The spine surgery and treatment field is changing, swept up in overall healthcare trends post-reform. With more data available and pressure toward pay-for-performance, new trends could take hold in the future.
"Back pain is one of the key reasons why people go to see a physician, so you have a big addressable population to figure out," says Mazor Senior Vice President Christopher Prentice. "We are transitioning from being paid to treat the patient more to a payment model that focuses on doing what's most efficient for patient care."
The healthcare system can't afford to put every patient through unnecessary tests and steps in the conservative care process if surgical intervention is the ultimate destination. For patients who are surgical candidates, going through ineffective interventions adds cost and stress to the process.
"We need more data on who would benefit from conservative care and who would benefit from surgical care," says Mr. Prentice. "We also need to figure out what treatments are most cost-effective. The best way to do that is with data collection. But right now we don't have uniformity with technology and procedures to perform a true comparison on the different treatments and medications."
There are several factors to consider when treating a patient, says Sarasota, Fla.-based spine surgeon Thomas Sweeney, MD, to provide efficient and cost-effective care:
• Choosing operative patients carefully with evidence-based diagnoses
• Find the least expensive method for physical therapy
• Educate patients on personal health and activity to avoid back pain
• Use the lest invasive procedure on operative patients
"We want to pick operations for patients that have the least morbidity after procedures so patients can return to their activities faster and stay at the hospital for a shorter amount of time," says Dr. Sweeney. "There are some surgeons doing outpatient surgery today, which is cost-effective but some insurance carriers aren't reimbursing for spine surgery in the outpatient setting."
Preventative measures are also key to keeping costs down. Dr. Sweeney now has a discussion with his back pain patients about maintaining active lifestyles; anecdotally, patients who were more active could tolerate compressions on the spinal canal better than less active patients. Activity could include yoga for strengthening or other activities they enjoy.
New technology is also designed for better outcomes, but not all surgeons are open to change. "I think spine surgeons could lead the way toward more sustainable spine care if we encourage each other to have an open mind to new technologies," says Dr. Sweeney. "I've tried to expose the patient population to new minimally invasive technologies and the use of robotic surgery. If patients demand new technologies that work, surgeons will incorporate them into their practice."
The variability in equipment and training makes a difference in outcomes. There are several studies and data benchmarks available as sheer numbers, but many don't describe which technologies are used with different surgeries and severe variability can distort the numbers.
"Surgeons are trying to figure out how to collect data because we don't have a standardized process right now," says Mr. Prentice. "But the greater philosophical argument needs to be won on what the true metrics are."
Some standardization is likely as a byproduct of creating reproducible high quality, low cost results. Data collection registries and other efforts to develop protocol and negotiate bundled payments could speed along the process.
"That takes some of the art out of surgery and makes it more of a scientific process," says Mr. Prentice. "That's going to take a lot of effort as well because we don't have a good way to collect data without any gaps. I can't claim one way of doing surgery is best because I could look at 10 different hospitals and see the same intent for outcomes, but their steps, equipment, implants and thought process is completely different."
Academic institutions have been conducting studies for years with varying results. However, not all of their data is relevant to every clinical practice setting. There are more surgeons now in the private sector collecting and processing data to show how different treatments work in the real-world setting. It's also a survival mechanism.
"Without data surgeons are losing the ability to market themselves, whether it's to a hospital for employment or to patients as a leading care provider," says Mr. Prentice. "I think surgeons are more willing to put their patients into registries to show the proof that they have good outcomes. I do believe when you have surgeons as employees of the hospital, they are seeing behind the scenes what it takes to provide healthcare. The relationship between hospital administration and surgeon's isn't as adversarial as it used to be."
Surgeons can see how their decisions impact the service line and develop an understanding for why it's important to pay attention to the bottom line — both for hospital and patient out-of-pocket costs. Other surgeons are taking on more business responsibilities by investing in outpatient surgery centers where even spinal fusions are now performed.
"Looking into the future, our ability as spine surgeons to perform surgery on an outpatient basis can save a lot of money because ASCs can do things more efficiently than hospitals," says Dr. Sweeney. "Payers don't always allow us to perform procedures there now."
The switch from fee-for-service to pay-for-performance could have other consequences as well. When volume increases revenue, you'll see more patients undergoing more care; if compensation is based on quality, there's more attention paid to outcomes and patient satisfaction.
"We have tried with good intent to increase the quality of healthcare in this country," says Mr. Prentice. "What hasn't been done is real calibration and improvement to what you can charge. There's been no real pay-for-quality. If you pay for quality, you'll get what you pay for."