50 spine surgeon predictions for 2018

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Here are 50 spine surgeon predictions for 2018.


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Healthcare market


Frank Phillips, MD. Director of Spine Surgery at Rush University Medical Center (Chicago): As we move toward a value-based system, major challenges revolve around defining "value." Value is defined quite differently by the various stakeholders in healthcare. For an insurance company, value is ultimately defined by returns to shareholders and profitability. I believe physicians, with their expertise, are in a unique position to play a pivotal role in defining value. Simply put, value represents outcomes divided by cost. Both numerator and denominator in this equation are challenging to define. Spine surgeons need to engage in this process.


A. Nick Shamie, MD. Chief of Orthopedic Spine Surgery at UCLA School of Medicine: 2018 brings us much change and turmoil in our healthcare delivery systems. It is imperative for us as physician scientists to use the "big data" of population and health records to better understand what's really going on. Clinical trials are an effective way to study certain new treatment modalities, but by using large data that is now available to us, we are increasingly able to see how certain treatments affect certain segments of a population and compare what happens with and without a particular intervention.


Neil Badlani, MD, Chief Medical Officer of Nobilis Health (Houston): Healthcare is becoming an increasingly consumer-driven industry. Patients have access to healthcare information everywhere because of the internet and direct-to-consumer marketing. They are more educated about their healthcare choices and they have higher expectations and want to be active as long as they possibly can.


Adam Bruggeman, MD. Texas Spine Care Center (San Antonio): I think it is clear that public and private insurers are increasingly interested in quality over quantity, but they pay based on quantity. With the transition to [the Merit-based Incentive Payment System] and the significant cost pressures, the treatment (operative and nonoperative) of spinal issues will be required to show value for the services provided. The easiest way surgeons will be able to show value is through partnering with CMS and private insurers through bundling in a way that financially incentivizes the physician significantly and also provides the insurance company with cost savings.


Brian Gill, MD. Nebraska Spine Hospital (Omaha): I think the typical issues of declining reimbursement and increasing expenses are always on the minds of practitioners. There continues to be consolidation in healthcare with various systems merging, which trickles down to individual groups merging. This is being done out of necessity rather than convenience.


Brian Gantwerker, MD. Founder of The Craniospinal Center of Los Angeles: The pressures of increased regulatory requirements are pushing doctors to leave private practice and to seek the (possibly) safe umbrella of employment. Of those coming out of residency or training, they seem to either not want or cannot function in a private practice situation.

William Tally, MD. Athens (Ga.) Orthopedic Clinic: I think the biggest impact [to the spine field] will be reimbursement and consolidation. Hospitals will continue to use leverage and power to force us into employment models. Those that can navigate the reimbursement changes will be able to stay viably self-employed. My biggest concern is the overall transition to employment-based practice and our subsequent loss of system control; that will not serve our patients well.


Thomas Scully, MD. Northwest NeuroSpecialists (Tucson, Ariz.): Insurance companies' continued lack of authorizations for procedures or imaging and the incessant hoops to jump through to care for patients continues to loom large. I really think the progressively aging community makes it difficult to know how aggressive to be with octogenarians, etc. We need to be good stewards with Medicare dollars, but also not deprive patients of increased quality of life given the right spinal surgical procedure.


Practice management


James L. Chappuis, MD. Founder of SpineCenterAtlanta: Key business challenges will be to continue to stay in business for smaller practices. This means thinking outside of the traditional reimbursement setting and developing new and innovative reimbursement models, especially for many of our patients who are under-insured or uninsured. I really believe this third party-payer system is one of many problems. If you can find a way to deliver your services directly to the patient (consumer), we return to the way mainstream business works in this country. This means, however, we must show good care, track and publish our outcomes, and show value! This cannot be accomplished in our current hospital model, but can in outpatient comprehensive spine care models such as ours [at] SpineCenterAtlanta.


Stephen Hochschuler, MD. Co-Founder of Texas Back Institute (Plano): I've always believed you have to watch what the competition is doing. That doesn't mean it regulates what you do, but be aware of it. If the hospitals are consolidating, figure out what hospital you'll do deformity procedures in and whether they'll give you credentials. Additionally, surgeons need to go to national conferences. They don't like to go, but that's where you make contacts and gain recognition in the field. Look at your situation: What is happening to your numbers? Do you have the same referrals as you did a few years ago? Are you achieving the same payment per case? Look at those trends, and from there you can predict what will happen in three to five years.


