Spine surgeon leaders from across the U.S. answer big questions about where the spine field is headed next year.
Question: Where will spine practices look like a year from now?
Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): A year from now, practices will look the same and hospitals will look the same. In my practice, there will be more and more cases in the ASC; there were already some procedures going there and this has accelerated it. Across the board, in terms of practices, there will be consolidation. I think these small three, four, five person practices had tough go of it during the shut down and they are looking for groups to share some of the downside risk with them. For our practice, which is an established practice, a year from now it will look similar.
At one point, I thought [bundled payments] was the future. We were all in to measure and get our metrics prepared for this. In spine, it has been a lot fits and starts, it hasn't really panned out. Total joints are pretty uniform; every total hip replacement looks about the same. Spine is just a different animal. A bundle for a lumbar fusion up to five levels encompasses so many different pathologies and the economics of those are so different.
We have tried within our group to be part of Medicare bundles and accept different types of care, and that has been difficult to do in spine. It hasn't really taken off like it has in joints and other areas of orthopedics. I still think the principle of value based care will stay, there is no doubt, but it's a tough thing in spine to execute. Obviously payers want to move away from fee for service and we at the same time have to prove the value of what we do. But formal value based programs have been very elusive in spine. I think we should collect data and it's important that all practices do it; if you don't you'll be in trouble. But is it going to be the way of the future that people have talked about? I'm less certain of that than I might have been three or four years ago.
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Q: What is the most controversial trend in spine today?
Alexander Vaccaro, MD, PhD, and Bryce Basques, MD. Rothman Orthopaedic Institute (Philadelphia): The most controversial trend I see in spine surgery is the development of "solutions looking for problems" by the device industry. The core fundamentals of good spine care have remained the same for years, yet there continues to be massive investment and marketing in various spinal technologies that seem to fill a void in untapped intellectual property voids, rather than a demand by patient needs.
Today, robotics and various minimally invasive techniques have high potential, yet I would caution surgeons, especially those early in practice, from broadly adopting these techniques without scrutiny. Especially in saturated markets, spine surgeons may think that these newer technologies are an opportunity to differentiate or market themselves. However, if adoption of these techniques leads to inefficiency, complications and poor outcomes, your reputation will suffer and any potential marketing benefit will be lost. In the current financial climate, surgeons will be expected to justify the cost of this technology to payers as well. I would encourage surgeons to be highly discerning in the technologies or advancements they adopt and pursue patient care avenues that demonstrate high value.
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Q: What is the biggest obstacle facing spine providers in the modern landscape?
Greg Gullung, MD. OrthoAlabama (Birmingham, Ala.): From personal experience and discussions with colleagues, it seems to be the approval environment from commercial insurance. Many of the advancements in technology, techniques and training have produced competent and caring surgeons, but their decisions for care are often guided by the local insurance providers. Fortunately, many of the treatment guidelines follow the guidelines of our professional societies, but not everyone fits neatly into a predetermined treatment algorithm — that is where the individual physician must provide detailed and research-backed explanations for their treatment plan. It has also been my experience that most companies are willing to provide approval for various treatment options given sound clinical decision-making.
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Q: What is the most essential technology for spine in the future?
Richard N.W. Wohns, MD, JD, MBA. Founder and President of NeoSpine (Puyallup, Wash.): My spin on the technology piece is that sometimes we have all the technology in the hospital and it's hard to get the same technology in the surgery center because of capital expenditures. That needs to change. We need partnership with industry to help promote use of $1 million robots, O-arms and other high cost technologies that are generally hospital based to be able to use in the surgery center. I use a robot in the hospital and I'm trying to get one for the surgery center, but to make it feasible, it's somewhat difficult. If we want to go the way we should be going, we need help from industry to make all the technology readily available in the outpatient surgery center. The payback will be there because the case will be able to migrate fully over if we have all the neuronavigation, robotics, orthobiologics that we need outpatient.
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Q: What will spine practices need to thrive in the future?
Kam Momi, MD. Founder and partner of CoastalSpine New Jersey (Mt. Laurel): We keep hearing about data and it's like oil: it's valuable, but not the way it comes out of the ground. You have to refine it, there are different products to come out of it; it is important for different people in different industries; and data is the same way. Raw data is not very useful, but we are learning how to sift through it and identify very important aspects of it for total joints and spine, and once we get that data in place, we will be able to make a difference on population health and predicting who needs surgery and also really be able to demonstrate outcomes as we've all talked about to challenge the insurance companies on their arbitrary, whimsical denials they often have.
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Q: What are you expecting from the spine field in 2021? What does a successful year look like for your practice?
William Taylor, MD. University of California San Diego: In my opinion 2021 will be a year of continued expansion for appropriate technology. This will allow us to shorten recovery time, improve outcomes and shorten surgical times. These improvements will come based on reduction in complications and decrease in reoperations from issues that can be rectified or prevented prior to leaving the OR. In addition, improved outcomes will be based on our use of artificial intelligence to help in patient selection. This will not only be based on entering appropriate patients in preoperative education and rehab, but lead to a decrease in the use of narcotics. That will allow us to select and individualize operative procedures that are appropriate for specific patients. Intraoperatively, the continued use of robotics, navigation and augmented reality will allow us to avoid some routine issues that have caused reoperations, infections or neurologic injury.
Success of our practice will be based on our ability to include this expanding technology in the appropriate setting, and working with stakeholders to ensure that it is used properly and effectively to provide increased value. Patients will continue to demand that we understand, implement and provide procedures that utilize the latest technology to improve their outcome.
Bradford Currier, MD. Mayo Clinic College of Medicine (Rochester, Minn.): COVID and politics dominated every aspect of our lives in 2020. The Dec. 13 electoral college vote and the FDA's vaccine clearance were propitious events that hopefully foretell a semblance of normalcy for 2021. Some positive changes will carry over from the pandemic, like more telehealth visits, fewer in-person administrative meetings, more online education and more attention directed at preventing infections, including getting rid of ties at work. Technical advances drive the spine field, and there are numerous candidates for disruptive technologies in 2021. Artificial intelligence, machine learning, robotics, image guidance, virtual reality, augmented reality and digital microscopy represent some of the advances that will potentially improve our field's ergonomics, safety, efficiency and outcomes. Lowering costs should be a top priority, but regrettably, that is not likely to happen in 2021.
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