Here are 50 things to know about the spine surgery field today.
Sign up for our FREE E-Weekly for more coverage like this sent to your inbox!
1. Average spine surgeon compensation in 2012 was $710,556 according to a report from the American Medical Group Association.
2. Neurosurgery generates $1.68 million in revenue for hospitals on average while the average 2012 hospital compensation for neurosurgeons was $669,000. The revenue-to-compensation ratio was 2.52:1, according to a report from Merritt Hawkins.
A separate report from Mercer reported neurosurgeons as among the top-=five highest paid physician specialists. Here are the average hospital neurosurgeon base salaries and total cash compensation in 2012:
Neurosurgeon base salary
25th percentile: $629,160
50th percentile: $663,760
75th percentile: $702,700
Neurosurgeon total cash compensation
25th percentile: $664,330
50th percentile: $713,740
75th percentile: $778,890
3. Between 1998 and 2008, the discharges for spinal fusion procedures increased 137 percent, according to data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. During the same period, laminectomy increased only 11.3 percent, hip replacement increased 49.8 percent and percutaneous coronary angioplasty increased 38.8 percent.
4. Long-term data on artificial disc replacement is now coming in. A recent study published in Spine showed the reoperation rate for total disc replacement in cervical procedures was 8.3 percent, compared with anterior cervical fusion with 21.2 percent.
5. The BlueCross BlueShield of North Carolina, which made the news in 2011 for its refusal to cover spinal fusions for degenerative disc disease as the only indication, released a statement labeling artificial discs as "ineffective." Spine surgeon advocates, including Domagoj Coric, MD, of ISASS responded to the statement citing information supporting artificial disc replacements in appropriate situations.
6. The American Medical Association implemented a new Category III CPT code to specifically describe sacroiliac joint arthrodesis performed with minimally invasive or percutaneous approaches. The new code, 0334T, went into effect on July 1.
7. The global spine surgery device market is anticipated to grow at an annual rate of 4 percent from 6.5 billion in 2011 to $8.7 billion in 2018, according to a Research and Markets analysis. Motion preservation technologies in non-fusion procedures will gain popularity and adoption in the coming years.
8. The implantable medical device market in the United States is expected to grow annually by 8 percent over seven years, according to Med City News. A report from Transparency Market Research estimates the market will be worth $73.9 billion by 2018. It was valued at $43.1 billion in 2011.
9. Discectomy for patients with disc herniation could generate a total net societal savings of $2.1 billion when compared with non-surgical treatment, according to an AAOS-commissioned study. The study compared patients who underwent treatment for disc herniation over a four-year period and found the per person net societal savings for the discectomy patients was $9,822.
10. Jeffrey Goldstein, MD, director of the spine service and associate director of the spine fellowship at NYU Langone Medical Center's Hospital for Joint Diseases, says more spine surgeons are seeing coverage denials from insurance companies for various reasons, including:
• Not medically necessary or a poor indication
• The surgery is experimental
• Conservative therapies were not met or structured physical therapy wasn't documented
• Medical terminology for the surgeon's dictated notes and imaging reports did not match the insurance company's medical guidelines terminology for approval
• When submitting the preauthorization, the surgery indicates an acronym
• Additional tests to the MRIs or CTs are necessary, including flexion/extension or nerve study tests
• Bone morphogenic protein use is not FDA approved for off label requests
11. Earlier this year, 55 hospitals agreed to pay more than $34 million total to resolve alleged false claims to Medicare for kyphoplasty procedures. The Department of Justice has now reached settlements with more than 100 hospitals totaling $75 million to resolve allegations they mis-charged Medicare for kyphoplasty.
12. At the 2013 AAOS Annual Meeting, researchers presented the results of a study of 45 academic medical centers' spinal implant purchasing records, focusing on anterior cervical plates, pedicle screws and posterior interbody cages. The study found a noteworthy correlation between lower implant costs and higher volume purchases. Samuel Bederman, MD, an assistant clinical professor of orthopedic surgery at the University of California Irvine Health and co-author of the study, advocates for more transparency from insurance companies about implant prices across different providers to sustain surgical services.
