"Spine surgery can be looked at as historically one of the largest offenders of non-sustainable care," says Robert S. Bray Jr., MD, Founder of DISC Sports & Spine Center in Marina del Rey, Calif. "There has been too much done without enough evidence behind it and physicians are paid a straight fee-for-service for doing so. That's not sustainable. We are all trying to figure out how to transition into a system that accounts for providing quality care for a large number of people in a cost-efficient manner."
When deconstructed, overall spine care costs include the required conservative care, imaging, physician consultations, anesthesia, preoperative care, surgery, implants, hospital stays, postoperative care and physician fees. Fixed costs amount to more than half the total bill, while implant costs account for 20 percent to 25 percent of the bill on average. The total cost varies depending on the patient, geography and interventions, but many bills total more than $100,000.
"That's a huge amount of money spent on a single person without much data behind it," says Dr. Bray. "We need to concentrate on the data to figure out what works and what doesn't. We want to know the complication rates and ultimate outcomes as well as the patient satisfaction and the cost. Quality data needs to be placed next to the cost, and if you can deliver high quality at a cost-efficient rate, you are doing well."
Many studies completed today focus on one aspect of care — either complication rate or cost; patient satisfaction or pain scores. The data is collected over short time periods as well — two to five years — and there isn't a standardized methodology for reporting results.
"Dartmouth has done a huge amount of research into what spine surgeons do and is starting to mold its data with some structure that looks at outcomes on a long-term basis versus the cost of an intervention," says Dr. Bray. "I see patients every day for whom other surgeons have recommended multi-level procedures, when — in my experience — they just need a microsurgery. If microsurgery is a much easier procedure for them, and I can achieve the same outcome, why would this patient want a fusion?"
Data collection and transparency are the catalysts for several paradigm shifts happening in healthcare impacting spine surgeons at the clinical and operational levels:
• Penalties for complications, readmissions and failed surgery
• Push toward less invasive procedures
• Consolidation to share risk
• More emphasis on patient satisfaction than volume
• Transition to outpatient care
Payers are focused on lowering the cost of care while providing a service for their members. Cost and quality data is becoming more transparent, and consumers are doing more independent research on finding the best deals in healthcare — high quality for a fair price. These trends are having an impact on how physicians practice today.
"I don't think DISC's future is as an independent; I think it will consolidate into a larger, broader healthcare delivery system," says Dr. Bray. "We are looking at how our involvement will be with risk-sharing pools. There are IPAs or other creative structures that share risk with an upside for providers. But I need to be conscious of the care I choose to deliver because it has to be effective. This shift has to come from the surgeon's point of view, and surgeons need to be involved in creating new structures."
In the future, Dr. Bray sees surgeons being rewarded to deliver care across a broad spectrum and achieve good outcomes. In a volume-based system, more surgery performed and more patient interaction resulted in more payment; this will change over the next few years. Failed and revision spine surgeries come at a huge cost to the healthcare system, and reducing risk of failure goes a long way to keeping spine surgery affordable and available.
"I'll do well if my patients do well; not if the costs are too high or patients have bad outcomes," says Dr. Bray. "I don't agree with everything in the Affordable Care Act, but at least people are thinking about how things are going to change. I believe we will see more outpatient centers because we can deliver a good product at decreased cost there."
DISC includes two ambulatory surgery centers where outpatient orthopedic and spine surgeries are performed. Procedures at the centers cost 50 percent to 60 percent less than in the hospital, and the ASCs haven't reported an infection yet. Complication rate is low and Dr. Bray is tracking outcomes to show how patients improve.
"Now I have to take this product and package it for the risk-sharing model," he says. "In a managed care structure, we can show payers how many people we put through our clinic, which procedures are done, patient data, outcomes data and a reasonable cost as a result. If we share in the responsibility and risk of taking care of patients, we can deliver a product that lowers costs and keeps patients happy. I think the spine field is a great place to start because straight fee-for-service has run its course and there is a lot of room to make improvements."
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