Over the past decade, spine care technology has exploded. Surgeons and engineers have contributed to new innovations, some of which have revolutionized the field while others haven't been proven in the literature. However, there is a large category of innovation that has a great potential to help patients, but without the appropriate funding this technology won't be developed or become available on the mainstream market. This becomes even more evident as we move closer to a two-tiered healthcare system in the United States. Dennis Crandall, MD, founder and CEO of Sonoran Spine Center in Phoenix, discusses where spine technology is headed and how healthcare reform could shape the market in the future.
Question: Where is the biggest innovation happening now?
Dr. Dennis Crandall: Everything is happening in biologics. There are some cool computer monitoring that we are involved in to try to identify where the stress in the bone is when we instrument the spine for degenerative disc disease. Our population is aging, so there is a lot we are doing there. Our thinking is, if we come up with these wonderful new techniques that are good for the bone, is there going to be a market place for that, especially if the payor is Medicare?
Q: Will the market be able to sustain all this new technology?
DC: One concern that a lot of us have is that new technologies burst onto the scene with a lot of enthusiasm, and intellectually they have a lot of promise, but the data backing these new technologies isn't always there. As a result, the discriminating spine surgeon is left to his or her own intuition as to whether its something they want to try. Based on surgeon skill and background, the surgeon will make a decision about whether the new technology merits a try at achieving a step forward for their patients. I think that's part of the reason why some technologies seem to splash onto the scene in a big way and then go away just as quickly.
Then the data arrives and the initial intuitive beliefs aren't born out in actual reality. We continue to see that in spine surgery as a specialty because it is relatively under developed and immature. It isn't like the total hip and knee markets where they are highly developed and incremental gains are much smaller. In the spine market, there is a lot we don't know and a lot we are still discovering.
Q: How can surgeons tell which innovations are the most important?
DC: Surgeons have a lot of good options with patients to achieve good results. Over time, we will see fewer technologies that are embraced long term because they are supported by the data. The spine industry right now is at the same point as the total hip and knee industry in the early 1980s in terms of research and development.
Q: How will healthcare reform impact spine surgery and technology in the future?
DC: Regardless of whether Obama or the Republicans win re-election, healthcare reform is coming in some shape or form, and healthcare delivery will take the shape of paying for accountable results. In my view, we will emerge with a segment of healthcare being under the title value segment and a smaller segment of healthcare being under the title of innovation. The "value" segment is the segment of the population that has straight forward disease that can be treated with straight forward procedures, technology and implants; these are less costly interventions. This will be the choice of cost containment efforts whether through Medicare or other insurance companies — they will choose low cost technology, which seems to do the job.
There will be a segment of spine disease that doesn't lend itself to value proposition; those patients — spinal deformity and more complex cases — fall under innovation. They are going to benefit from high levels of technology that would produce results. For these patients, generic implants or technology won't be as good; instead, more expensive technology that I hope will still be funded will provide better care. We need the funding so we still have innovation and advancement in the care we provide.
I think the generic devices will emerge as the primary technology and spinal implants and devices we have at our disposal to treat most patients, particularly those with degenerative disc disease.
Q: What challenges could arise from grouping into the "value" segment and "innovation" segment of the two tiered system?
DC: If we go to the two tiered system, the people who have access to the innovation segment will be the people with the latest and greatest healthcare surgery techniques and technology. The question is whether their outcomes will be truly better — I think they will be. But how much are we willing to pay for incremental improvements in outcomes? If it's your back, you want it; but if you are paying for someone else, maybe it isn't quite as important.
Right now, the industry is heavily weighted toward innovation — I don't think the faucet has been turned off for new technologies or companies yet to develop whatever is next on the horizon. The question comes with what happens with healthcare reform and the dramatic shrinking of healthcare dollar resources. If the companies are not getting reimbursed for their technology, they can't continue to develop it and do research that would lead to the next big thing. Then we will settle into a vast pool of mediocrity in healthcare whereas we've been a leader in innovation in the world.
It might have to be private insurers that promote innovation in the future.
Q: How will the population divide into the two segments?
DC: Off the cuff, I would estimate we would end up with about 70 percent of the population in the value segment and 30 percent in the innovation segment with access to new technology — and that may shrink over time. We might get to the point where the innovation segment would be 10 percent of the market, if the value segment produces care that the population thinks is good enough. If this is the case, there wouldn't be a push to fund the innovation segment. When generic implants do a good enough job, people stop paying for the brand name.
Right now, people are looking at journal articles and making decisions about payment based on the numbers in high quality studies. They say they will cover a technology for a specific indication because there is data, or they won't because the data isn't good enough or there isn't enough data. Until there is data saying that the technology provides good outcomes, the value system won't accept it.
The innovation segment would accept the technology if patients and physicians think its best.
Q: What impact does the focus on cost containment and development of generic implants have on innovation?
DC: Whether it's Medicare or another version of government payor, if they really want to cut costs they won't support innovation in a meaningful way. They would support the value segment and fund specific costs for implants.
For instance, minimal access surgery and biologics involved in a sacroiliac joint fusion or spinal deformity implants are more elaborate and evolved than generic implants. Anything that is more evolved than the typical generic implant would fit into the innovation segment and if it is better than the traditional treatment, we have to show the value of cost. It has to decrease pain, shorten operating room times and have more reliable outcomes than the standard treatment. That will be the way they decide whether to pay for the incremental improvement of the technology.
When that day comes, we are in trouble because we will sink into mediocrity.
Q: Will surgeons still be able to engage in research and innovation in the two tiered system?
DC: A lot of surgeons are like me and do research truly for the fun of it; its great fun thinking and developing new technology to treat patients better. I envision a scenario where I would continue to tinker and think of new things with engineers even if the funding isn't there, but at some point to get the ideas off the paper and computer and into biomechanical testing, regardless of how altruistic I am, it wont' be made or tested if it can't show improvements.
More Articles on Spine Surgeons:
8 Spine Surgeons on the Future of Spinal Fusions
6 Spine Surgeons on How Young Surgeons Can Position Themselves for Success in the Future
What Percentage of Your Spine Practice is Medicare Patients?