Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
Next week's question: What are some of the biggest opportunities for spine surgeons under the new administration?
Please send responses to Anuja Vaidya at firstname.lastname@example.org by Wednesday, Feb. 22, at 5 p.m. CST.
Question: What is the most pressing financial challenges facing your practice at the moment?
J. Brian Gill, MD, MBA. Nebraska Spine Hospital (Omaha): The financial challenges that our practice faces hasn't changed over the years — declining reimbursement with rising expenses. The modest reimbursement increases have not kept pace with the cost of doing business. This trend has continued for quite some time and is a common theme amongst most if not all practices. For those practices with ancillary income, it has become harder to make these services profitable due to the reductions in reimbursement or increased regulations. MACRA and its associated reporting places a greater burden on practices to collect the required data or otherwise be penalized for not submitting the data.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: Cash flow from payers continues to be an issue, as my few contracted payers still do not pay on time with clean claims and precertification of medical necessity. As a consequence there may be more pressure to go completely out-of-network unfortunately. Most primary care doctors I know have gone concierge, and patients are accepting it. Most patients are realizing they will have to pay more to not be in a patient mill. So, I am considering my options.
Richard Kube, MD. Founder and CEO, Prairie Spine & Pain Institute (Peoria, Ill.): Frankly, it is the insurance company's refusal to pay bills in a timely manner if at all. We have gone over to a certified mail-only submission of claims for our surgical facility. We have gone so far as to include a table of contents with the claim as well. It is maddening how many times claims are submitted and resubmitted only to have someone say they never received the paperwork. Payment delay is tied to this nonsense with an increasing frequency. We also have carriers that refuse to take phone calls or answer emails regarding delinquent payments. We are assessing our options for filing lawsuits against several national insurers.
Vladimir Sinkov, MD. Spine Surgeon at New Hampshire Orthopaedic Center (Nashua): Keeping up with the regulatory requirements for EMRs, opioid prescribing rules and meaningful use/MACRA.
Renato V. Bosita, Jr., MD, MBA. Texas back Institute (Plano): The most pressing financial challenges facing my practice at Texas Back Institute are the rapidly increasing fixed costs of running a large multidisciplinary spine practice and declining reimbursement relative to the time and effort needed to deliver excellent spine care to our patients. The shrinking delta between these two forces must be accounted for in all of our yearly budgets, three-year and five-year plans as well as long-term expansion in order for us to continue being both solvent and autonomous. What's at risk is not just dollars and cents, but actually the paradigm of physician-based healthcare delivery in America.
With regard to our fixed costs, not a single element of our fixed cost structure is going down (or even staying the same). EMR and PACS require bandwidth, servers, hundreds of monitors/computers/mobile devices, expensive yearly licenses and mandatory "optional" upgrades. Wages and benefits for our employees are also growing faster than inflation as we must compete with other medical practices for talented physician's assistants, medical assistants, administrative assistants and information technology personnel. Health insurance premiums rise, as do 401k contributions. Rent in good locations near growing, attractive population centers is also skyrocketing as more doctors flock to large, but tight medical communities centered around key medical access points, such as hospitals, surgery centers, imaging centers and even freestanding emergency rooms. It is somewhat paradoxical, but increasing the number of providers and healthcare access points has actually increased the demand from providers for prime office space near these venues.
On the revenue side, the rise in fixed costs has not been offset by a rise in reimbursement. Overall reimbursement rates are flat or even declining when inflation and increases in costs of living are taken into account over the last 10 years. Surgeon's fees are stagnant at best. Assistant's fees are decreasing. Out-of-network opportunities have evaporated. Meaningful use reimbursement from the government pays off pennies of each dollar actually spent on technology infrastructure. Ancillary income opportunities have also been stunted by increasing government regulations prohibiting the development of new physician-owned hospitals and highly regulating the expansion of existing physician-owned facilities. Even the tax structure under the Obama administration has been a detriment to finances because of the way dividends were treated as simple income — hopefully, President Trump and the new Republican administration can give us some relief here!
The financial risks of being a spine surgeon are getting worse and worse. Physician super-groups and hospital systems are using this uncertainty to employ physicians, especially young ones with lots of medical student debt who are wary of these financial burdens and reluctant to take on the financial risk of running a practice where costs are increasing and revenue is flat or declining. Unfortunately, avoiding the risks of practice also eliminates much of the autonomy that so many of our predecessors have enjoyed. It is my sincere hope that physician leaders in spine surgery and across all fields of medicine can rise up and help doctors remain at least partially in control of the future of medicine.
Bonventure Ngu, MD. Premier Spine Institute (The Woodlands, Texas): For me, it's reimbursement. Part of my practice is out-of-network, which can be challenging. But in-network reimbursement is also low.
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