13. The best states for physicians to practice are states with low physician density, low cost of living, few malpractice claims and strong financial markets. According to the Medscape Best and Worst Places to Practice: 2013 report, states in each region of the country include:
• Texas
• Idaho
• Tennessee
• Virginia
• Indiana
• New Hampshire
14. A study published in Spine assessed surgeon exposure to radiation during lateral lumbar interbody fusion procedures.
Researchers used optically stimulated luminescence technology dosimeters to record radiation exposure at five anatomic locations during 18 LLIF procedures. The study authors also advise surgeons to follow radiation safety guidelines. With following the guidelines, 2,700 LLIF procedures can be performed per year before exceeding occupational dose limits.
15. Conditions are ripe for spine surgery to transition into the outpatient setting, whether performed in a hospital outpatient department or ambulatory surgery center. Factors in that change include:
• Clinical studies proving minimally invasive procedures and surgery in the outpatient setting are as effective or better than open spine surgery in an inpatient hospital setting;
• Instrumentation has evolved to allow spine surgeons to perform more complex procedures confidently through minimal access points.
• Young surgeons are training on new minimally invasive techniques;
• Ambulatory surgery centers and outpatient departments are more economically viable than inpatient hospitals.
16. Spine surgeons transitioning into ambulatory surgery centers may face difficulty with gaining coverage from insurance companies. Barbara Cataletto, CEO and founder of Business Dynamics, says surgeons should:
• Provide evidence showing transfers are unlikely;
• Educate payers on new less invasive techniques for spine surgery;
• Negotiate in-network contracts, as out-of-network increases the cost for insurance companies;
• Gain preoperative authorization for spine surgery in the ASC;
• Avoid using unlisted codes;
• Leave bundled codes bundled.
17. Bone morphogenic protein use remains controversial. The Yale Open Data Access Project recently published two studies showing lower degrees of efficacy and higher rates of adverse effects when using rhBMP-2 than in the original industry-sponsored reports by Medtronic for its product, Infuse.
18. Steven Garfin, MD, chief of spine surgery and the department chair of orthopedic surgery at the University of California San Diego received the 2013 ISSLS Wiltse Lifetime Achievement Award.
19. According to John Finkenberg, MD, a member of the North American Spine Society board of directors and chair of the advocacy committee, said the top advocacy issues for the group this year are:
• Repeal of the sustainable growth rate
• Medical liability reform
• Independent Payment Advisory Board repeal
• Modifying electronic medical record programs and implementation for Meaningful Use
• Maintaining the Stark law in-office ancillary services exemption
20. Half of patients have yet to hear their regular physician discuss healthcare reform or the Patient Protection and Affordable Care Act at appointments, according to a HealthPocket survey. The survey was based on 1,176 responses to an online survey conducted from June 26 to June 28. Out of the 75 percent of patient respondents who indicated they have a physician, half have not had their physician comment on the PPACA.
21. Most orthopedic surgeons are still in private practice, according to the American Academy of Orthopaedic Surgeons' 2012 Orthopaedic Surgeon Census.
Of the orthopedic surgeons included in the census:
• 44 percent are in a private practice orthopedic group
• 18 percent are in a solo private practice
• 9 percent are in a multispecialty private practice group
• 9 percent are in academic practice and receive their salary from the academic institution
• 9 percent practice at a hospital
• 3 percent are in academic practice and earn their salary from a private practice
• 2 percent are in military practice
• 2 percent are in practice with and receive their salary from an HMO
• 2 percent are in an other forms of practice
22. The North American Spine Society has launched a pilot registry program to collect data on spine treatment clinical outcomes. The registry's goal is to detect early problems in patient care that deserve further study. The pilot program has been funded by NASS to jump start the interest in collecting data for improved spine treatments. If the study is successful, a permanent registry with additional funding should follow.
23. Johns Hopkins Hospital topped the U.S. News & World Report as a best hospital for neurology and neurosurgery. Johns Hopkins was followed by Mayo Clinic, New York-Presbyterian University Hospital of Columbia and Cornell, Massachusetts General Hospital and UCSF Medical Center. Hospital for Special Surgery was top-ranked for orthopedics, followed by Mayo Clinic, Cleveland Clinic, Massachusetts General Hospital and Hospital for Joint Diseases in New York.
