The Real Cost of Spine Surgery: 8 Ways Surgeons Can Take Control

Robert S. Bray, Jr., MD, is the founder and CEO of DISC Sports & Spine Center in Marina del Rey, Calif. He has an interest in minimally invasive spine procedures and has performed more than 10,000 spine surgeries throughout his career. Dr. Bray also founded The Institute for Spinal Disorders at Cedars Sinai Medical Center in Los Angeles and opened a second DISC location in Orange County in 2012.

Throughout his many years in the business and practice of spine, Dr. Bray has honed techniques for providing patient care while maintaining an efficient, successful business. As spine costs industry-wide continue to increase, spine surgeons can gain back control of their practice by getting to the root cost of each procedure putting smart techniques into action.

Here are Dr. Bray's eight ways spine surgeons can take control of all aspects of their spine surgery expenses.

1. Break down case costs per surgeon. The best place to start when trying to control costs is to get information on exactly how much each spine procedure is costing the surgery center or hospital. Dr. Bray recommends figuring out the case costs by surgeon to see if any large discrepancies exist. With a clearer knowledge of costs, surgeons have the ability to find ways to lower their individual case costs with help from their more cost-efficient peers.

2. Renegotiate any high-volume supplies. DISC's supply costs were dramatically lowered when the management team hired an independent technician to come in to the center, scan all bills and look at high volume use products. The leaders were then able to go and renegotiate the cost of any high volume pieces of equipment.

He also recommends using a group purchasing organization in conjunction with outside purchases that can be found for lower prices.

"Go to companies and say, 'You need to be less,'" he says. "Bring them into line."

3. Have firm rules for implants. Implants are a major contributing factor to the cost of many spine procedures. To keep implant costs from reaching unprofitable levels, Dr. Bray says to have firm rules and fees for implant vendors.

"We have a per-level fee with implants," he says. "For instance, for a one-level stabilization, they get a $2,000 fee. If a company wants to match that, then they can go on the list. If they don't want to match the fee, they won't go on the list."

Spine surgeons and facility decision makers should also use caution when working with implant representatives peddling brand new devices. Dr. Bray and his team of managers have a rule that if device representatives ask surgeons to use a product without having it pre-authorized as a pre-sale, then the device is free of charge. "Reps have to sign that to work here," he says.

Firmly adhere to only using devices and implants pre-authorized for a negotiated price. The implant world is tough, Dr. Bray says. Be aggressive and look at all possible areas for optimal savings.

4. Consider eliminating device reps wherever possible. Spine practices can save substantial dollars by not having a device representative in the operating during for frequently-performed procedures with standard implants.

"Going to a no-rep fee purchase can knock 30 percent off the cost of the implant," Dr. Bray says. "We have to have someone reorder and restock the trays, but in many places reps can be cut out."

Another option could be to use an implant dispensing machine, where a company representative is only required to refill the machine when it runs out.

5. Closely monitor biologics usage. Like implants, biologics can vary widely in price. Maintaining a close watch on all biologics usage in a spine facility will keep surgeons from using off-label biologics and driving up costs. Off-label use can run up thousands of dollars in additional charges per case, Dr. Bray says.

Form an oversight committee tasked with approving all biologic doses and uses and holding all surgeons accountable for adhering to the standard.

6. Pay attention to appropriate patient selection. Proper patient and indication selection is crucial to the success of a surgery and can keep patients from needing revision surgeries or other costly follow-up visits.

"Eighty percent of healthcare dollars spent on spine are spent on failures in spine, including failures that result in long-term drug use or pain management," Dr. Bray says.

Surgeons must maintain the ability to use their best judgment and knowledge to select patients who are proper candidates for surgery. Insurance companies try to get involved in patient selection, but "you can't have them do that," he says. It's the wrong place for oversight.

7. Minimize the risk for complications. Surgical complications also drive up costs, and working to eliminate complications plays an important role in controlling costs. The cost of a post-operative pulmonary embolism or a wrong level surgery is massive, Dr. Bray says.

An important step to minimizing complications is setting protocols for all surgeons to follow. Post-operative protocols, including proper catheter drainage and use of the bladder to avoid infection, result in huge cost savings for patients and providers.

"Protocol management of patients to avoid complications dramatically reduces the cost of delivering care," he says. "This involves education of the nursing staff and proper selection of surgeons."

8. Take control. The only way for surgeons to cut the costs associated with spine surgery is to take control of all aspects of the procedure. Often surgeons employed by hospitals have less of a say in the purchase of implants, supplies and more compared to ambulatory surgery center physicians who may have greater decision-making powers. That's not OK, Dr. Bray says.

"If a surgeon says he has no control, then he is showing no interest," he says. "Look at hospitals or ASC committees. Get involved in the committees that look at these areas."

Surgeons must take a more active role in the elements of the procedures they perform. If they do not, the decisions are made by administrators or insurance companies.

"If your hospital doesn't have a cost analysis person, then start the program," he says. "Get the hospital going."

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