Dr. Frank Phillips: Bundled payments will continue to evolve with the inevitable march away from a fee-for-service model. Bundles are readily managed for spinal procedures with reproducible and predictable outcomes, such as ACDF. More complex treatments, such as surgery for advanced spinal deformity, will remain a challenge in a value-based purchasing system. With increased emphasis on value and transparency, practices' and practitioners' outcomes will become increasingly available to the public, who will become much more sophisticated healthcare shoppers.


Dr. Neil Badlani: Healthcare dollars are also being shifted more toward our patients in the form of higher deductibles and co-insurance payments. This trend of consumerism in healthcare is not going away, and physicians should be equipped to handle it. As physicians, it is our responsibility to educate our patients with accurate and comprehensive information about their conditions and treatment options. Direct-to-consumer marketing is an increasingly important way to provide that patient education and an opportunity for physicians to grow their practices for continued success.


Dr. Brian Gantwerker: As to why we are seeing diminishing reimbursements, I would guess that the main method is insurance companies are trying to squeeze more profit out of the insured and pay less to the physicians. It's not clear to me the logic behind paying less to quality doctors. My overall feeling is that more doctors will opt out of insurance completely to counter the trend.


Dr. Brian Gill: From a clinical standpoint, spine surgeons are facing greater scrutiny in getting care authorized from insurance companies. Over the past year, I have had more peer reviews for authorizing care than I had in all of my previous years combined.


Nitin Khanna, MD. Spine Care Specialists (Munster, Ind.): The most important trend for spine surgeons in 2018 is the move to outpatient spine. However, remaining independent will continue to be a challenge with the consolidation of healthcare entities. Gaining minimally invasive expertise and marketing knowledge to move cases to an outpatient facility is the best opportunity this year.


Todd J. Lansford, MD. South Carolina Sports Medicine & Orthopaedic Center (North Charleston): The key clinical and business challenges will continue to be reimbursement issues and health insurance reform. There is considerable uncertainty in this sector, which insurance companies hate. This all leads to challenges for the patients and providers. From a business standpoint, corporate tax changes will be a challenge for many private practice groups. The challenge is not a bad one, but confusing nonetheless.


James Sanfilippo, MD. Reconstructive Orthopedics (Moorestown, N.J.): Surgeons are more frequently exploring collaboration with nonoperative physicians, such as primary care musculoskeletal medicine, rheumatology and pain management [physicians]. This allows for a controlled flow of patients to the appropriate provider depending on the patients' response to conservative treatment. In most cases, these physicians can collaborate on an algorithmic patient care protocol to limit therapies and treatments that may not be producing results, thus driving down unnecessary costs of care.


Vladimir Sinkov, MD. New Hampshire Orthopaedic Center (Manchester, N.H.): Ironically, the demise of private practice will not be due to competition; it will be due to lack of competition. Competition is actually good, and makes everyone try harder and be better at what they do. This ultimately provides better care for patients and more efficient healthcare with fewer costs. The current system is anti-competitive. It provides an unfair legal and financial advantage for non-for-profit tax-exempt large hospital systems and insurance companies.


Dean Toumbis, MD, PhD. Citrus Spine Institute (Crystal River, Fla.): I believe the future for independent spine practices is still a strong one, and is likely to become even stronger as many of the surgeons out of residency and fellowship are now seeking employed positions. Good personalized patient care will always be rewarded in the spine profession. Additionally, collaborative efforts, with not only our orthopedic colleagues, but also with hospital administration, are key to success in the future. A successful spine practitioner will also need to be more business-minded now and in the future. Contract negotiations, cost containment and strong staffing are all critical to high profitability.


Anthony Yeung, MD. Founder of Desert Institute for Spine Care (Phoenix): There will continue to be downward pressure by payers on independent spine surgeons regardless of their reputation and skills. Unfortunately, the trend and pay for all surgeons, independent spine surgeons or salaried spine surgeons, will continue to trend downward in the long term. Reimbursement may increase temporarily in situations in which even "above-average" or "superstar" surgeons who are dependent on insurance or government payers will be impacted. All who are expected to pay or receive payment will continue to leverage their dominance in the reimbursement industry to aggressively and routinely try to maximize reimbursement, while payers will continue to relentlessly reduce payment with their own reimbursement criteria. Either way, the reimbursement trend will force not just spine surgeons but all business entities to distinguish themselves by narrowing their surgical area of expertise.




John Finkenberg, MD. Sharp (San Diego): The most important trend for 2018 will be seen as the creation of instrumentation and procedures that blur the lines between MIS and minimal-access surgery. 2018 will bring on a new tax code, which may positively affect many professional businesses. Tax ceilings and opportunities to buy digital radiograph equipment with advantageous depreciation rules should be considered.


