The spine surgeon's ability to negotiate payer contracts and approval for procedures and new technology is an important part of running an effective practice.
Here, four spine surgeons discuss the big payer trends in spine and identify opportunities for the future.
Q: What payer trends are you seeing in the spine space? How are you combating the downward pressure?
Robert Bray, MD. DISC Sports & Spine Center (Newport Beach, Calf.): Insurers keep tightening reimbursements, and in some cases, reimbursements have gotten so low we can't afford to provide care. There isn't any other sector in the business world that gets 200 to 300 percent in pay reductions and are expected to expand. However, the insurers cutting reimbursement down has created a market for ASCs and what they do: take higher acuity cases to the outpatient environment where they have a better margin and outcomes.
I created a new program at DISC, partnering with Global One and Blue Shield, and expanded that principle to start a project around a global billing packaging. For our scope of services, we package the pricing and partner with the insurance companies so patients pay the insurance company directly. When the patient walks in the door, I say, 'Thank you for having insurance, you're not in the billing cycle. You're not going to get a bill other than the copay or deductible — we'll settle this with your insurance company.'
The patient has access to our center, and we aligned their incentives with ours and the insurer. We are in the process of expanding this to multiple providers and working with United to move forward into this format. DISC receives the payment from the insurer, and we guarantee that everyone is in-network for the agreed rate. Insurance companies love it and they're helping to promote the program.
Read the full Q&A here.
Q: How do you feel about the move toward increased price transparency? Will this have an impact on spine?
Alok Sharan, MD. Westmed Spine Center (Yonkers, N.Y.): Increased price transparency will force providers to scrutinize their activities and ensure that they are truly delivering good quality care at a reasonable cost. Unfortunately, price transparency will lead to the commoditization of a lot of the services that a physician offers. Patients/consumers are very cost sensitive; providers should be aware of their costs as compared to relative benchmarks and should be able to justify their prices. While most patients do not want to shop for care I do think patients will want to understand why one provider charges more than another.
As services become more commoditized, physicians should really rethink their strategy, and more importantly, understand how they can deliver a unique value proposition. If you cannot differentiate yourself from the next provider, then you will have to compete on price, which is never a good strategy.
Read the full Q&A here.
Q: What are the three biggest business or healthcare trends you expect to affect your practice this year?
Jocelyn Idema, DO. Spine Surgeon in Pennsylvania: Although there are many trends that could affect my practice in 2019, I find that the continual struggle with insurance companies continues to be an issue for both patient and provider alike. Many insurance companies continue to bundle and/or narrow procedures that can be done, as well as where the procedures can be done. As a result, many of my colleagues and I end up having to carry privileges at multiple hospitals and surgery centers in order to accommodate where procedures are allowed to be done.
The second biggest trend that I see affecting my practice will be bundling of payments. Our spine team is continually working to stay on top of the latest changes with regard to bundling. For example, what used to be three separate codes for reimbursement is now one, thus this allows for decreased reimbursement to not only the physician but the facility as well. I have found that some facilities because of these changes, are now limiting the numbers of those types of surgeries to be done.
Finally, in the private and independent sector where I operate, changes and high turnover of staff continues to work against developing great teams. I fortunately continue to work with the same staff, however we have recognized the need to cross-train all members so that they may fill-in as necessary. Building a great team is key to continuing to thrive in this type of environment and medical climate.
Read the full Q&A here.
Q: What does the future hold for bundled payments in spine?
Praveen Mummaneni, MD. University of California San Francisco: Bundled payments may work for a portion of spine cases done annually. The one-level degenerative case in a healthy patient has a predictable outcome and could be bundled. However, many spine cases do not easily fit into a bundle. How does one predict outcomes and potential complications for a scoliosis correction in an elderly patient with diabetes and a history of heart disease? How to do a bundle for a spinal metastatic tumor causing paraplegia on a weekend?
There are so many variables due to comorbidities and surgical approaches. If such complex cases are bundled, then the elderly and sick patients may not be able to easily access care. We should not set up a system where these patients have barriers to care.
Read the full Q&A here.