With a potentially new era of healthcare upon us, spine surgeons are bracing for more change in 2017. One trend, however, is not losing steam this year, as spine surgeons continue to struggle with falling reimbursements.
Learn more about the spine industry and outpatinet spine surgery at the Becker's 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine event, June 22-24, 2017 in Chicago. To learn more and register for the event, click here.
Here are 50 things to know about the spine industry.
Spine surgeons on industry trends
1. Scott Blumenthal, MD, Texas Back Institute in Plano:
"We are seeing greater coverage for two-level cervical artificial disc replacement from major insurance carriers in the last year, giving more patients more options. Patients are becoming more educated about their insurance options, being their own advocate when procedures are denied, and fighting for the services they need and want."
2. Alan Hilibrand, MD, co-director of spine surgery and director of the spine fellowship at Rothman Institute in Philadelphia:
"The biggest movement in the industry has been a new focus on nanotechnology and design of implant surfaces to take advantage of what have been touted as favorable biological properties. Previously, 'biologic strategies' included bioactive compounds like BMP. Now, the industry is promoting surface technologies as 'biological.' Expect studies to prove or disprove the advantages of these devices in the near future."
3. Michael S. Hisey, MD, Texas Back Institute in Plano:
"Stem cells are certainly very trendy. Whether that will pan out to something meaningful for patients remains to be seen. Nanotechnology, though, is looking to be a game-changer, particularly with surface bone growth technologies.
Challenges are still on the reimbursement side of medicine generally. In terms of clinical challenges, the aging population and therefore the number of patients with osteoporosis will become increasingly important over the next few years."
4. Isador H. Lieberman, MD, MBA, director of scoliosis and spine tumor center of Texas Back Institute in Plano:
"'Is it business as usual, or with the new administration do we need to start all over again?' It is hard to plan for anything when you have no idea what the decision makers will do."
5. A. Nick Shamie, MD, professor and chief of orthopedic spine surgery at UCLA School of Medicine in Los Angeles:
"There is no question that the need for treatment of spinal disorders is expanding with the aging baby boomers. The challenge is how do we provide care for these patients, maintaining our expedited and high quality care, with decreasing reimbursements?
There will be more push towards providing outpatient care for our spine patients, which will in turn popularize more minimally invasive procedures and their complementing implants.
Through my years of practice, I have seen the healthcare delivery environment go through drastic changes. There remains an unwavering need for upholding the sacred doctor-patient relationship. By far, the biggest enjoyment for me in my practice is the feedback I get from my grateful patients; it keeps me going and charge ahead to put my patients' needs first and motivate me in my daily work as an administrator/physician."
6. F. Todd Wetzel, MD, department of orthopedics and sports medicine professor and vice chair as well as neurosurgery professor at Philadelphia-based Lewis Katz School of Medicine at Temple University; North American Spine Society president:
"I think that the single greatest challenge that all providers will face is reimbursement. Specifically, with the dramatic sea change in Washington and a newly minted secretary of Health and Human Services who, while in Congress, was an implacable opponent of the Affordable Care Act, I think that there is considerable anxiety about how healthcare finances may change. We have all braced for MACRA and value-based care, but the implementation of these reforms is far from certain. As such, it is difficult to allocate educational resources in the face of such uncertainty; watchful waiting appears to be the order of the day. Fortunately with the breadth and depth of healthcare policy resources at NASS, we should be in a position to help our membership regardless of direction that the federal government will take."
Spine market
7. The U.S. spine surgery devices market is expected to grow at a compound annual growth rate of 7.3 percent to 2019, based on a Medical Market Research report. The spinal fusion and fixation devices segment represents the largest section in the market, and will also experience the fastest growth through 2019.
8. The U.S. spine implants market is expected to grow at a compound annual growth rate of 5.29 percent between 2016 and 2020, according to a Research and Markets report. Robotic technology is gaining traction in the industry, with a market penetration of about 35 percent in the United States.
9. ResearchMoz analysts forecasted the U.S. market for lateral lumbar interbody fusion will grow at a compound annual growth rate of 7.05 percent between 2016 and 2020.
10. The global spine surgery market is anticipated to grow at a compound annual growth rate of 5.49 percent through 2019, based on a Wise Guy Reports analysis, which indicates companies will develop more surfaced-modified titanium in spine devices.
11. A ResearchMoz report predicted the global spinal implants market will likely grow at a compound annual growth rate of 5.91 percent through 2020. Outpatient spine surgery will boost the market, as it offers cost savings.
12. The global lumbar spine fusion market will likely continue to grow at a compound annual growth rate of 4.9 percent through 2020, according to a Market Reports World analysis. North America will continue to lead the MIS neurosurgery market because of the high volume of performed surgical procedures. Europe follows, with a large market drive due to technological advancements.
