Strengthening spine surgeon education is just one of many things Edward Dohring, MD, wants to accomplish as he steps into the role of president for the North American Spine Society. He also wants to grow diversity among leadership and engagement.
Dr. Dohring, a spine surgeon at Spine Institute of Arizona, shared his goals for NASS with Becker's, along with his outlook for minimally invasive surgery and concerns about payers.
Note: This conversation was edited for style and clarity.
Question: Looking at the year ahead for NASS, what do you hope to achieve as president?
Dr. Edward Dohring: A lot of my vision is continuing several projects that have already been initiated at NASS. We've been working before COVID-19 to expand the video resources that are on our website and also on our website search capability so that it can be used as a resource for surgeons and non-surgical physicians who are trying to understand how they can provide better care. The pandemic accelerated that whole process just because everything went virtual for a while.
Personally, I have always been involved in residency and fellowship training, and have been on the American Academy of Orthopaedic Surgeons Fellowship Committee, and on the American Board of Surgery and ACGME panels with regard to fellowship training and certification. And then, of course, the NASS committees that work on those areas. I think it's important that we continue to work on making sure that fellowship training meets at least certain minimum standards. Currently, about 70 percent of the spine surgery fellowships and a similar percentage of the interventional pain fellowships are not certified. Although most of them are really good and work hard to provide an excellent education, there's no sort of standard to aspire to. Many of these programs have requested an alternative certification pathway to that provided by the ACGME. So during my presidency, I'd really like to see us continue our work on that and perhaps even get a formal certification process together for those programs that don’t want to go through the ACGME process.
The leadership of NASS is also committed to improving the diversity of our membership and of our leadership. We have engaged a diversity consultant who is in the middle of a project that is surveying the membership and trying to help us think of creative ways to encourage women and people of color to become more involved in the field of spine care, and to become more involved in NASS. The initial survey shows that these people, for the most part, do feel welcome and feel included and feel that leadership possibilities are available to them, but also has revealed areas of weakness that we can work on so as to encourage them even more.
We've always partnered with industry for teaching and research, but during the pandemic some of that hasn't been able to be carried out as we'd like. So our goal there would be to engage industry in a much more robust way. We have overlapping goals of training the best surgeons and interventional pain specialists, and of making sure the outcomes for patients are the best they can be. Industry often provides its own training platforms, and we are meeting with various leaders of industry to see how we can increase and further the collaboration.
Q: How is NASS addressing surgeon concerns about payer relations and the 2022 CMS proposal to bring back the inpatient-only list?
ED: NASS has dedicated significant resources to developing and maintaining respected relationships with government and private payers to develop fair and evidence-based coverage for spine procedures and services. NASS provides its coverage recommendations to payers free of charge. NASS is also very active in reviewing draft coverage policies provided by payers, and collaborates with payers and utilization management companies to define appropriate coverage policies for spine care.
Regarding the IPO list, NASS is supportive of maintaining the list as a mechanism to ensure that patients who require medically necessary inpatient care following spine surgery are able to receive it. There is already an effective process in place for removing codes from the IPO list, for procedures that can be safely performed in the outpatient setting. NASS has urged CMS to maintain the current process and continues to advocate that physicians need to be allowed to use their clinical judgement to determine the best setting for safe and efficacious patient care.
NASS is also concerned that wholesale elimination of the IPO list would be an administrative burden for physicians and facilities who are treating the most ill and vulnerable patients, and could have unintended consequences due to changing payment rates between the inpatient and outpatient settings. NASS believes that CMS needs to work with all stakeholders as it considers changing its IPO list policies, and avoid making significant changes over a short time period. We have recently met with and authored several letters to key policy makers outlining our opinions and offering to collaborate with them towards the best patient care pathways.
Q: What other areas are top of interest for NASS members going into the next year?
ED: Other interests include stopping the 3.75 percent cut to the Medicare conversion factor and the other statutorily mandated cuts that will result in a total 9.75 percent Medicare payment cut. Such drastic cuts will have a significant negative impact on Medicare beneficiaries and physicians, particularly during the ongoing public health emergency. Physicians are facing payment cuts while facilities continue to receive payment increases. We have recently met, with and authored several letters to, key policy makers outlining our opinions and offering to collaborate with them towards retaining patient access to care.
Another area of interest is reducing administrative burdens. NASS continues to advocate on both the regulatory and legislative fronts to reduce administrative burdens on physicians to allow them to spend less time on paperwork and more time on patient care. In particular, NASS is concerned about the recently enacted prior authorization requirements for cervical fusion and disc replacement and for the implantation of neurostimulators when performed in the outpatient hospital setting, and has advocated for rolling back these requirements and not requiring prior authorization for any additional procedures. We have recently met with, and authored several letters to, key policy makers outlining our opinions and offering to collaborate with them towards the best patient care pathways.
Q: You’ve done work to train spine surgeons around the globe in minimally invasive spine surgery. How has adoption of MIS evolved in the last few years? How widespread do you predict it will be in the next five years?
ED: To be honest, I have been surprised by the seemingly glacial pace at which MIS improvements to patient care have been adopted. I did my first MIS screw-rod fusion through a tube in 1998, and my first MIS direct lateral trans-psoas interbody cage surgery in 2003. At the time, I thought these approaches would take our world by storm and be universally applied within five years. Instead, I have experienced the real-world manifestation of the concept that it takes 17 years for evidence-based research to be adopted by the majority of clinical practices. There are many reasons for this, but I do believe that at this time many forms of MIS have reached the 50 percent practice threshold, and will continue to evolve as we improve the use of navigation and robotics in spine surgery. At least we aren’t as slow as the British Merchant Marine, who took 264 years to formally adopt Lancaster’s scientific method of preventing scurvy!