The healthcare industry's tumultuous nature offers a challenging place to practice and perform surgery. Increasing premiums and stubborn payers have lodged surgeons into a corner, forcing them to make call after call for approval to perform necessary surgeries.
And reimbursement continues to fall, with innovation following close behind. "Innovation is consistently dropping," says Need Anand, MD, a clinical professor of surgery and director of spine trauma at 
Cedars-Sinai Spine Center in Los Angeles. "Innovation is almost at a standstill right now."
And a major shift is underway, as the industry redefines itself as value driven. The value-based arena recognizes quality based on metrics, but Dr. Anand believes this intense focus on numbers will reward quantity over quality.
"The numbers and metrics seem to be more important than the actual quality of how a patient does — especially in spine, because spine is not a very finite field where every patient with stenosis or back pain gets the same operation," he says.
Spine surgery involves many variables, not conforming to mandated metrics. However, those variables are not taken into account when assessing patient outcomes. For example, analyzing length of stay to assess the quality of a patient outcome is not necessarily accurate in the spine field.
"It's not a fair metric to look at," says Dr. Anand. Many of the patients are elderly with comorbidities that may keep them in the hospital longer than that related to the spine surgery.
He suggests focusing on clinical criteria. Many a time social conditions dictate when a patient can return safely home. Instead, metrics' such as narcotic intake post-surgery may be useful as well, indicated and executed surgery can reduce the medications a patient is taking. Health-Related Quality of Life scores, such as the SF-36, and more area specific measures, such as Oswestry Disability Index for low back pain, and disease-specific measures, such as SRS-22 for scoliosis, are more appropriate metrics.
After all, a patient with only back pain is very different form a patient with back pain and leg pain. Just relieving the patient's excruciating leg pain is a life-changing event for many patients and most metrics' do not capture that.
"What we're looking at is not the right way to look at it, because we're bundling ourselves with other fields," says Dr. Anand. "We have to do really well with clinical metrics to define ourselves as what we do…That will show the industry and everyone as a whole that we are making a difference in spine surgery in a big way."