Frank Cammisa, MD, Chief of the Spine Service at Hospital for Special Surgery in New York City, discusses the biggest challenges for spine surgery heading into 2012.
1. Influence of insurance companies on access to spine care. Over the past few years, insurance companies have tightened their guidelines on spine coverage, making it difficult for surgeons to perform surgery in once-routine cases. More frequently than in the past, surgeons are being asked to speak with medical representatives in peer-to-peer reviews which often still result in coverage denial.
"I think the biggest concern is the influence of insurance companies on our ability to see patients," says Dr. Cammisa. "For example, there is a push not to authorize fusion-type surgeries for patients. In these cases, we must do a peer review. We spend a lot of time talking on the phone to insurance companies substantiating why we think a certain type of procedure should be done. It's onerous for the surgeon and the patient because it takes the physician/patient relationship and inserts a middle man who decides whether the patient will have surgery."
There is a perception among some circles of healthcare that too much spine surgery is being done and payors must control rates of surgery, says Dr. Cammisa. "Will we be able to independently recommend surgery for our patients or will there be an arbiter?" he says. "This is a concern for every medical specialty."
2. Dealing with regional differences in spine care. The perception of too much spine surgery has been propagated by several sources, including statistics showing rates of spine surgery are higher in some parts of the country than others. Dr. Cammisa says there are several factors contributing to this difference, including:
• How quickly new procedures are introduced
• When spine surgeons are willing to adopt new procedures
• Demographics — percentage of the population who are likely candidates for spine surgery
"It may be that one area is treating spinal conditions more aggressively, but another area might not have the resources available to perform the same procedures on their patients," says Dr. Cammisa. "There may be just as many patients needing surgery in both areas in terms of population percentage, but the care isn't as advanced. From the statistics, it's hard to tell whether surgery is being overused or underused in different regions of the country."
3. Minimizing peer reviews with insurance companies. Since conducting peer reviews is a time consuming process, most surgeons prefer to minimize these conversations whenever possible. "We try to make sure all the documentation is well outlined in our initial note to the insurance company," says Dr. Cammisa. "We send all the information so they know the patient had epidurals, physical therapy and other conservative care and everything is well outlined saying they failed non-surgical treatment — or that their care was an emergency."
In cases of an emergency, Dr. Cammisa's office sends electromyography confirmation of a severe nerve abnormality or other defect. "When the reviewer looks at our reports, they have all the information and dates in front of them," he says. "What concerns me is when I get on the phone with peer reviewers, they often aren't peers — they may be an internist, or another medical professional who doesn't specialize in spine surgery."
When reviewers don't have a spine background, they are more likely to stick to guidelines and staunch treatment pathways before approving surgery. "They don't understand that every patient is different and there are a lot of nuances in spine care," says Dr. Cammisa.
4. Proving the effectiveness of spine surgery in the literature. Approval for spine procedures depends on published outcomes data now more than ever. Strong evidence-based medicine is essential for specialists to show procedures they recommend will have a positive impact on the patient's life. Spine surgeons are more focused today on participating in strong studies and publishing their results.
"What I find particularly exciting is the fact that at one point spine surgery was considered a black box — we weren't sure whether something really worked for the better — but now we are coming out with good research to prove the effectiveness of our procedures," says Dr. Cammisa. "I participated in the SPORT study where we were able to show good outcomes for appropriately indicated surgeries. As we go on, we'll be able to recommend surgery when the patient will likely have a positive outcome and have the data to back that decision up."
5. Paying practice overhead. With declining reimbursements and more hurdles for seeking approval from insurance companies, many spine surgeons are having a difficult time paying practice overhead. In 2011, Congress debated physician fee fixes for the sustainable growth rate, but the big cuts were continuously postponed to a later date. Now, specialists are facing up to 27 percent decrease in reimbursement for Medicare cases in March if another solution isn't reached.
"Any physician is worried about reimbursement being fair," says Dr. Cammisa. "You have to pay your overhead. We need to be realistic about what it costs to run a practice when we think about reimbursement rates."
