Payers and CMS have been pain points for spine surgeons in 2024 and some physicians are thinking about the year ahead.
From biologics coverage to declining reimbursements, here are the payer obstacles that spine surgeons anticipate in 2025.
Editor's note: Responses have been lightly edited for clarity and length.
Question: What is the next payer challenge spine surgeons should anticipate in 2025?
Brian Fiani, DO. Spine surgeon. (Birmingham, Mich.): In 2025, spine surgeons may anticipate several payer challenges, including:
1. Value-based care models: As healthcare shifts toward value-based care, spine surgeons will need to demonstrate the effectiveness and cost-efficiency of their treatments. Payers may require more evidence of outcomes and patient satisfaction to approve procedures.
2. Prior authorization requirements: There may be an increase in prior authorization requirements for spinal surgeries and related interventions. Surgeons will need to prepare for potential delays in treatment while navigating these processes.
3. Cost transparency initiatives: With a growing emphasis on cost transparency, spine surgeons might face pressure to provide clear estimates of procedural costs, including all associated fees. This could necessitate adjustments in how they discuss financial aspects with patients.
4. Changes in reimbursement models: Payers may continue to revise reimbursement models, possibly reducing payments for certain procedures or shifting toward bundled payments. Surgeons should stay informed about these changes and adapt accordingly.
5. Regulatory and policy changes: Ongoing changes in healthcare regulations and policies can impact how spine surgeries are reimbursed. Staying updated on legislative developments will be crucial for surgeons to navigate the payer landscape effectively.
By being proactive and understanding these challenges, spine surgeons can better prepare for the evolving healthcare environment and advocate for their patients effectively.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The next big payer challenge, and I have already seen this, is prepayment review. That is when you get the surgery authorized, you do the surgery, then before they pay you, they revisit the claim. It is yet another step that allows the insurer to place more delays on your payment. Until we streamline this process, tighten it up, the skullduggery will continue. The most insane thing about this, though, is that the insurers are actually hurtling themselves towards obsolescence. If they keep this up, we will get single payer, and they will likely cease to exist.
Alok Sharan, MD. Spine and Performance Institute. (Edison, N.J.): It is clear that payers are facing significant headwinds financially. The headlines around CVS/Aetna are an example of the challenges that payers are currently facing. When value-based care was initially introduced in the form of ACOs and bundled payments, payers thought that this would be a reasonable method for controlling costs without sacrificing quality. It is clear now that value based care has not been able to deliver on those promises.
Payers should develop better criteria for determining those spine surgeons who are the most cost efficient in their ability to deliver high-quality care at a reasonable cost. The current Centers of Excellence criteria have not been able to deliver that information. For example, patients should be encouraged to see spine surgeons who are able to transition many of their cases to lower cost ambulatory surgery centers. Currently this is being done through lower copays or deductibles. Unfortunately, the payers are not looking deeper at the quality and outcome scores for the surgeons leading to indiscriminate incentives for patients.
As the ability to collect meaningful data becomes better for payers, spine surgeons should anticipate financial incentives being implemented to nudge patients toward more cost-effective surgeons. To stay ahead of this spine surgeons should collectively come up with their own criteria for a Center of Excellence and partner with payers to inform patients of their choices. Coming up with this criteria will be the next challenge for payers and surgeons.
Vladimir Sinkov, MD. Sinkov Spine. (Las Vegas): Most likely it will be more of the same — decreasing reimbursement and more rules, regulations, and denials of treatment authorization requests. The health insurance premiums will continue increasing, however.
Medicare is expected to reduce physician reimbursement in 2025. A lot of private payers' contracts are tied to a percentage of Medicare, so those reimbursements will decrease as well.
I do not think that the "gold card" initiatives to streamline prior authorizations will have any positive effect. The programs I saw are basically built for show and will not ease the overall burden of prior authorization.
William Taylor, MD. University of California San Diego Health: I continue to be increasingly challenged into the use of bone-graft materials. This would include the vast and clinically/functional variety that we use currently. Each clinical setting will need to justify the use of either more expensive and proprietary materials.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute. (Boise, Idaho): Both physicians and large hospital systems face numerous challenges with receiving reimbursements, such as fluctuating reimbursement schedules, audits of payments, billing code errors, unexpected denials, lengthy appeals, and services that are not covered. In some instances, the aftercare denials and withholds by insurers for frivolous and unsubstantiated reasons are closely approaching ten percent especially in the surgical subspecialities, where reliable margins have precipitously declined in the last five years.
Another challenge which parallels the previous point is the re-appeal process or aftercare submissions which requires a team of coding specialists and physician engagement to complete. For years, our surgery approval teams accurately included detailed symptoms, thorough examination and salient modality findings to conclude our surgical requisitions. Fortunately, our appeals process is low, but usually hinges on semantics or time allotments for conservative treatments.