Five spine surgeons discuss how the Patient Protection and Affordable Care Act's reforms will affect their spine practice.
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: Where should the spine industry's attention be focused right now?
Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, Oct. 23, at 5 p.m. CST.
Brian Gantwerker, MD, Spine Surgeon, The Craniospinal Center of Los Angeles: I expect more delays in payments, more rejection of appropriately coded surgeries and more roadblocks to getting the right surgery approved by the insurance carriers.
Eugene Carragee, MD, Vice Chairman of the Department of Orthopedic Surgery, Stanford (Calif.) University School of Medicine: The Affordable Care Act will be challenging for everyone in the healthcare system and spine care providers in particular. The care of chronic back pain has been targeted as an area where there has been excessive and wasteful utilization of medical services. Overall, the spine care system will need to shift from incentivizing fragmented high-cost care to encouraging coordinated high-value care. It will have to document patient outcomes, quality measures and costs explicitly so that patients can make educated choices and shop for value in the medical marketplace.
The ACA will also mandate a new transparency under the "Sunshine Act" and some patients may steer away from providers with conflicts of interest that might affect their care and inflate their costs. This could be a wake-up call for many in spine care — and in industry.
There will be an influx of an estimated 23 million new patients as the ACA expands insurance coverage, particularly for those at lower socioeconomic levels. Some will have definitive spinal pathologies. But many more will have complex co-morbid conditions, psychosocial issues and economic problems — a mix that will test even the most knowledgeable providers.
The transition under the ACA will involve a shift in scientific research. There is a need to better understand the life course of back and neck pain. A small minority of patients incurs the lion's share of both direct and indirect costs. We need to do a better job of identifying those with a need for continuing cost-effective management over years and decades — and the appropriate balance of surgical and nonsurgical services.
Though technical advances have made spine surgery safer and more predictable, many spine care interventions, particularly those for axial back pain, have not yet been validated in high-quality independent clinical trials. This compromises the ability of spine care providers and their patients to engage in the shared decision-making and fully informed consent required under the new law. So the Affordable Care Act could require a rapid upgrade in research standards as well as healthcare standards. This may be of enormous benefit to patients who have problems in "gray" areas where care can only be improved by better understanding the disease and the effect of treatment.
Richard Kube, MD, Founder & CEO of Prairie Spine & Pain Institute, Peoria, Ill.: Certainly, the first thing we are seeing is a healthy increase in our insurance premium contributions for our staff. We expect to see an increase of 20 to 25 percent next year, which far exceeds any previous year and equates to the salary of a full time employee. There are not any other significant differences I expect to see right away. There may be some added patients to the insured class, but the reimbursement rates do not appear favorable. Realistically, the biggest issue is the unknown. I do not believe there is anyone who can really tell you what will or will not change at a grassroots level with the implementation of PPACA.
Therefore, the regular increase in our practice size, namely hiring of physicians and support personnel, will decrease compared to previous years. We are consciously exercising relative caution with respect to business growth and development. The timely access to care to which our practice is so dedicated will be harder to maintain with the staff crunch, especially given the age of the Baby Boomer generation and its increasing need for medical services.
Christian Zimmerman, MD, Neurosurgeon, Idaho Neurological Institute, Boise: In early 2012, CMS bolstered by the Affordable Care Act, delivered a significant decrease to the reimbursement structure toward hospital systems and other billable outlets. For physicians who have remained with their Medicare patients, these cuts were advanced by the bundling of procedures under singular working relative value unit categories, carrying this practice even further.
The sociological impact of treating Medicare patients with their high prevalence of degenerative spinal disease continues to widen. Patient insurance profiling, not disease type, denominate the physician practice. The heuristic argument as it relates to the "uncertainty principles" in healthcare reform, are becoming much clearer; politics will drive the economics.
Ara Deukmedjian, MD, Neurosurgeon and CEO, Deuk Spine Institute, Melbourne, Fla.: It will very negatively affect my practice. The Affordable Care Act can be summed up as "force healthcare providers (physicians, hospitals, imaging, etc.) to do more work for far less pay." There will be NO improvement in quality of care. Essentially private insurer stockholders/executives and board members will be the ultimate and sole benificiaries of this program as they are seeing dramatic increases in profits while the providers and patients are getting much less. The ACA is forcing physicians out of private practice and into hospital employed models at an unprecedented rate. Once doctors are integrated into healthcare systems and incentivized to reduce costs for the insurer, they will invariably accomplish this by reducing the amount and quality of care to patients. Patients will suffer.
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