6. Maintaining efficiency in the practice. With an increased focus on quality and cost of care, efficiency has become a big part of successful practice management. In spine care, this means integrating operative and non-operative caregivers. "It's important to have an integrated practice because if you are trained to perform surgery, you need to spend time in the operating room," says Dr. Cammisa. "In my practice, we make sure operative and non-operative specialists are available so everything runs efficiently and the patient has a good clinical experience."
By having non-operative specialists on hand, patients who don't need surgery won't have to wait for a surgeon with a busy operating schedule. "Seeing patients in a timely manner gives them a good feeling about their care and they will refer you to their friends," says Dr. Cammisa. "The best referrals are patient-to-patient."
7. Figuring out how to support new innovation. Reform of the Food and Drug Administration's medical device approval process was one of the key initiatives in healthcare reform. The FDA's approval process is now stricter about the data needed for clearance, which is forcing companies to jump through several hoops just to put their products on the market. This is a concern for spine surgeons because it could slow the rapidly evolving field of spine innovation.
"It is becoming more and more difficult to get innovation from the bench because it's hard to get through all the regulatory hurdles," says Dr. Cammisa. "There is concern that innovation is going to slow down because of costs in today's regulatory environment."
8. Defining minimally invasive spine surgery. There are several spine surgeons around the country performing "minimally invasive surgery," but the term doesn't describe one uniform procedure; some procedures are proven in the literature as superior to open surgery while others may not have long-term success.
"What I think is important over the next few years is that we sort out what really works," says Dr. Cammisa. "There are several surgeons calling their procedures minimally invasive, but they have very little outcomes research to back up their use. I think spine surgery is going to improve because we will sort out what works and what doesn't. That's where we're headed in the future."
Related Articles on Spine Surgery:
5 Trends Impacting Outpatient Spine in 2012: Thoughts From Dr. Thomas Schuler
7 Spine Surgeons on Using Robotic Technology
7 Top Concerns for Spine Surgeons in 2012
1. Influence of insurance companies on access to spine care. Over the past few years, insurance companies have tightened their guidelines on spine coverage, making it difficult for surgeons to perform surgery in once-routine cases. More frequently than in the past, surgeons are being asked to speak with medical representatives in peer-to-peer reviews which often still result in coverage denial.
"I think the biggest concern is the influence of insurance companies on our ability to see patients," says Dr. Cammisa. "For example, there is a push not to authorize fusion-type surgeries for patients. In these cases, we must do a peer review. We spend a lot of time talking on the phone to insurance companies substantiating why we think a certain type of procedure should be done. It's onerous for the surgeon and the patient because it takes the physician/patient relationship and inserts a middle man who decides whether the patient will have surgery."
There is a perception among some circles of healthcare that too much spine surgery is being done and payors must control rates of surgery, says Dr. Cammisa. "Will we be able to independently recommend surgery for our patients or will there be an arbiter?" he says. "This is a concern for every medical specialty."
2. Dealing with regional differences in spine care. The perception of too much spine surgery has been propagated by several sources, including statistics showing rates of spine surgery are higher in some parts of the country than others. Dr. Cammisa says there are several factors contributing to this difference, including:
• How quickly new procedures are introduced
• When spine surgeons are willing to adopt new procedures
• Demographics — percentage of the population who are likely candidates for spine surgery
"It may be that one area is treating spinal conditions more aggressively, but another area might not have the resources available to perform the same procedures on their patients," says Dr. Cammisa. "There may be just as many patients needing surgery in both areas in terms of population percentage, but the care isn't as advanced. From the statistics, it's hard to tell whether surgery is being overused or underused in different regions of the country."
3. Minimizing peer reviews with insurance companies. Since conducting peer reviews is a time consuming process, most surgeons prefer to minimize these conversations whenever possible. "We try to make sure all the documentation is well outlined in our initial note to the insurance company," says Dr. Cammisa. "We send all the information so they know the patient had epidurals, physical therapy and other conservative care and everything is well outlined saying they failed non-surgical treatment — or that their care was an emergency."