Richard Chua, MD. Northwest NeuroSpecialists (Tucson, Ariz.): I believe there will be continued growth in the application of minimally invasive spine surgical techniques, including improvements in implant technology, biologics, instrumentation and biomechanical considerations. In addition, the move toward outpatient spine surgical services may continue to grow as reimbursement and payers demand more efficiency, reduced cost and better resource utilization.


Kern Singh, MD. Co-Director of the Minimally Invasive Spine Institute at Rush (Chicago): 2018 will be the year of the robot in spine surgery. Almost every major spine company will have released their next-generation robot. Look for robots to do more than just help place pedicle screws. Navigation, surgical assistance and even help with the surgical decompressions are on the horizon.


Mick Perez-Cruet, MD. Director of Minimally Invasive Spine Surgery and Spine Program at Oakland University William Beaumont (Rochester, Mich.): The most important spine technology trend for 2018 will be the further development of minimally invasive spine surgery and stem cell-based biologics. The best opportunity for spine surgeons will be to bring cases into outpatient spine surgery centers in which they hold an equity stake.


Michael Musacchio, MD. NorthShore University HealthSystem's Neurological Institute (Evanston, Ill.): Technology is the game changer for spine surgeons and their patients, especially 3-D capabilities. A paradigm shift is in play; 3-D navigation has improved accuracy and safety of screw placement and the overall procedure. It has further advanced minimally invasive techniques and it reduces, if not eliminates, redo surgeries for screw misplacement. Robotics has better enabled the integration of 3-D navigation through software to aid in deformity correction. Deformity correction technologies include preop planning software, intraoperative assist devices, rod benders and more.


Dr. Brian Gill: I am interested in seeing how 3-D technology/printing capabilities will translate into implant design and function; whether this technology translates into quantifiable better outcomes remains to be seen.


Andrew Hecht, MD. Chief of Spine Surgery at Mount Sinai Hospital and Health System (New York City): The most important technology trends in 2018 are continuing to find the appropriate carriers and doses for the use of BMP-2 (Infuse) to minimize complications and yet harness its effective capabilities. In addition, spine surgeons continue to explore the appropriate indications for minimally invasive fusions for degenerative, trauma and deformity applications. Lastly, spine surgeons continue to define the appropriate indications for cervical disc replacement and how to minimize heterotopic ossification after TDR.


Jocelyn Idema, DO. Advanced Orthopaedics and Rehabilitation (Washington, Pa.): There is recent data with regard to lumbar disc replacement and a five-year follow-through that has shown highly favorable patient outcomes and reduction in overall healthcare costs due to a significantly decreased revision rate for adjacent-level pathology. As more insurance companies and hospital systems begin to align and recognize these significant changes in spine surgery, there will be more opportunities in the near future for improved quality of care.

Other innovative technologies, such as improved navigation systems, robotics and the various implant techniques, will continue to positively impact the spine industry in the future. It is important to note that although these technologies continue to change and improve, the spine industry must also balance the cost-effectiveness and value of these technologies, always striving for the best patient outcome and experience for the patient.


Dr. Todd Lansford: The most important trend in spine technology would be the continued integration of biplanar fluoro to navigation. I say this especially because the use of robotics is an expanding field; advances in imaging will increase the speed for robot procedures. Once navigation improves in speed and ease, robots will be used more frequently. The second trend I see is use of titanium/tritanium implants. This has shown superiority over PEEK and will gain in use throughout the year.

Thomas Schuler, MD. Founder of Virginia Spine Institute (Reston): The top two areas affecting spine surgery are artificial intelligence and arthroplasty. Both of these shift the paradigm of decision-making and treatment options. Artificial intelligence applied to robotic surgery simplifies surgeries, decreasing complication rates while enabling smaller, less invasive operations. These preserve more natural passive and active stabilizers of the spine, minimizing adjacent segment disease. Arthroplasty is achieving a similar outcome by protecting adjacent segments. Regenerative medicine is impacting nonoperative care and providing a new option for mild adjacent segment pathology.


Paul Slosar, MD. President of SpineCare Medical Group (Daly City, Calif.): The focus is now on surface technologies for fusion implants. The most sophisticated and advanced surface has a unique titanium nano-technology to stimulate the host bone to grow rapidly, promoting early osseous-integration. This should lower surgeons' dependence on expensive or inflammatory biologics. The porous implants may be better than smooth surfaces, but still lag behind in terms of stimulating a cellular response.


Dr. William Tally: The biggest technical change will be the continued rise of minimally invasive spine and the correlated transfer of spine procedures into an ambulatory surgery center setting.


