As today’s healthcare environment grows more challenging for spine surgeons, those who are leaders in the field continue to innovate and stay ahead of the curve for successful private practice.
At the 12th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference + The Future of Spine, a panel of spine surgeons discussed six key questions about the future. The panel included John Caruso, MD, FACS, a neurosurgeon with Parkway Surgery Center in Hagerstown, Md.; Richard Wohns, MD, Founder and President of NeoSpine; and Kenny Hancock, president and chief development officer of Meridian Surgical Partners. The panel was moderated by Becker’s Healthcare Publisher and Chairman at McGuireWoods Healthcare Department Scott Becker.
The six questions were:
1. Where is pay headed?
2. Where is reimbursement headed?
3. Should I own an ASC?
4. Should I become a hospital employee?
5. How do I recruit fellows?
6. How much can I make from a co-management?
The panelists discussed reimbursement trends and whether any of the surgeons are having success with in-network or out-of-network contracts. For ambulatory surgery centers, Mr. Hancock mentioned some difficulty going in-network for spine cases.
“We’ve had some challenges in developing new business because we do our due diligence in the marketplace and talked to insurance companies thinking we’ll get a good case rate, but then didn't end up get one that made sense,” he said. “They didn’t want to reimburse us for implants.”
Another aspect of future pay is whether Medicare will pay for spine cases in the ASC; Medicare currently doesn’t reimburse for spine surgery in an ASC and the impact of eventual reimbursement remains to be seen.
“If we can get CMS to say, for the low morbidity cases in healthy Medicare patients, outpatient spine surgery can occur, it would be beneficial if they would pay more at the commercial rates than the Medicare levels,” said Dr. Wohns. “That would benefit the patients, owners of ASCs and put a dent in solving the GDP issue. The problem is, if we end up accepting the Medicare rate for spine surgery, commercial payers will drop to that level and that’s an issue.”
There are currently several clear-cut outpatient procedures that could be performed in the ASC but Medicare and some insurance companies won’t pay for them unless they are in the hospital. Dr. Wohns was among the first to develop a spine-focused ASC and collected data on how long procedures take, when patients return home and the cost-savings provided in the ASC setting. There are also opportunities to incorporate ancillary services into the group.
“The number one thing is that a spine surgeon can’t make it independently today without an ASC and other ancillary revenues,” said Dr. Wohns. “Your overhead is so high and your chance of real financial success is so low that most surgeons don’t want to do that. It would turn into a volume-driven business.”
Dr. Caruso was among the first in his region to establish a spine-focused surgery center and the business has allowed him and his partners to remain independent. “The most successful thing we did was build the center,” he said. “We’ve had almost 300 percent return. It’s a great revenue stabilizer for physicians.”
Many hospitals are now employing surgeons and have viewed ASCs as adversaries in the past. In some markets, however, that attitude is beginning to change. “The hospitals are starting to have more respect for us,” said Dr. Caruso. “They still don’t see us as collegial, but their attitudes are starting to change. We are going to be called upon to do more and become more engaged in managing patients. We don’t think in terms of competition anymore. We are looking at ways to bridge past differences and look for associations and alignments.”
ASC owners and operators across the country are looking for better ways to become more integrated in patient care, in some cases to provide the full continuity of care. Some spine groups are adding pain management, imaging and other ancillary services to become a “one-stop shop” for back pain care. A healthy ASC also requires continual physician recruitment, another challenge in an era when physicians coming out of medical school are opting for employment.
“The statistics are abysmal for the number of newly-trained spine surgeons that want to go into private practice,” said Dr. Wohns. “The pool is small, but competitive. Surgeons will go to a place that’s nice to live and there are fewer interested in private practice. Hospitals employ surgeons at big dollar values for the first few years; the dollar values are anywhere from $500,000 to $1 million for a starting spine surgeon.”
With the hospital also covering malpractice insurance, staff overhead and data management, signing an employment contract seems less risky than striking out on their own. Dr. Caruso and his colleagues have been educating surgeons in training about the long term benefits of private practice and hope more will opt for it in the future.
“These panelists are successful, entrepreneurial spine surgeons,” said Mr. Becker. “They have two full time jobs; making themselves great surgeons and great business people. The reality of building a practice as a surgeon is like having a second full time job to make sure you have long term business sustainability and thrivability.”
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