Here, five spine surgeons discuss how the physician shortage, combined with the increase in the insured population, will affect spine care delivery.
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. We invite all spine surgeon and specialist responses.
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Question: Would the physician shortage affect spine care? Why?
John C. Liu, MD, Co-Director, USC Spine Center, Keck Medicine of USC, Los Angeles: I do not think the anticipated physician shortage will affect spine care. As the healthcare market continues to change, spine care practitioners will need to adapt because patients and payers will demand appropriate, high-quality care no matter what. A movement away from procedural, volume-driven spine care to more preventative and conservative care will likely decrease the number of spine surgeons required in the future. Improvements in quality and technical precision in diagnosis and surgery will reduce failed spine surgeries and unnecessary surgical interventions, while much of the current care provided by spine surgeons will likely be supported by other specialists or physician extenders.
Walter Eckman, MD, Aurora Spine Center, Tupelo, Miss.: Yes, spine pain patients need more time and patience.
Richard Kube, MD, Founder, CEO, Prairie Spine & Pain Institute, Peoria, Ill.: The answer is a pretty complex economic equation given all of the variables. Obviously, it is really hard to predict exact changes. The simplest concept is supply and demand. Fewer doctors and more patients — think baby boomers — would tend to be favorable for physicians. With market forces pushing doctors into employment rather than independence, this force could help to counter or weaken that trend.
We do, however, see greater numbers of ancillary providers providing a greater amount of care. For example, a couple dozen states allow nurse practitioners to practice independently from physicians. We could see those individuals filling the supply/demand gap and changing how and by whom patients are treated. There can be treatment delays on more complex issues that only the surgeon can address which can lead to different types of patient presentations to be treated. Unfortunately, there may be increased stratification of access to care based upon type of payer.
One can speculate further about infinite possibilities, but I think it is really just important to follow internal metrics and try to identify trends in payer mix, patient age, referral source, etc., so that your practice can read the tea leaves so to speak and be better prepared for what is to come. Though the shortage is still on the horizon, changes will not happen over night, and you can always count on a few surprise variables. Also, given the time it takes to train a spine surgeon, it will take some time to add the physicians through traditional methods. Hence, hope for higher volume, but don't make it a forgone conclusion. Be thoughtful and diligent and embrace the need to evolve with the market.
Bryan Oh, MD, Neurosurgeon, BASIC Spine, Newport Beach, Calif.: With the continued aging of the baby boomer generation, comes 
more degenerative healthcare-related issues such as spine degeneration and thus, an increased need for patient access to healthcare and spine providers. Any event that limits patient access to those healthcare providers will have a negative impact on the delivery of that healthcare.
There is a projected shortage of physicians throughout all different specialties, including spine surgery. The anticipated physician shortage, mostly in primary care specialties, will mean fewer patients will have timely access to diagnosis and treatment of their spine conditions. Ultimately, patients being able to access spine specialists via a referral network will be negatively affected. As a result, I do anticipate advanced practice practitioners, such as physician assistants and nurse practitioners, to be more prevalent in the spine world.
As with anything, there will be a learning curve for these new providers. In the interim, spine care may be adversely affected, but with better specialty-specific training for these APPs and an expectation that they will be integral to the care of spine patients, I do believe that quality spine care will still be present.
If the spine provider shortage is severe enough, new models in which patients have direct access to specialty spine care without referrals may need to be developed. Models like telemedicine may also become more prevalent as time goes on to provide additional access points for patients to directly reach their spine physician.
Theodore Belanger, MD, Texas Back Institute, Plano: I feel the MD shortage will significantly affect spine care. With an aging population, there are going to be more and more people that develop degenerative spine conditions as well as spinal deformities and other problems associated with aging. Osteoporosis leads to an increased risk of fractures from low energy trauma. More people with osteoporosis and arthritic conditions means more demand on spine care providers in the future.
The demand cannot all be met by a shrinking pool of spine surgeons, especially in the face of decreasing reimbursement and job satisfaction. The talented individuals will seek out more innovative ways to avoid the lower-reimbursing and more inconvenient patient base, becoming more and more super specialized and "boutique," catering to other patient populations in exchange for a better lifestyle and financial reward. This means spine care in the future will increasingly fall on individuals within healthcare that have less specialized knowledge and training, and less ability to provide a high level of appropriate care efficiently. This translates into a human cost for our patients.