Eight spine surgeons discuss where the spine industry should be focusing its attention currently.
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 steps do you take to increase patient satisfaction?
Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, Oct. 30, at 5 p.m. CST.
Neel Anand, MD, Clinical Professor of Surgery and Director of Spine Trauma, Cedars-Sinai Spine Center, Los Angeles: The industry should be focused on providing quality outcome studies of whatever we do. It's imperative right now. The studies need to be both quality short- and long-term outcomes studies showing that we are truly benefiting our patients in whatever we do. Society will demand that of us; payers are demanding that of us; and the public rightly demands that of us. The best way to do this is to conduct multicenter studies where we are looking at a number of different places doing the same procedure. Are they uniform? Are we improving patient outcomes? We need to provide more cost utility studies to show if the costs truly justify the outcomes. Lastly, we have to move toward minimally invasive ways of doing things, that is, more muscle sparing and less tissue destructive ways of achieving the same outcomes.
Erik Spayde, MD, Orthopedic Spine Surgeon, Los Robles Hospital & Medical Center, Thousand Oaks, Calif.: The spine industry should be focused on outcomes research to demonstrate the effectiveness of fusion and artificial disc technology in order to help patients more easily obtain authorization for surgical procedures.
Kenneth Pettine, MD, Spine Surgeon, The Spine Institute, Johnstown, Colo.: I believe biologics are the future in spine care. We are aggressively pursuing research through the Orthopedic Stem Cell Institute and would encourage everyone to visit our website. I believe biologics have a great future potential.
Robert Watkins Jr., MD, Co-Director of Marina Spine Center, Marina Del Rey (Calif.) Hospital: The number one threat to patient safety and outcomes is the time spine surgeons are able to spend with each individual patient. A detailed history and physical exam, thorough scrutiny of medical records and studies, and elaborate time spent discussing treatment options with patients is essential to providing quality of care. Because of declining reimbursements to spine surgeons, the ability to properly treat patients is under assault. The spine industry should focus on reimbursements to spine surgeons and hospitals to allow them to provide safe and effective patient care.
Scott Spann, MD, Founder, Westlake Orthopaedics Spine & Sports, Austin, Texas: The industry should be trying to continue providing doctors with the best and most innovative devices and technology to optimize outcomes for their patients while still being able to maintain the best business practices.Ideally, this will allow for both groups to maintain their positions at the pinnacles of the industry.
Brian Gantwerker, MD, Spine Surgeon, The Craniospinal Center of Los Angeles: The industry should be focused on creating standards for conduct of the insurance companies, such as payment practices, and revamping the criteria for fusion. The Milliman criteria are outdated, antiquated and inappropriate for many cases.
Eugene Carragee, MD, Vice Chairman of the Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, Calif.: The Affordable Care Act will have a profound impact on industry. It will redefine relationships with government, healthcare systems and payers. It will eventually expand the spine care market in the United States by millions of new patients and billions of dollars in new revenues. The ACA will also reconfigure industry relationships with spine researchers and spine care providers and help transform the entire research enterprise. This is where the spine industry should focus its attention, since the evolution of research standards will ultimately determine the face of this field.
As the recent controversy over rhBMP-2 illustrated, the traditional model of developing spinal devices, drugs and technologies has potential problems that are made worse when research data does not undergo external review. In most cases, clinical trials of new products should not be performed by researchers with significant conflicts of interest or written by company technical writers for peer review, nor can we depend on marketing and publicity campaigns led by opinion leaders with similar biases. Given the ACA's emphasis on quality, accountability and value, the spine care field needs to speed up the evaluation of new products and do so in ways that guarantee the legitimacy of the research process. Clinical trials on safety and effectiveness should be performed by researchers and surgeons who have no financial conflicts of interest and are free to access, control and publish their results.
Major journals are already demanding access to the full body of evidence regarding clinical trials of new products, including patient-level data. And the peer review process at prominent journals is becoming increasingly stringent — no longer a rubber stamp for poorly validated treatments and technologies. The ACA's "Sunshine Act" will help patients determine whether their surgeons and spine care providers are free of financial conflicts and can act as independent arbiters of the pros and cons of novel interventions.
The ACA mandates shared decision making, so that patients and healthcare providers can shop intelligently for treatments that deliver optimal quality and value. To that end, all clinical trials should be published so that patients and physicians can make fully informed choices based on the total body of evidence. The spine industry should ultimately compete for market share over the quality of the scientific evidence and not just with marketing and public relations prowess. The entire spine field needs to work toward this goal.
Ara Deukmedjian, MD, Neurosurgeon and CEO, Deuk Spine Institute, Melbourne, Fla.: Spine care is under heavy attack by private health insurance companies. The health insurance industry is the enemy. Any other perceived enemy is merely a distraction created by private health insurers for the sole purpose of throwing all concerned stakeholders off the scent of the private health insurers who are solely responsible for undermining the delivery of high-quality medical care to people suffering with chronic pain. Why are insurers attacking spine care? Simply put, high-quality spine care is expensive to deliver. Of course the health insurer has to pay for medical care for its beneficiaries, but only if the tests or treatment ordered by the doctor is determined by the insurer to be medically necessary. So, if the insurance company could change the definition of medically necessary, manipulate it or hone it to be what the insurance company wants it to be, then there is unlimited opportunity for growing profits for the insurer because they could deny any medical care they wanted to simply by calling it not medically necessary.
Unfortunately, this is indeed exactly what is happening today, and it's gaining more momentum. Insurers are now calling some of the most common surgeries, treatments, medications and testing ordered by doctors experimental. Now patients needing surgery must come up with $100,000-plus to pay for their own medical care. Insurance companies are now calling the standard treatments we doctors have been providing patients for the last 50-plus years as experimental and therefore not medically necessary for the sole purpose of getting out of paying for the medical treatment the doctor ordered. Invariably, the insurance company has a policy that clearly states that unless pre-authorization is obtained before the treatment is given, they will not pay.
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