Here four spine surgeons discuss how the spine industry and care delivery has changed over the course of their career.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
Next week's question: What trait(s) are essential for a good mentor?
Please send responses to Anuja Vaidya at avaidya@beckershealthcare.com by Wednesday, May 11, at 5 p.m. CST.
Question: What is the biggest change in the spine industry since you started practicing?
Kern Singh, MD, Minimally Invasive Spine Institute, Chicago: The biggest change is the evolution of value-based spine surgery. The days of using a device just because it's better are done. Now we have to justify the increase in cost and prove to the insurers and patients that these new devices are not only better but are also cost effective.
Richard Kube, MD, Founder, CEO, Prairie Spine & Pain Institute (Peoria, Ill.): I would break up the answer into two parts. From a strictly industry standpoint, there is a lot more regulation and innovation has become much harder. The average physician has a harder time being involved in much of the consulting for new products as their time is further stretched with patient care. Also, many current consulting options are money-loss propositions for the physician so getting the best and brightest to help innovate and bring a product from the lab to the operating room is more difficult.
From a practice standpoint, the explosion of minimally invasive techniques has created a huge change. Many of the procedures I do now didn't exist when I was a fellow 10 years ago. The dynamics of practice are different as we aren't rounding daily on a large service of patients. Most of my cases are done outpatient or are discharged early the morning after the surgery. That would have been unheard of during my training. That change has then opened the opportunity to do surgeries in an ambulatory setting. During my training, 0 percent of our cases were performed there, but now more than 90 percent of my cases are done in the outpatient setting. Spine has really evolved away from the days when you had cases lasting several hours and patients admitted for days or more. Though some of our cases still require that type of postoperative care, it only applies to a distinct few instead of the practice as a whole.
Jack Zigler, MD, Medical Director, Texas Back Institute, Plano: The biggest change I have seen is the intrusion of the health insurance industry into the doctor-patient relationship. My career started before the era of prior authorization. If a patient was seen with a large disc herniation and an acute foot drop, they were taken to the operating room and the problem addressed. Although there were undoubtedly physicians and surgeons who took advantage of that system, one has to wonder if the enormous cost of the layers of bureaucracy involved in pre-authorization, on both insurance and physician side, have offset that potential overuse.
Far worse has been the erosion of the unique bond between a surgeon and patient. The surgeon uses his/her education, knowledge and clinical experience base to make a surgical recommendation specific to the patient, who in turn must literally trust the surgeon with their life. But now the insurance industry has come between this historically sacred relationship, imposing their poorly explained "medical policies" and even more puzzling guidelines to delay and even deny care. Despite the existence of longer term level I data in the peer-reviewed literature, it is not uncommon to see four different insurance companies make four different coverage decisions based on the exact same data. And patients, paying their ever-increasing monthly insurance premiums, are blind-sided when they learn that the procedure recommended by their doctor is capriciously considered "experimental and investigational" by their insurance company, and not a covered benefit.
The loss of professional respectability by the medical provider, being morphed into a "line-item widget" in a provider's portfolio, has been tremendously disappointing to me when looking back at my 35-year career as an orthopedic spine surgeon. I do not see this as an improvement in medical care delivery.
Brian R. Gantwerker, MD, The Craniospinal Center of Los Angeles: The industry has really shifted toward ambulatory surgery, as well as toward deformity correction. These seem irreconcilable but I think the government and insurers will push back when it comes to deformity. I admire the work that is being done, but the pressure from payers will change the way we practice even more than it already has. The industry itself is offering up more innovative ways to do minimally invasive surgery as well as motion-preserving technologies. Hopefully, the money for research and development will still flow into the industry so we can offer evolving ways to help people.