Here are four spine surgeons on their current research focuses, as well as where reimbursements are headed.
Question: Where is your current research focus?
W. Daniel Bradley, MD, Orthopedic Surgeon, Texas Back Institute, Denton, Texas: With the arrival of both the Patient Protection and Affordable Care Act and the ever-increasing black hole that is the FDA, my research focus has moved away from the familiar investigational device exemption study of new technology in spine. The ever-increasing difficulty and expense of obtaining FDA approval as well as lack of coverage from insurance companies even after FDA approval has all but stopped new innovation in our field.
More common now are smaller, post market studies which validate the clinical efficacy, as well as safety of products cleared through the 510k process. In addition, I am focused on research that evaluates the cost versus clinical outcomes of various surgical treatments of spinal disease. This research looks to demonstrate value for much of the current practice of spine surgery.
Unfortunately, limited overall funding for spine research continues to hamper advancements in quality and value.
Kenneth Pettine, MD, Spine Surgeon, The Spine Institute, Johnstown, Colo.: Without question, our research focus is in the use of biologics which I believe has a tremendous potential in the future of spine care. The FDA has killed innovation in spine and orthopedics in the United States. I am the principal investigator for 15 FDA studies, and of all of those, only one is active. Venture capitalists and invest banking money has been completely removed from any future IDE studies, and I do not see any future at all in implant innovation.
Robert Watkins, Jr., MD, Co-Director of Marina Spine Center, Marina Del Rey Hospital, Marina del Rey, Calif.: My current research focuses in on treatment outcomes. Spine surgeons need to demonstrate the outcomes of non-operative and operative care. The doctor needs to provide the guidance for accurate outcome assessment so that payers do not selectively bias results.
Q: What trends are you experiencing with spine surgery reimbursements? Are they impacting what you can do for patients?
Dr. Pettine: As far as the trends for spine surgery reimbursements, all reimbursements are decreasing. The ability to pick and choose implants is also decreasing. Thus, everything is headed more toward generic care. I do foresee a two-tier system.
Joseph Cheng, MD, Director of Neurosurgery Spine Program, Vanderbilt University Medical Center, Nashville, Tenn.: I think all surgeons will agree that the trends in spine surgery reimbursements are on the decline. This has been happening subtlety for years now, and "hidden" in the aggregate insurance payments to surgeons along with monthly volume and case mix variability, which make it hard for the average surgeon to pick up.
For example, Medicare used to reimburse $1,205 for a lumbar discectomy (CPT 63030) in 1997, and now reimburses $961 in 2013. A lumbar fusion (CPT 22612) used to reimburse $1,801 in 1997, and now Medicare pays $1,593 in 2013. Add in variables such as inflation and more private payers basing their contracts on Medicare payments, rather than a fee schedule, have surgeons seeing a continued slow decrease in their overall collections, which most correct by increasing their volume.
Unfortunately, while reimbursements are declining, a surgeon's overhead and expenses, such as malpractice costs, continue to increase. With mortgage, car payments and the monthly bills seen with supporting their families, the only thing a surgeon can really do to meet their obligations with declining payments is to keep work longer hours to care for more patients than they had in the past.
Q: How are lower reimbursements impacting spine surgeons' practices?
Dr. Cheng: This is forcing the surgeons to be more efficient at the expense of spending less unpaid for time such as calling their patients back on the phone, filling out forms and writing letters for them, spending extra time talking to their family members, or just time at the patient's bedside offering comfort and reassurance. Another impact on patient care due to declining surgeon reimbursement is the push by payers to perform cheaper services, even if the surgeon does not feel it is in the best interest in their patient.
For example, if you had a patient who needed a revision anterior cervical fusion due to pseudoarthrosis with risk factors which precluded using a structural allograft, your surgery using a PEEK cage may be denied. While not using a PEEK cage lowers reimbursement, I think those who do not actively practice medicine are forgetting that our medical decision making is based foremost on the patients' needs and not on what is paid and impacting what we can do as physicians to help our patients.
More Articles on Spine Surgery:
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