13. The global cervical total disc replacement device market will likely continue to grow at a compound annual growth rate of 23.1 percent through 2021, according to a Persistence Market Research report. The CTDR device market is expected to be worth $1.75 billion by 2021. North America is anticipated to continue dominating the market, with the Asian market growing at a 23.8 percent CAGR and the Latin American market growing at an 18.5 percent CAGR through 2021.
14. The spine surgical robotics market is expected to explode over the next five years, according to a new Researchmoz Global report. The market is currently at $26 million and expected to hit $2.77 billion by 2022. Technological advances and breakthroughs are leveraging new materials and sensor configurations, and sophisticated software is further evolving the product implementation. The report estimates when spinal robots achieve 35 percent penetration in a country, spinal surgeons will demand hospitals offer the spinal surgical robot capabilities.
Orthopedic spine surgeon and neurosurgeon compensation statistics
15. An orthopedic spine surgeon's average starting salary is $303,560 with a sign-on bonus of $40,000.1
16. The total compensation of an orthopedic spine surgeon is $777,262.2
17. Orthopedic spine surgeon compensation based on practice type:
• Physician-owned practice — $705,695
• Hospital/integrated delivery system-owned practice compensation — $924,361
18. Orthopedic spine surgeon compensation based on region:
• Eastern — $760,025
• Midwest — $906,490
• Southern — $708,949
• Western — $555,800
19. Orthopedic spine surgeon total compensation based on experience:
• Three to seven years in practice — $906,490
• Eight to 12 years in practice — $1.17 million
• 23 or more years in practice — $650,714
20. Orthopedic spine surgeons' work RVUs total 11,822.3
21. A neurosurgeon's entry-level compensation totals $304,468.4
22. Average annual compensation of full-time neurosurgeons:5
• Salary: $782,222
• Benefits: $156,444.40
• Total Compensation: $938,666.40
• National average gross revenue per neurosurgeon: $2.3 million
23. Average hourly compensation of full-time neurosurgeons:
• Salary: $376.07
• Benefits: $75.21
• Total Compensation: $3451
• National average gross revenue per neurosurgeon: $1,140.35
24. A neurosurgeon's on-call compensation per day totals $2,448.4
Best hospitals for neurology and neurosurgery
25. U.S. News & World Report ranked the top hospitals for neurology and neurosurgery:
• Mayo Clinic in Rochester, Minn.
• Johns Hopkins Hospital in Baltimore
• NewYork-Presbyterian University Hospital of Columbia and Cornell in New York City
• Massachusetts General Hospital in Boston
• UCSF Medical Center in San Francisco
• Cleveland Clinic
• NYU Langone Medical Center in New York City
• UCLA Medical Center in Los Angeles
• Northwestern memorial Hospital in Chicago
• Barnes-Jewish Hospital/Washington University in Saint Louis
Spine device company powerhouses
26. DePuy Synthes (Raynham, Mass.): DePuy Synthes is a part of New Brunswick, N.J.-based Johnson & Johnson. The company's orthopedics business reported $2.3 billion sales in the fourth quarter of fiscal year 2016 and $9.3 billion for the full year. Spine and other sales slumped 3.1 percent in the fourth quarter, hitting $988 million. The full-year spine and other sales were $3.8 billion, down 0.7 percent when compared with last year.
27. Stryker (Kalamazoo, Mich.): Stryker is expected to report net sales of $11.3 billion for 2016, according to the company's preliminary fourth quarter and full year financial report. The full-year net sales for each of the business segments were:
- Orthopedics: $4.4 billion, up 4.7 percent
- MedSurg: $4.9 billion, up 25.7 percent
- Neurotechnology and spine: $2 billion, up 9.8 percent
28. Medtronic (Dublin, Ireland): The company reported third quarter revenue of $7.2 billion, a 5 percent increase over the same period last year. Revenue in the United States represented 56 percent of the company's total revenue and increased 4 percent over the same period last year. Medtronic's spine revenue increased 3 percent to $657 million for the quarter. The spine revenue experienced its strongest quarterly year-over-year growth in more than seven years.
29. Zimmer Biomet (Warsaw, Ind.): Zimmer Biomet reported fourth quarter net sales of $2.01 billion, which translates to a 4.1 percent increase from 2015. The company's full-year 2016 earnings totaled $302.9 million, an increase of 106 percent compared to 2015 earnings.
30. Globus Medical (Audubon, Pa.): Globus Medical saw $0.29 earnings per share and revenue of $135.7 million in the third quarter of 2016. Globus reported a net margin of 21.19 percent as well as a return on equity of 15.43 percent.
