Data collection is the best way for spine surgeons to prepare for success in the future. Hospitals and physicians are already reporting quality data to Medicare that's reported publicly. Cost data isn't far behind as payers and patients are engaging in more cost-comparisons to decide where they'll spend their healthcare dollars.
In the past surgeons largely focused on clinical success — selecting surgical or non-surgical patients based on their experience and expertise. However, electronic medical records and other data gathering mechanisms make it possible to track treatment trends and decipher likely outcomes for patients based on previous patients with similar conditions and situations. The data can also show which treatments provide the best outcomes for patients, and which deliver similar results.
When technologies and techniques yield similar results, patients and payers look toward cost as the next variable to determine value. Spine surgery is costly, with the hospital fees and surgical implants comprising the largest portion of the bill. Even though the spine surgeon is the least costly they often can have the largest impact on costs.
"The days when surgeons could say they want a particular implant regardless of the cost and quality effectiveness is certainly coming to an end," says Hyun Bae, MD, director of spine education at Cedars-Sinai Medical Center in Los Angeles. "If you work at a small hospital, you may be able to make decisions, but most major hospital organizations are consolidating and making decisions based on cost-utility. They are using leverage with large purchasing organizations to cut costs across the board."
The larger implant companies have more leverage to cut costs for spinal implants because they provide package deals with other instrumentation, supplies and hard goods needed at the hospital. Smaller implant companies can't offer the same deals, but may be able to lower prices on commodity implants.
However, it's the surgeon's responsibility to ensure the implants available have the appropriate effectiveness to ensure repeatable results for the patient. Surgeons who are already contributing to management decisions at the hospital will have the opportunity to take on those responsibilities and decide what implants will be used.
"It's hard for surgeons to be on the management side, but they are going to have to align themselves with the hospital — whether through employment agreements or comanagement — to make themselves administratively available to participate in the decision making process. Otherwise decision will get made for them," says Dr. Bae.
Independent spine surgeons will have the opportunity to gather data as well, but unless they align with larger groups and other spine practitioners their data probably won't carry much weight.
"The only way outcomes matter is with the big organization or group; a center of 10 to 15 surgeons or a hospital program tracking outcomes," says Dr. Bae. "Organizations will then promote the metrics most important to payers. The large employers like Boeing or Home Depot with 10,000, 20,000 or 100,000 employees are looking at those outcomes and deciding where to send them for care."
"You won't have much leverage if you are a solo guy," says Dr. Bae. "I think there has to be some sort of alignment between the solo physicians, especially since physicians are already at a disadvantage in payer negotiations. Payers have been collecting data for years and we're just beginning to conduct similar data collection."
Spine surgeons can grow their outcomes databases quickly through partnerships between orthopedic spine and neurospine surgeons. There aren't currently many organizations with collaboration between orthospine and neurospine surgeons across the country, but spine practitioners could be take the lead in aligning the two specialties.
"We have to find a way to align and gain leverage with larger groups," says Dr. Bae.
Another method for lowering costs and gathering data is through outpatient surgery. Surgeons can move smaller cases to the ASC setting where they control the patient environment, control costs and collect data at the ASC as well as through a corporate partner's larger ASC network. ASCs typically are paid less per case than hospitals, but surgeon typically are already aligned at the ASC with ownership. This allows ASC to be more cost efficient all the while delivering care in an environment that the patient and the surgeon prefers over a hospital. It is a win win for everyone.
"Everyone is bullish on outpatient surgery and there is no question a lot of cases are going to move to the outpatient spine center," says Dr. Bae. "One-hundred percent of spine cases won't go to the ASC. There are surgeons who estimate that 50 percent of cases could be performed in the outpatient center, but I think the real number is between 25 to 33 percent."
Complex spine procedures must be performed in the hospital setting. The number of Medicare patients needing spine surgery will likely increase over the next decade as the number of people 65 years and older increases.
"There will still be a lot of patients who undergo spine surgery in the hospital because complex spine surgery is the fastest growing segment in spine today," says Dr. Bae.