Four spine surgeons discuss current trends in spine surgery reimbursement and insurance coverage.
A. Nick Shamie, MD. Chief of Orthopedic Spine Surgery and Neurosurgery at UCLA School of Medicine: Firstly, we have a growing population of our baby boomers reaching the age that will demand more healthcare across the board. This will result in lower reimbursement for each healthcare sector. In spine surgery, it will be more important to show good results in order to maintain coverage for various procedures. Only the highly successful surgeries will continue to be reimbursed.
Secondly, with the advent of new technologies and surgical protocols over the last few decades, we have the opportunity to treat patients in an outpatient setting more regularly than ever before. This trend will continue which will in turn lower the cost of spine care. We have to make sure to use the new technologies responsibly and only when we have shown superiority to more traditional methods.
Thirdly, with the granularity of the outcomes data available to payers and patients alike, individual surgeons will be evaluated by all stakeholders based on available data. So making sure that you provide individualized and effective care for every spine patient will be an important factor for any successful surgeon.
J. Brian Gill, MD. Nebraska Spine Hospital (Omaha): Over the past year, patients have had a greater responsibility for out-of-pocket expenses for medical care, with higher deductible plans becoming more of the norm to offset rising premiums. This is only going to continue for the foreseeable future as employers try to offset their costs by pushing their employees into these type of plans. Additionally, insurers are promoting these plans to employers and consumers as it shifts the risk to the patient to make the decision.
Bundled-payments continue to gain traction as Medicare has launched a program for hospitals in an attempt to control costs. There is more pressure to be more vertically integrated in an attempt to control costs from start to finish for procedural episodes such as spine surgery. Ongoing reports show independent practices are continuing to dwindle as healthcare systems drive to control costs and gain market share. As a partner in an independent practice, we have to continue to work with our healthcare systems to provide value with mutual strategic goals and alliances.
This year, more than any other year that I can remember, insurers have taken longer to approve procedures and imaging. There has been a greater burden of proof placed on providers to show documentation of medical records, which can be difficult to obtain at times. Additionally, the number of modalities necessary to be done has placed an undue burden on patients wasting time and money. I only see this trend continuing as insurers place roadblocks up for patients and providers.
Robert Masson, MD. Founder and Medical Director of Masson Spine Institute (Ocoee, Fla.): The reimbursement decline for complex spine procedures has put a premium on quality of patients and systemwide efficiencies.
We also are increasingly placing our spine surgery patients in our ASC environment with increased penetration and this is probably one of our greatest opportunities moving forward.
In the world of bundled payments, abolition of narcotic overuse (finally) and big data, we have fully enacted pre-habilitation regimens preoperatively to both prepare our patients for rapid surgical mobilization and recovery, and to accentuate and validate not only the need for surgery but the intended surgical diagnostic targets, which we correlate with imaging. The clinical syndrome defines scope of surgery, not the imaging in many cases.
Our success has been centered around our ability to reach our patients with success strategies and increasingly concierge-style spine health messaging while simplifying our practice focus to surgical treatment for complex spine health episodes of care. Our goal is more and more aimed towards optimization of personal functional performance in the face of a spine health crisis and it reflects in our culture, our philosophy, our messaging and ultimately the loyalty and growth of our patient base.
Jocelyn Idema, DO. Orthopedic Spine Surgeon (South Hills of Pittsburgh; Washington, Pa.): Although there are many trends that could affect my practice in 2019, I find that the continual struggle with insurance companies continues to be an issue for both patient and provider alike. Many insurance companies continue to bundle and/or narrow procedures that can be done, as well as where the procedures can be done. As a result, many of my colleagues and I end up having to carry privileges at multiple hospitals and surgery centers in order to accommodate where procedures are allowed to be done.
The second biggest trend that I see affecting my practice will be bundling of payments. Our spine team is continually working to stay on top of the latest changes with regard to bundling. For example, what used to be three separate codes for reimbursement is now one, thus this allows for decreased reimbursement to not only the physician but the facility as well. I have found that some facilities because of these changes, are now limiting the numbers of those types of surgeries to be done.
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