In cases of an emergency, Dr. Cammisa's office sends electromyography confirmation of a severe nerve abnormality or other defect. "When the reviewer looks at our reports, they have all the information and dates in front of them," he says. "What concerns me is when I get on the phone with peer reviewers, they often aren't peers — they may be an internist, or another medical professional who doesn't specialize in spine surgery."
When reviewers don't have a spine background, they are more likely to stick to guidelines and staunch treatment pathways before approving surgery. "They don't understand that every patient is different and there are a lot of nuances in spine care," says Dr. Cammisa.
4. Proving the effectiveness of spine surgery in the literature. Approval for spine procedures depends on published outcomes data now more than ever. Strong evidence-based medicine is essential for specialists to show procedures they recommend will have a positive impact on the patient's life. Spine surgeons are more focused today on participating in strong studies and publishing their results.
"What I find particularly exciting is the fact that at one point spine surgery was considered a black box — we weren't sure whether something really worked for the better — but now we are coming out with good research to prove the effectiveness of our procedures," says Dr. Cammisa. "I participated in the SPORT study where we were able to show good outcomes for appropriately indicated surgeries. As we go on, we'll be able to recommend surgery when the patient will likely have a positive outcome and have the data to back that decision up."
5. Paying practice overhead. With declining reimbursements and more hurdles for seeking approval from insurance companies, many spine surgeons are having a difficult time paying practice overhead. In 2011, Congress debated physician fee fixes for the sustainable growth rate, but the big cuts were continuously postponed to a later date. Now, specialists are facing up to 27 percent decrease in reimbursement for Medicare cases in March if another solution isn't reached.
"Any physician is worried about reimbursement being fair," says Dr. Cammisa. "You have to pay your overhead. We need to be realistic about what it costs to run a practice when we think about reimbursement rates."
6. Maintaining efficiency in the practice. With an increased focus on quality and cost of care, efficiency has become a big part of successful practice management. In spine care, this means integrating operative and non-operative caregivers. "It's important to have an integrated practice because if you are trained to perform surgery, you need to spend time in the operating room," says Dr. Cammisa. "In my practice, we make sure operative and non-operative specialists are available so everything runs efficiently and the patient has a good clinical experience."
By having non-operative specialists on hand, patients who don't need surgery won't have to wait for a surgeon with a busy operating schedule. "Seeing patients in a timely manner gives them a good feeling about their care and they will refer you to their friends," says Dr. Cammisa. "The best referrals are patient-to-patient."
7. Figuring out how to support new innovation. Reform of the Food and Drug Administration's medical device approval process was one of the key initiatives in healthcare reform. The FDA's approval process is now stricter about the data needed for clearance, which is forcing companies to jump through several hoops just to put their products on the market. This is a concern for spine surgeons because it could slow the rapidly evolving field of spine innovation.
"It is becoming more and more difficult to get innovation from the bench because it's hard to get through all the regulatory hurdles," says Dr. Cammisa. "There is concern that innovation is going to slow down because of costs in today's regulatory environment."
8. Defining minimally invasive spine surgery. There are several spine surgeons around the country performing "minimally invasive surgery," but the term doesn't describe one uniform procedure; some procedures are proven in the literature as superior to open surgery while others may not have long-term success.
"What I think is important over the next few years is that we sort out what really works," says Dr. Cammisa. "There are several surgeons calling their procedures minimally invasive, but they have very little outcomes research to back up their use. I think spine surgery is going to improve because we will sort out what works and what doesn't. That's where we're headed in the future."
Related Articles on Spine Surgery:
5 Trends Impacting Outpatient Spine in 2012: Thoughts From Dr. Thomas Schuler
7 Spine Surgeons on Using Robotic Technology
7 Top Concerns for Spine Surgeons in 2012