31. K2M (Leesburg, Va.): K2M reported preliminary financial results for the fourth quarter and full year of 2016, ended Dec. 31. The company's full year revenue will likely reach between $236.1 million to $236.6 million. This range reflects a 9 percent to 10 percent upsurge year-over-year. K2M reported U.S. complex spine growth in excess of 17 percent year-over-year for Q4 2016; U.S. minimally invasive surgery growth in excess of 35 percent year-over-year; and U.S. degenerative growth in excess of 18 percent year-over-year.
32. NuVasive (San Diego): NuVasive saw revenue of $962.1 million for the full year of 2016, an 18.6 percent increase from full-year 2015. In the fourth quarter of 2016, NuVasive's revenue totaled $271.1 million, reflecting a 25.9 percent boost from the same period the year prior. In 2017, the company will look to expand its spine deformity presence, boost in-sourced manufacturing and streamline operations.
Acquisitions
33. In February 2017, Plainsboro, N.J.-based Integra LifeSciences made a $1.05 billion cash binding offer to acquire Johnson & Johnson's Codman Neurosurgery business, based in Raynham, Mass.
34. In January 2016, NuVasive acquired skeletal deformity medical device company Aliso Viejo, Calif.-based Ellipse Technologies, including the MAGEC and PRECICE technologies, for $380 million.
35. In April 2016, Stryker acquired San Diego-based CareFusion's vertebral compression fracture portfolio, which is comprised of minimally invasive systems used in vertebroplasty and vertebral augmentation procedures.
36. In August 2016, Carlsbad, Calif.-based SeaSpine signed a definitive agreement to acquire NLT Spine, an Israel-based medical device company creating minimally invasive spine surgery products.
Outpatient spine surgery
37. In November 2016, CMS approved these 10 new spine codes for the ASC payable list in 2017:
- Spine bone autograft local add-on (20936)
- Spine bone autograft morsel add-on (20937)
- Spine bone autograft struct add-on (20938)
- Additional neck spine fusion (22552)
- Insert spine fixation device (22840)
- Insert spine fixation device (22842)
- Insert spine fixation device (22845)
- Insj biomechanical device (22853)
- Insj biomechanical device (22853)
- Insj biomechanical device (22859)
38. In 2015, CMS approved these codes for spine surgeries in ASCs:
- [Neck spine fuse & remov bel c2 (22551)]
- Neck spine fusion (22554)
- Lumbar spine fusion (22612)
- Neck spine disc surgery (63020)
- Low back disc surgery (63030)
- Laminectomy single lumbar (63042)
- Removal of spinal lamina (63045)
- Removal of spinal lamina (63047)
- Decompression spinal cord (63056)
39. Paradigm Spine's coflex Interlaminar Stabilization device earned FDA pre-market approval in 2012. The device is intended to fit at one or two contiguous levels in the L1-L5 interlaminar space. A FDA clinical trial compared the coflex to pedicle screw spinal fusion surgery,which revelaed:
• Ninety-four percent of coflex patients reported outcome satisfaction at two-year post-surgery, compared to 87 percent of fusion patients.
• Seventy-seven percent of coflex patients experienced early improvement in physical function compared to 67 percent of fusion patients, at six-weeks post-surgery.
• Ninety percent of coflex patients had early spinal stenosis sytmptom relief at six-weeks, compared to 77 percent of fusion patients.
40. Stryker introduced a new implant delivery solution for low-acuity spine surgeries designed for the ambulatory surgery center. The new solution, Ascential, offers sterile-packaged implants, customized service levels and a streamlined distribution model. It is intended for operational efficiencies, competitive pricing and reduced operating costs for ASCs. The spine products available through Ascential include ACP 1 Anterior Cervical Plating System, IBD Peek Anterior Cervical Spacer System and VBA Vitoss Foam Pack.
Minimally invasive spine surgery
41. Minimally invasive spine surgery is gaining popularity with the flow of new research espousing its benefits, such as less pain; lower infection and complication rates; less blood loss; shorter hospital stays; and quicker recovery.
According to an April 2016 Spine study, patients undergoing minimally invasive fusions experienced lower blood loss (88.7 percent lower) than the open procedure group. Additionally, the study found, hospital stays among the minimally invasive group were 64 percent shorter than hospital stays in the open procedure group.
Society for Minimally Invasive Spine Surgery President Greg Anderson, MD, of Philadelphia-based Rothman Institute, offered key insights on MIS spine's promising future during a May 2016 interview with Becker's: "There are still skeptics, as well, which is healthy because as physicians we should always hold ourselves to asking for proof of benefit when we consider changing our standards of care."
42. Market Research Report analysts predicted the global minimally invasive spine surgery market will grow at a compound annual growth rate of 7.57 percent through 2020. A growing number of spinal disorder cases will spur market growth, as well as the increasing adoption of the MIS sacroiliac joint fusion technique. A dearth of skilled surgeons in MIS techniques will pose as an obstacle to market growth, however.