24. The percentage of physicians in the United States that reported using a basic EHR system increased from 12 percent in 2002 to 34 percent in 2011, according to "Health Information Technology in the United States," released by The Robert Wood Johnson Foundation, Mathematica Policy Research and Harvard School of Public Health.
25. A study published in Spine reported 13.4 percent reoperation rate for five years after surgery for lumbar herniated intervertebral discs, with half of the reoperations occurring during the first year postoperaitvely.
- 5.4 percent of all patients underwent reoperation after three months.
- 7.4 percent was the cumulative reoperation rate at one year.
- 9 percent of all patients had undergone reoperation by the second year after surgery.
- 12.1 percent was the cumulative reoperation rate at four years.
- 13.4 percent of the patients underwent reoperation by five years.
- Reoperation rates after laminectomy were 18.6 percent.
- Reoperation rates after nucleolysis were 14.7 percent.
- After open discectomy, 13.8 percent of patients underwent reoperations within five years.
- Around 12.4 percent of patients who underwent endoscopic discectomy within five years.
- Reoperation rates for patients who underwent fusion were 11.8 percent.
26. North American Spine Society announced that Michael G. Fehlings, MD, PhD, received the Henry Farfan Award. The award recognizes outstanding contributions in spine related basic science research. Dr. Fehlings, a researcher at Toronto Western Research Institute in Canada, is an expert in spinal cord injuries.
27. Physician group advocates continue to work on sustainable growth rate repeal. The House Energy and Commerce Health Subcommittee has passed a bipartisan proposal that would repeal Medicare's sustainable growth rate, which Medicare used to determine physician reimbursement. The proposed bill would have SGR no longer starting next year and grant physicians a 0.5 percent increase in Medicare reimbursement until 2018.
28. Sixty-nine percent of healthcare providers expect that healthcare legislation and mandates will drive patients to the outpatient setting, according to a Healthcare Finance News report. Reimbursements were named by 48 percent of providers as the most significant influence on health systems.
29. A Wolters Kluwer Health 2013 Physician Outlook Survey has found that 34 percent of physicians are "very" or "somewhat" likely to leave their practices in the near future. Of those planning to leave, 29 percent said they would make the decision because they were struggling make their practices profitable.
30. The American Association of Neurological Surgeons elected William T. Couldwell, MD, PhD, as president for the second year in July. He has served on the board of directors since 2006.
31. Rothman Institute researchers published a study in The Spine Journal that found patients undergoing minimally invasive techniques for posterior lumbar instrumentation and fusion demonstrated less need for transfusion during the perioperative time, less blood loss and shorter hospital stays than patients undergoing open surgery.
32. The International Society for the Advancement of Spine Surgery released guidelines for vertebral augmentation treatment. Most notably, the guidelines state that the presence of vertebral compression fractures alone are not indications for vertebral augmentation.
33. Eric Woodard, MD, chief medical officer of InVivo Therapeutics announced participation in an FDA trial of the company's implantable scaffold device for spinal cord injury treatment. The first trial includes five patients and comes on the heels of Geron's clinical trial for a biologic treatment for spinal cord injury patients, which was halted in late 2011.
34. The Centers for Medicare and Medicaid released chargemaster data showing hospital charges for spinal fusions range from $19,000 to $470,000. The highest charge came from Lourdes Medical Center of Burlington County in Willingboro, N.J., at $471,121.
35. The Congress of Neurological Surgeons and the American Association of Neurological Surgeons released the first new set of acute cervical spine and spinal cord injury focused guidelines in the past decade. The guidelines now recommend against using steroids in the first 24 to 48 hours that an acute spinal cord injury occurs.
36. The top factor in whether spine surgeons will choose to practice in the academic field after completing a fellowship program is graduation from a top-20 medical school, according to a study in Spine. The other top factors include:
• Graduation from a top-20 medical school
• Indication of a desire to enter the academic field
• Five or more national presentations
• Research Fellowship completion
• Letters of reference stating likelihood of pursuing academics on hiring the applicant
37. Researchers have discovered a possible link between rising cervical spine surgery costs and older patients. The National Inpatient Sample Hospital Cost and Utilization Project database showed cervical spine surgeries increased by 64,000 between 2002 and 2009, and the average age of patients increased from 56.4 years to 58 years. The average cost per patient increased by $4,531, a rise which may be due to an older patient population, according to the report.
