The payer and spine surgeon relationship has been complicated over the years. Six spine surgeons discuss how those relationships can be improved.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, August 7.
Editor's note: Responses were lightly edited for clarity and length.
Question: What will it take for the payer/surgeon relationship to strengthen in spine?
Rachel Bratescu, MD. George Washington University (Washington, D.C.): Collaboration between payers and providers is a key determinant of success. What has previously been missing from this conversation and what is further needed is the alignment of goals between these two groups. Historically, this relationship at its surface has been contentious — with both groups at odds regarding their differing objectives; cost efficiency versus patient outcomes.
Improving this relationship will require action on three fronts, communication, data sharing (and how that data is measured, acquired and what patient populations), and price transparency. Alignment of interests between payers and surgeons can reduce both financial risk and improve patient outcomes resulting in the delivery of better-quality care to patients.
Robert Bray Jr., MD. Founder of DISC Sports & Spine Center (Newport Beach, Calif.): The simple answer to the payer-surgeon relationship is to align incentives and become relevant. The payers need to see a reason to develop any specific relationship past the usual contracting.
As a provider, this means showing a cost-effective solution over a broad enough market. This is where health systems have gained the advantage over individual physicians. In spine (or total joint in a similar fashion), data on cost-effective quality outcomes is critical when combined with the event of care via a physician-involved model.
As an ASC, a group of physicians can demonstrate enough market share that it becomes meaningful. Both are now aligned on the same goal and the relationship strengthens tremendously.
This is a unique time in the migration of high-acuity cases to the outpatient environment. For physicians to engage and proactively change the situation, data is vital, as well as the time to develop the relationship at corporate payer levels.
Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): To strengthen the payer/surgeon relationship in spine, it is absolutely necessary for payer companies to pay the surgeons adequate fees for their handwork. Surgeons are dedicated to providing patients with top-notch care. Payer companies need to carry the responsibility of providing surgeons with better fees. Open communication and collaboration will help. Payers and surgeons should work together to align incentives, share data and outcomes, and develop evidence-based guidelines for treatment. Building trust and mutual respect between both parties is key to creating a successful partnership in spine care.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Payers and surgeons are diametrically opposed. I have been to many conferences where surgeons happily report how much data they have given to payers and how "good" their contracts are. Unfortunately, as the payers are able to essentially control the stream of patients in some cases as well as dictate what procedures we do, we will continue to see a diminution of reimbursements. Especially since when taking into account inflation, physicians are seeing about a 20%-30% reduction in their pay over the last 15 or so years.
With Medicare leading the way in terms of cuts, I don’t anticipate that relationship will improve, especially with physicians so willing to show they can do more for less money. It is truly a race to the bottom with all of us shoving each other out of the way to reach the bottom of the abyss.
Until physicians stop doing more for less in the name of "value," things will not get better. We are already good stewards of healthcare, who are good stewards for us?
Grant Shifflett, MD. DISC Sports & Spine Center: The payer-surgeon relationship has come under tremendous strain for a number of reasons, and while the net effect has not been good for either party involved, patients are ultimately the most harmed. In order for things to improve, we need to see progress on several fronts:
First, we need more open lines of communication between surgeons and payers – a better way for doctors to get past the barriers to insurance company decision makers.
Second, the peer-to-peer experience needs to be reimagined. In its current state, physicians on the insurer side often lack expertise in fields like spine surgery and/or have no power or means to make appropriate decisions for spine patients and their treatment plans. Additionally, many peer-to-peer reviews are triggered for administrative issues, which are disruptive and time-wasting for surgeons, who are not compensated for the extra hours spent. The review process needs to be expedited, streamlined and improved. Bad actors should certainly be watched and carefully monitored, but the surgeons doing good work should be rewarded with fast-track approvals.
Finally, the payer-surgeon relationship would improve if claims were paid without surgeons needing to fight or grovel after taking care of patients, making the right decisions, and then performing the best surgeries for those patients, especially when pre-approval is required and received.
These are the critical issues that need to change in order for things to be better. In DISC's case, we are fortunate to have TriasMD actively negotiating with payers to address the challenges and ultimately create a dynamic that benefits everyone involved – patient, surgeon and payer alike.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Having been a multi-specialty physician advisor to a regional insurance company, the perdurable discussions surrounding spinal care and approvals invariably ended on cost. Requests for ineffective fusion procedures and symptomless criteria are always met with additional scrutiny and long-term memory. Reviewers' criterions remain the same. Our submission data sets routinely include specific neurologic findings and parallel modality pictures to assist in the process. Affability and willingness to appeal specific, especially urgencies, play a significant role.