43. Kern Singh, MD, co-director of the Minimally Invasive Spine Institute at Midwest Orthopedics at Rush in Chicago, founded the Minimally Invasive Spine Study Group in February 2017. "The MISSG is an international organization dedicated to advancement of minimally invasive spine surgery that is truly the first of its kind," said Dr. Singh. "This collaborative effort between the world's leading minimally invasive spine surgeons will revolutionize the way in which we conduct minimally invasive spine research."
Spine studies
44. A study published in Spine in February 2017, compares the short-term outcomes for primary and revision anterior cervical discectomy and fusion. The patients who underwent revision procedures were more likely to return to the operating room and receive blood transfusions. Thirty days after surgery, the revision patients had an increased risk of readmissions. The primary spine surgery patients' operative time was seven minutes less on average and they stayed at the hospital for half a day less than patients in the revision group.
45. A study published in Spine in February 2017, examines surgical site infection for pediatric spine surgery patients. Deep surgical site infection occurred in 3.6 percent of the patients; 3.3 percent of the patients reported deep SSI after their primary surgery and 8.3 percent reported deep SSI after a revision procedure. Staphylococcus epidermidis was the most common SSI, representing 26 percent of the infections. The second most common was a tie between methicillin-sensitive Staphylococcus aureus, Propionibacterium acnes and Escherichia coli at 18 percent each.
46. A study published in The Spine Journal in November 2016, compared the "biomechanical properties in terms of stress at adjacent segments" of utilizing robot-assisted pedicle screw insertion versus freehand for posterior lumbar interbody fusion. The researchers found the robot-assisted insertions demonstrated biomechanical superiority in terms of "alleviation of stress increments at adjacent segments" following fusion, but they warned the sample size was small.
Global spine surgeon societies
47. Here are the major spine surgeon societies' current presidents and chairpersons:
- AO Spine: Global Spine Conference: Jeffrey Wang, MD, congress chairperson
- Cervical Spine Research Society: Darrel S. Brodke, MD, president
- International Society for the Advancement of Spine Surgery: Hee Kit Wong, MD, president
- International Spine Intervention Society: John MacVicar, MB, ChB, president
- North American Spine Society: F. Todd Wetzel, MD, president
- Scoliosis Research Society: Kenneth MC Cheung, MD, president
- Society for Minimally Invasive Spine Surgery: Greg Anderson, MD, president
- The International Society for the Study of the Lumbar Spine: Keith DK Luk, MBBS, FRCS, president
Lawsuits
48. Neurosurgeon Aria Sabit, MD, received a 235-month prison sentence on Jan. 10, 2017, for fraud, as reported by Medscape. Dr. Sabit pled guilty to four counts of healthcare fraud, one count of conspiracy to commit healthcare fraud and one count of unlawfully distributing a controlled substance. He convinced patients to undergo potentially unnecessary spinal fusions and billed for implants he didn't use. For some cases, Dr. Sabit billed for implants even though he used tissue. The U.S. Attorney's Office reported Dr. Sabit unlawfully billed for $11 million.
49. On Jan. 30, 2017, a Boston jury determined a Massachusetts General Hospital spine surgeon's concurrent surgery schedule in 2012 did not result in a patient's quadriplegia, The Boston Globe reported. While a surgeon at Massachusetts General Hospital, Kirkham Wood, MD, and his team performed an 11-hour surgery concurrently with another surgery. The patient was paralyzed during the 11-hour procedure, and later sued. The Suffolk Superior Court jury found that Dr. Wood violated informed consent by not telling the patient he would be performing two surgeries during the same time period, but did not find a connection between Dr. Wood's split time and the patient's paralysis. Thus, the jury did not award the patient any financial damages.
50. On Feb. 20, 2017, Christopher Duntsch, MD, PhD, a former neurosurgeon practicing in Plano, Texas, was sentenced to life in prison for intentionally injuring his patients. The jury deliberated for one hour before sentencing Dr. Duntsch to the maximum penalty after taking four hours last week to find him guilty of intentionally causing bodily harm. On Feb. 14, 2017, Dr. Duntsch received a guilty verdict for a count of "injury to an elderly person," CBS DFW reports. The jury determined Dr. Duntsch demonstrated "malicious and reckless actions" during a botched spinal surgery on an elderly patient, CBS DFW reports. He performed the surgery at Dallas Medical Center in 2012, according to D Magazine.
References:
1. 2011 Orthopedic Recruiting Trends & Starting Salary Overview from Orthopedic Recruiting Group
2. 2016 MGMA Provider Compensation and Production Report, based on 2015 survey data
3. MGMA DataDive Provider Compensation Work RVUs: 2015 Report Based on 2014 Data
4. Entry-Level Neurosurgeon Salary from payscale.com, Updated Oct. 28, 2016 with 323 individuals reporting
5. Jackson & Coker's 2016 Physician Salary Calculator