38. According to the American Academy of Orthopaedic Surgeons, the highest density of orthopedic surgeons are in Wyoming , at 14.96 orthopedic surgeons per 100,000 people, followed by the District of Columbia, Montana, New Hampshire and Vermont. The lowest density states are:
1. Mississippi: 6.55
2. West Virginia: 6.58
3. Texas: 6.83
4. Arkansas: 6.91
5. Nevada: 7.01
39. 51 percent of orthopedists say they spend five to 14 hours on administrative activities and paperwork each week, according to the Medscape Orthopedist Compensation Report: 2013.
40. North American Spine Society announced that Lawrence G. Lenke, MD, received the Leon Wiltse Award. The award recognizes excellence in leadership and/or clinical research in spine care. Dr. Lenke is the chief of orthopedic spine surgery and co-director of adult/pediatric scoliosis and reconstructive spinal surgery at the Washington University School of Medicine in St. Louis.
41. On-call pay for surgical specialists dropped 10 percent in 2012, according to an MGMA Medical Directorship and On-Call Compensation Survey. The averge surgical specialist reported daily stipends as $900 in 2012.
42. The HHS Office of Inspector General issued a special fraud alert focused on specific attributions of physician-owned distributorships the agency believes "produce substantial fraud and abuse risk and pose dangers to patient safety" in March. In its alert, the OIG said it is concerned about the proliferation of PODs and views them as "inherently suspect under the antikickback statute." The OIG also listed eight specific "suspect characteristics" of PODs or physician-owners that are likely to attract more scrutiny. The Wall Street Journal recently reported a new investigation into a network of PODs.
43. According to an AANS survey of 221 neurosurgeons, 55 percent of the surgeons were in multispecialty groups while 40 percent were in single-specialty groups. The average group size was four neurosurgeons. Among the surgeons who decided to become hospital-employed, the top factors in that decision were:
1. Malpractice coverage
2. Salary
3. Maintaining a private practice became financially challenging
4. Maintaining a private practice became difficult because of government regulations and mandates
5. Location
6. Job change
7. Ability to focus on subspecialty
8. Opportunities available at the time of completion of residency or when seeking a new job
9. Research opportunities
10. Concern over the new regulations of the Patient Protection and Affordable Care Act
11. Our hospital has formed an Accredited Care Organization that I would like to join
44. Huge growth is expected in the motion preservation and non-fusion spine device markets over the next five years. According to a Research and Markets analysis, the global spine surgery device market will growth at an annual rate of 4 percent through 2018 to $8.7 billion, with artificial disc replacement, dynamic stabilization and interspinous process decompression driving this growth.
45. The Physician Payment Sunshine Act went into effect August 1, 2013, requiring industry members to report interactions with physicians. Spine surgeons have several types of relationships with device companies, and the Sunshine Act with focus on direct and in-direct financial transactions. This information will also be made public next year and could mean some physicians shy away from working with device companies as they did in the past.
46. Orthopedic and spine device companies are seeing mixed success in the market this year. For the first half of the year, SpineGuard posted a 27 percent increase in revenue while Exactech saw spine revenue jump 6 percent. At the same time, Biomet saw a $15 million decrease in spine sales and Stryker net earnings dipped 34.5 percent in the second quarter due to orthopedic device recalls. However, spine and neurotechnology sales for Stryker increased 5.4 percent.
47. The 2.3 percent medical device excise tax cost the industry an estimated $1 billion since it went into effect on Jan. 1, with device manufacturers losing an average of $194 million per month. The tax was levied to raise funds for healthcare reform.
48. Johnson & Johnson's DePuy-Synthes was recently awarded $16 million in a patent-infringement suit against Globus Medical after the judge ruled that Globus infringed on J&J's patents for an ALIF system.
49. The United States spends around $86 billion per year on back pain, according to a UPI report.
50. The Wall Street Journal recently covered a report showing the number of physicians opting out of Medicare in 2012 tripled from the previous three years. This trend could become highly prevalent in spine and orthopedics. There were 9,539 physicians who opted out of Medicare in 2012, however there were still 685,000 physicians enrolled to participate in Medicare last year.