There are several changes in healthcare impacting spine surgery and innovation in the field. Here are 10 spine surgeons discussing some of the biggest challenges and windows for success in the future.
Q: Consolidation is huge in the healthcare industry today. How is this trend impacting physician practices and technology purchases?
Christian G. Zimmerman, MD, MBA, Saint Alphonsus Medical Group, SAHS Neuroscience Institute: Practice consolidation or exclusion, is the working model for provider employment and hospital corporate intellect as a five-year plan. For those who qualify within a set of national standards — i.e. Crimson Systems — patient steerage and volume retention will be directed. Hospitals will survive.
Gowriharan "Ty" Thaiyananthan, Founder of BASIC, Newport Beach, Calif.: Consolidation of physician practices is prelude to the formation of accountable care organizations. The emphasis is going to be on minimizing healthcare utilization to curb costs while meeting an ever increasing bar for the quality of care that is delivered. Costs and outcomes will be the metrics that these consolidated physician practices are graded by.
The emphasis is going to be on less costly treatment modalities that yield results. The economics of this change will probably drive changes in the industry towards more ultra minimally invasive techniques that preserve motion and minimize hospital lengths of stay and treatment related co-morbidities.
Richard A. Kube II, MD, CEO, Founder, Prairie Spine & Pain Institute, Peoria, Ill.: Consolidation eventually leads to monopoly. Any movement that decreases competition or consolidates thought into a smaller number of groups does nothing to stimulate innovation or promote value. Ultimately market forces will allow a model of that type to drive value down in the form of lesser service at same or higher cost. Medicine will succumb to the same market forces and end results as any other business industry.
Q: There have been a few big orthopedic and spine device company deals this year. How will this consolidation impact surgeons and care in the future?
Brian R. Gantwerker, MD, The Craniospinal Center of Los Angeles: I think the market drives toward consolidation and unfortunately, it will decrease the drive to innovate. One has to understand who is driving the consolidation: hospital systems and universities that are interested in quality benchmarks, cost containment and uniformity of service.
Cost-cutting measures will likely force consolidation in the industry, which we have already seen. There will be a tipping point, I think, that will push toward three or four large companies vying for market share and probably making nearly equivalent hardware. There will be maybe a few niche companies, but I think it will be difficult for them to be viable.
Q: What will be the next big clinical innovation in spine surgery? What excites you most?
Neel Anand, MD, Clinical Professor of Surgery, Director, Spine Trauma, Cedars-Sinai Spine Center, Los Angeles: It doesn't matter what scientifically is the next big thing. It will be dominated by so many outside forces — insurance regulations, for example. The main thing is to continue doing multi-center studies that can hopefully help develop paradigms that work for everybody.
Artificial discs to me were one of the biggest game-changing technologies in the industry. It is sad to me that it has not advanced. It just hasn't been able to take.
Dr. Gantwerker: I feel continued improvement and development of non-fusion techniques and technology will be at the forefront. With the evolving marketplace and constraints payers are placing on fusion, those companies and surgeons who can minimize the number of or shorten the length of fusion procedures will be regarded as at the forefront of the field.
William Taylor, Director, Spine Surgery, Vice Chairman, Division of Neurological Surgery, University of California, San Diego: Continued effort to promote, describe and research treatments for adult degenerative scoliosis. This is opening up a whole new treatment paradigm for elder patients who a few years ago would have been ignored. The ability of thought leaders and surgeons to successfully understand the tenets of balance, correction and applications to this patient population is exciting. It will have continued growth and expand into how we view our everyday 'simple cases' soon.
Purnendu Gupta, MD, Director, Chicago Spine Center, Weiss Memorial Hospital, Chicago: As a scoliosis specialist, the most exciting innovation is the ability to modulate the growth of the spine in a developing child. This would allow manipulation of an abnormal curvature to straighten or prevent progression of the deformity.
We now have spinal instrumentation which can be lengthened without the need for open surgery. Another alternative is vertebral body tethering, which may be a fusion-less treatment option. The combination of these two technologies could be used to modulate the growing spine. In addition to the possibility of significantly reducing spinal fusions, this technology would be an alternative to multiple annual surgeries that are currently done on children with growing rods instrumentation.
Q: Are there any devices or innovations out there that could disrupt the spine field in the future?
Isador Lieberman, MD, MBA, Director, Scoliosis & Spine Tumor Center, Texas Back Institute (Plano): The first successful implantation of a 3D printed vertebra in China is one of the most exciting clinical developments in spine surgery today. As far as I know, this is the first time such a procedure has been done. This represents an important new trend in medicine.
Additionally, in the very near future, we may be able to regenerate the spinal cord. Instead of implanting artificial devices, we will be able to apply genetic knowledge, combined with biologic materials to stimulate cell growth. This material won't be metal or plastic. It will be composed of the patient's own cells.
Another exciting area for spine surgery in the future involves using robotics to integrate the brain with the nervous system. With these types of advances, there will come a time in the future when no one will be paralyzed. We will be able to biologically or robotically correct this condition.
Q: The Sunshine Act has been implemented for more than a year, and now payment information is available online. Will the Sunshine Act dissuade young spine surgeons from forming relationships with device companies? Do you see this as a positive trend?
Sheeraz Qureshi, MD, Assistant Professor, Spinal Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York: I don't believe the Sunshine Act will dissuade spine surgeons (young or old) from forming relationships with device companies. I think this is a positive trend that allows for transparency and protects surgeons, companies and ultimately patients.
There are so many positives that come from surgeon-industry collaboration and we should view full disclosure as a way to highlight how this collaboration helps to advance the field of medicine and patient care.
Nader Dahdaleh, MD, Northwestern Medicine Neurosurgeon, Assistant Professor, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago: The Sunshine Act was designed to provide transparent and objective information to the public on the types of financial relationships that exist between manufacturers and physicians. Physicians have a 45-day window to review and dispute any data that appears inaccurate. This is of particular importance to spine surgeons who are prone to liability and scrutiny.
Since patients' reactions towards conflicts of interest are unpredictable and based on beliefs, education, background and a multitude of other factors, young spine surgeons will keep their relationships to industry to a minimum. This potentially would be of benefit to young spine surgeons who are trying to build their reputation and referral base. Their primary focus and energy should be channeled towards patient care and favorable outcomes.
On the other hand, industry has always played a significant role in advancing the field through supporting innovation, education and creativity and hence, in the long run a delicate balance should be achieved.
Dr. Taylor: The Sunshine Act, by focusing solely on monetary payments, ignores the many positive aspects of an appropriate industry relationship. An interaction that includes but is not limited to technology assessment, teaching courses, lectures, product development, technique evaluations and post/pre-market analysis is beneficial to both physical therapists and surgeons. There are few better ways to become a better doctor and surgeon than engaging in the above interactions.