Consolidation, artificial intelligence advancements and the rise in robotic-assisted procedures are three healthcare trends that spine and orthopedic surgeons are closely following.
Here, five surgeons answered the question: What are the top trends you are following in healthcare today and why?
Note: Responses have been lightly edited for length and clarity.
Daniel Li, MD. Orthopedic surgeon at the Ohio State University Wexner Medical Center (Columbus):
- Robotic-assisted surgery: Robotics have come into the total knee market for every major orthopedic company, though only one vendor (Stryker-MAKO) has CT-guided pre-op imaging, whereas the other vendors rely on intra-op landmark registration. The next generation of robotics, which is already coming into fruition, will enhance the ability of the user to assess soft tissue tension throughout the arc of motion, and not just 0 and 90 degrees of flexion. However, it is important to keep in mind that fundamentally, the physiologic knee has the majority of its ligaments in the toe-off region of the stress-strain curve, and when undergoing varus/valgus stresses, the ligaments shift into their elastic region with a higher elastic modulus. These future robotic technologies may be able to account for these soft tissue principles when it comes to balancing. Robotics provide real-time feedback to the surgeon during the procedure. As we know, robotics allow for near perfect bony cuts and greater precision/accuracy; however, a large subset of patients, 15 to 20 percent, still remain unhappy. Is it possible that we are simply not aiming for the correct targets? Or are there simply different targets for different patients?
- Artificial intelligence and machine learning. This may be used in preoperative planning by taking a patient's medical history, imaging data, weight, activity levels, anatomical abnormalities or pathology, to create a personalized surgical plan that can help improve surgical outcomes, potentially selecting the most appropriate implant for that specific patient. For example, a patient in the not-too-distant future may have some form of pre-op "gait analysis," and data from that study is implemented into a machine learning algorithm that churns out precisely how the implant should be positioned, and perhaps guide physical therapy post-op. Intraoperatively, it may be used to navigate component positioning to actually hit the target that it was planned for. Furthermore, it can aid in predicting postoperative outcomes and complications. By analyzing large datasets of patient outcomes and identifying patterns, algorithms can help predict which patients are at higher risk of complications or implant failure, allowing for proactive measures to be taken to prevent or minimize such complications. However, we are still quite a ways from this as we have imperfect data collection, and novel "smart knee" implants like the persona will likely give us significant amounts of data, but we may be unsure of how to use the massive data set effectively. Machine learning is a powerful technology that has revolutionized the way we solve complex problems.
Philip Louie, MD. Spine surgeon at Virginia Mason Franciscan Health (Seattle):
- The consolidation of healthcare as a whole. Much like how we have seen much of the business world consolidate their brick and mortar physical working spaces and schedules, healthcare will require innovation to redesign how we package the care that we deliver.
- The rapid rise of enabling technologies. The goal of these innovations is to improve the way we care for patients, and ultimately, drive meaningful change in how we practice. As multiple companies work towards an all-in-one combination of various pre-op planning tools, augmented reality, surgical robot/navigation and collection of postoperative outcomes, we hope that these tools will guide us through the whole perioperative episode and provide us with crucial data on our planning and results.
- The establishment of "big data." This follows the previous trend. The large amount of data that we can obtain will be the background of these integrated systems (achieved from machine learning and artificial intelligence) and ultimately drive our decision-making throughout the whole continuum of patient care. We will see the collaboration of multiple industries and research minds that will drive these changes in an evidence-based manner that can keep up with the demands for higher-quality care in a cost-constrained landscape.
Hooman Melamed, MD. Spine surgeon at The Spine Pro (Beverly Hills, Calif.):
- Private practice physicians are being driven into extinction because big healthcare entities and corporations are buying up and employing many private physicians. This is resulting in much higher healthcare costs at the expense of driving down quality of patient care. Since these big hospitals and healthcare corporations have much better contracts than the private practice, insurance companies are then reducing payments to private practice physicians, increasing patients' premiums and deductibles and allowing less coverage, which overall results in much lower quality of care and higher out-of-pocket costs to patients.
Paul Perry, MD. Orthopedic surgeon at Tri-State Orthopaedic Surgeons (Evansville, Ind.):
- Consolidation. Both hospital systems and physician-led organizations continue to consolidate at an accelerating pace. As the leader of an integrated physician practice, we continue to monitor these developments, particularly with regards to private equity's role in the orthopedic practice space. There are obviously pros and cons to a roll up and our team is continuously evaluating our market position and the best pathway for protecting the independent practice of medicine that we cherish.
- Trends in outpatient surgery. The migration of total joint arthroplasty and spine surgery to an outpatient/short-stay setting is well underway but in my opinion is still in the early innings. On the other end of this spectrum, some surgical cases are migrating to an in-office site of service, particularly in pain procedures, as well as hand and foot cases. ASCs must adapt to this transition in important ways which will require increasing investment in facility infrastructure and staff training. The same is true of in office procedure capabilities. This is a top-of-mind issue as our practice looks to the future of healthcare and the future of our surgical practice. This migration has legs as it is a strong value proposition for our patients and for third-party payers.
- Hospital-physician-employment. The 20-plus-year trend of increasing numbers of physicians choosing hospital employment over other practice arrangements is at an interesting crossroads. Inertia alone and the current regulatory environment would strongly suggest that this trend will continue unabated. This is part of the consolidation discussed above. Nevertheless, proposed changes in restricted covenants, frustration with the hospital employment model and increasing desire for physician autonomy could all play a role in decelerating or reversing this long-term trend. This is an issue which deserves monitoring in the strategic planning of physician-led practices and organizations.
James Wylie, MD. Associate Medical Director for Hip and Knee Preservation at Intermountain Healthcare (Salt Lake City):
- The biggest trend I am looking at in healthcare is the transition from fee-for-service based payment to value based care. Given the cost of healthcare in the U.S. there needs to be a fundamental change in how it is financed. Rather than paying for care when people are sick, it is much more financially viable for the system to value preventive care that keeps people healthy. The problem is that the majority of our healthcare landscape is built on a fee-for-service model. This will require fundamental changes in the finances of our healthcare system to divert resources to preventive care and payment based on giving high-quality care at a low cost. It also requires integrated systems that control the payer, the infrastructure/hospital/ASC and the physician acting as a team to provide high-quality care at low cost rather than maximize the profit for each part of the system in its own silo.