Four spine surgeons discuss the Medicare and Medicaid data recently released on spinal fusions and how data transparency is changing healthcare, for better or for worse.
Q: How has the release of Medicare and Medicaid data impacted spine surgeons?
Frank Phillips, MD, Professor of Orthopaedic Surgery, Co-Founder, Minimally Invasive Spine Institute at Midwest Orthopaedics at Rush (Chicago): The data was released with little explanation or context. We have already seen media outlets using this data to generate stories about high volume Medicare providers. The data could reflect badly on surgeons if they have a high number of fusions compared to the national average; sometimes the volume may be justified based on practice patterns whereas in other instances the numbers may reflect excessive surgical volume and inappropriate care.
It's hard to differentiate these scenarios based on the raw data provided. This data likely will also be combed by attorneys to imply that higher surgical fusion volume predicts a lower level of care and less optimal results.
Hyun Bae, MD, Medical Director, Director of Spine Education, Cedars-Sinai Medical Center (Los Angeles): People are being scrutinized more and that brings more negative publicity to the field, but ultimately I don't think it will make a big impact 
on how surgeons practice. I think a lot of surgeons were more surprised at how little we make for the work we're doing. The data release has made good fodder for the media, but I think it will have little impact on most surgeons and patients.
A. Nick Shamie, MD, Chief, Orthopaedic Spine Surgery, UCLA Health System (Los Angeles): the old adage is, if you haven't done anything wrong, why would transparency be a problem? I agree with the general rule, but I think we are in a very critical stage of determining what transparency will do for society; are we going to use it to elevate healthcare in this country or are we opening doors for skeptics who will continue criticizing us all by focusing on few bad examples.
Q: Have any patients asked about the data release or questioned your rates?
Dr. Bae: I don't have patients in my practice asking me questions about the Medicare data. The data release is an annoyance, but it won't impact the way I interact with my patients.
Michael Hisey, MD, Texas Back Institute (Plano): This data will be interesting for patients as they choose their surgeons and physicians will be able to see where they stand, but the data can't be taken at face value. Physicians need to have the
ability to see the data and challenge it before it's published. Surgeons have the ability to log in and see their information, which is important.
Q: Are there instances where surgeons have legitimately high fusion rates?
Dr. Hisey: Someone who has a high number of fusions may be seeing a high volume of patients, or just the surgical candidates instead of all back pain patients. The data really can't be looked at in a vacuum, and people should not chastise surgeons based on just the data. I think it's a good thing overall to have the information available, but it should be evaluated in context.
Dr. Shamie: Just because you are fusing 20 percent or more of the patients you see as a surgeon doesn't mean you are doing unnecessary surgery. But now, we have a figure for national average and anyone who is above this national average is being criticized. If you really think about it, the data is promoting surgeons to be average. Is that, as a medical society, what we want to promote? Or do we want to excel? Does that mean surgeons with higher fusion rates should lower their rates? Are surgeons going to fuse fewer patients out of fear, rather than what is right for their patients?
Maybe the surgeon is only referred operative patients, already screened by a colleague, so they have a high fusion rate. In other practices where surgeons have a low fusion rate, the patients might not be triaged appropriately. I think data transparency is good, but how we interpret the data must be in a guided fashion and the beneficiaries. Patients should be involved in the discussion.
Q: Ideally, how would the data be released?
Dr. Phillips: If the data were presented with context, it would be more meaningful. There are many nuances in terms of patient demographics and surgeon practice patterns that could drive the number of fusions performed on the Medicare populations by a particular surgeon in a specific geographic location.
Dr. Shamie: I think there is more policing going on today and the data release has created a feeling of apprehension rather than teamwork. Ultimately, the beneficiaries are the patients, and they are the most silent group when it comes to discussions about what is right and what is wrong. I hope that this will not limit access to care or have a negative impact on our healthcare delivery systems.
Q: What is the long term impact of CMS data transparency?
Dr. Phillips: I certainly support transparency and believe that if appropriately provided, helps better inform patients about their medical care and treatment and provider options. However, unless the CMS data is provided in a way that actually allows reasonable and informed conclusions to be drawn, it will eventually become "noise" out there that really doesn’t have a significant impact on health care or services provided.
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