating patients with spinal disorders. I started going to his scoliosis clinic during my first year and was impressed by his caring and kindness in taking care of these children. I worked with Dr. Haher throughout four years medical school and kept in contact with him throughout residency and fellowship.
Q: How has the practice of spine surgery changed since you first graduated from medical school?
CK: The practice of spine surgery has changed greatly since I graduated medical school. There was a period of time I when I was a resident when the new innovations and devices where coming out fast and they appeared to show significant promise in the treatment of spinal disorders. Some of these techniques and devices were successful while others failed. At that time physicians were able to use the latest techniques and devices using their discretion and knowledge.
There has been significant focus on the failures in spine surgery especially when it comes to the use of new technology and this has led to much greater restrictions on delivery of care and surgical options. Some of this restriction has been appropriate but unfortunately there has been too much focus on failed procedures and not enough focus on all the techniques and procedures which continue to help patients with spinal disorders.
Q: Have you worked with any other spine surgeons or mentors who have shaped your practice?
CK: I have had the opportunity to work with three outstanding mentors throughout my career. In medical school I worked with Dr. Haher for four years and have considered him to be a role model and mentor throughout my professional career. During residency I was fortunate enough to work with Casey Lee, MD. Dr. Lee is an outstanding clinician, surgeon and researcher. I had the opportunity to work with him in all three areas and continue to use the knowledge I obtained while working with him for my daily care of patients.
I did my fellowship with Steven Garfin, MD, at UCSD. It was a great opportunity to work and train with Dr. Garfin as a fellow for that year. I also was able to stay on as clinical faculty for four more years. Dr. Garfin is a world-renowned clinician and scientist. My surgical practice and treatment of patients is a direct result of all that I have learned from him. My interest in working with NASS is a direct result of working with Dr. Lee and Dr. Garfin. I consider myself very lucky to have had the opportunity to work and learn from with such leaders in spine care.
Q: Why have you chosen to stay in private practice, and what are the pros and cons to this decision?
CK: I have worked in both academic practice and private practice. I loved working in academic practice and reflect fondly on the opportunity I had while at UCSD on the spine service with Dr. Garfin. I found working with the residents and fellows caring for complex spinal problems to be very rewarding.
I chose to go into private practice mainly secondary to financial pressures and constraints from medical school debt.
I consider myself fortunate to have had the opportunity to work in both academic and private practice settings, as I believe it has given me a broader perspective of both physician and patient care issues.
The pros of working in private practice are:
1. I get to see the most typical problems that bother patients during her lifetime. In academic practice I was often focused on revision situations, tumors and infection cases. All these cases are extremely rewarding to evaluate and treat but they are not the most common that affects the majority of patients.
2. In private practice I still have significant autonomy regarding my scheduling of clinic and surgery. This autonomy is priceless when it comes to family life and family activities.
3. In private practice I am more closely aware of patients' problems they encounter with obtaining treatment for spinal conditions. I am directly aware of the problems patients have obtaining medications, therapy and surgical intervention.
The cons of working in private practice are:
1. I truly miss the opportunity of working with residents, fellows and medical students on a daily basis. I miss the opportunity to participate in their education and the daily interaction. It was their questions which kept me on my toes regarding the literature and treatment of spinal conditions.
2. Private practice is acutely sensitive to the changes in reimbursement and increased difficulty in getting precertification for medications, non-operative treatments and surgery. In private practice I'm directly responsible for the employees necessary to conduct the business of medicine. It is difficult for employees to understand that their wages and benefits are directly related to medical reimbursement. With decreasing reimbursement and increasing costs it is difficult to maintain employees at the level of reimbursement that may be possible at larger healthcare organizations.
3. One of the other cons of private practice is the decreased opportunity for collegiality in reviewing patient care. All private practice physicians suffer the same constraints with decreasing reimbursement and increased time demands both in the hospital and out of the hospital. These increased time demands take away from time available for case conferences and/or having non-direct patient care related conferences.
Q: How did you get involved with the Professional, Economic and Regulatory Committee? What are the committee's goals for this year?
CK: I have had the opportunity to serve NASS as the chairman of the professional economic and regular committee at NASS for two years. I got involved with the committee following being the chairman of coding in reimbursement committee and course at NASS for seven years.
The goals of PERC are to evaluate the policies of payers as we become aware of them either from members or from the payers asking for our opinion. Our main goal is to make sure that appropriate spine care remains available for patients. We review the evidence-based medicine for each topic and come up with recommendations regarding whether the evidenced-based medicine supports the use of these treatments. While it would be ideal to have level I evidence for all treatments, we just don't have that for many effective treatments. There are some treatments it would be unethical to go back and redo studies that either withhold or compare them with non-treatment.
Our main goal at NASS on PERC is to make sure that appropriate spine care is available for all patients with spinal conditions and that payers are not inappropriately denying coverage for patients with spinal conditions.
Q: In light of your coding background, how do you expect ICD-10 will impact spine surgeons? In what ways should they be preparing for this change?
CK: ICD–10 provides more accurate diagnostic coding of medical problems because it has significantly increased granularity. This will be frustrating at first because there is so much more specificity regarding diagnosis. Spine surgeons should expect ICD-10 coding to allow for more accurate diagnosis and coding of patients' individual problems. At first this will be a very difficult and time consuming change, however with time surgeons will be able to adjust and will potentially allow them to go back and review results by more specific diagnosis.
I think the biggest obstacle is the financial one. Diagnoses will not automatically just migrate from ICD-9 to ICD-10. There will be significant costs for providers in updating their electronic health record and billing systems. The payers will have to do the same. For smaller practices this cost could be a very significant hit to their yearly operating costs.
The obvious question becomes what the U.S. will get out of this expensive change to a more specific diagnostic nomenclature system. This remains unclear. Certainly the costs to individual providers and smaller groups will likely outweigh any perceived benefit. Whether more specific diagnosis improves the delivery of care in the U.S. will take many years to sort out.
Q: What are the biggest challenges currently facing the industry?
CK: The biggest challenges facing the industry today and in the future are how they will perform clinical trials on the new procedures and new technology. It used to be as long as the procedure was a standard procedure that changing the instrumentation did not affect payment for the procedure. This has changed. Any type of new technology or new procedure is now more heavily scrutinized using evidence-based medicine. The use of evidence-based medicine in evaluating procedures is good for physicians and their patients; however it presents significant challenges from economic standpoints as to who is responsible for financially covering new procedures which show promise. There are very high costs to doing good clinical research.
Q: What is most fulfilling part of practicing as a spine surgeon?
CK: The most fulfilling part of being a spine surgeon is helping patients relieve their pain and suffering and returning them to activities that they enjoy. Just recently I participated in the care of a patient who had become paralyzed secondary to an epidural abscess. I was able to decompress the spinal cord and stabilize the spine. This patient had near complete restoration of function. It is being able to help patients in these situations that I find most rewarding and fulfilling.
More Articles on Spine:
8 Inexpensive Ideas to Improve Patient Experience at Spine Centers
Lakes Surgery Center: 4 Steps to Making Spine in the ASC a Reality
Medtronic Releases Efficacy Data from iPad Games for Surgeons