Christian Zimmerman, MD. Saint Alphonsus Medical Group (Boise, Idaho): Advancements in onsite hardware creation may be a thing of the extreme future, but online custom-made hardware may realize a place in the implant market.


Opportunities for the future


Roger Hartl, MD. Director of Spinal Surgery at Weill Cornell Medical Center and Director of the Weill Cornell Center for Comprehensive Spine Care (New York City): The best opportunity for spine surgeons in 2018 is integration of spinal surgical care in the setting of multispecialty practice. The times of solo spine practitioners are over. Targeted minimally invasive surgery has lots to offer for most spinal pathologies. This requires, however, accurate diagnosis and effective aftercare, rehab and lifestyle modification in the interdisciplinary setting.


Dr. Todd Lansford: The best opportunities for spine surgeons will continue to be ASCs. We are expanding the types of cases and patients suitable to this environment. As spine surgeons, there is still growth in this arena, so the opportunities are quite plentiful.


Robert Masson, MD. Founder of Masson Spine Institute (Ocoee, Fla.): We have only scratched the surface of the [outpatient spine industry's] net potential to expand the outpatient spine arena on behalf of our patients. The payers have been difficult in opening outpatient panels for contracting, but all trends suggest outpatient cost reductions are a mandate, and I think this will improve the payer receptiveness toward outpatient contracts and believe progressive practices will continue to invest heavily in their outpatient capabilities.


Dwight Tyndall, MD. Private Practice (Munster, Ind.): Important trends are the growth of outpatient spine surgery, bundled payments and application of robot technology. The key business challenges spine surgeons will face this year are decreasing reimbursements and access to patients as narrow networks continue to grow. The best opportunity is to show value within bundled care and to capitalize on outpatient spine surgery as a way to contain cost while showing superior patient outcomes and satisfaction.


Sunny Uppal, MD. Glenwood Surgical Center (Riverside, Calif.): The next type of case that will move to the ASCs will include any case in which soft tissue dissection can be minimized. This will include minimal invasive techniques to place posterior pedicle instrumentation for lumbar fusions. The limiting factor [right now] in cases done at ASCs is soft tissue dissection and pain control.


Dr. Paul Slosar: Although it's been on the radar for several years, this may be the year that bundled payment models finally hit their stride. While CMS has adopted a more voluntary posture toward participation, that hasn’t discouraged interest in their Bundled Payments for Care Improvement program, now entering its third year. Commercial payers are following and, in 2018, some will begin with small, selective networks of spine specialists to grow their own risk-sharing programs.


Scott Blumenthal, MD. Texas Back Institute (Plano): The biggest opportunities for spine surgeons next year is social media and clinical research. The smartest way for young entrepreneurial-minded surgeons to begin their business today would be to offer a service that no one else does — maybe medical or a service such as an app for your practice or the ability to schedule or get answers to other inquiries digitally. Think of your future patients as millennials and how do they access other services?


Dr. Richard Chua: I believe that the integration of image guidance and robotics will be the next big thing in spine surgery over the next five to 10 years. The ability to improve accuracy of instrumentation placement, reduce X-ray exposure to the patient, surgeon and staff, as well as the ability to more efficiently correct deformities will result as robotics, engineering and surgeon adoption become more feasible.


Dr. Michael Musacchio: Over the next five years, we will see a full conversion to 3-D navigation in spine surgery, further simplifying procedures, and that will mostly benefit patients in need of correcting deformities. Meanwhile, 3-D printing and custom implants are providing a better fit for patients, resulting in potential cost reductions.

Dr. James Sanfilippo: Partnering with healthcare systems will allow surgeons to open more access for patients, especially in systems that are self-insured. Through centers of excellence, co-management agreements, or through clinically integrated networks, surgeons and systems can come together to also lower costs of care by reducing variations in preoperative, perioperative and postoperative protocols, reducing system waste and using data analytics to drive best practices. Partnering with vendors can also drive down the cost of care, but this requires both the surgeons and the system to be tightly aligned.


Dr. A. Nick Shamie: Stem cell therapy is still very experimental in the treatment of spinal conditions, but we look forward to regenerative medicine having an impact in the spine field in the way we treat our patients … and even perhaps being able to cure certain conditions.


Dr. Kern Singh: EHR will continue to take a toll on small or individual practices. The cost to keep these systems up to date, the numerous government mandated requirements and the loss in clinical productivity will continue to challenge small orthopedic and neurosurgical groups, forcing them into further consolidation with large health consortiums.


Dr. Vladimir Sinkov: Innovative and entrepreneurial physicians who value their independence will continue to thrive and adapt to the ever-changing landscape of medicine in the U.S. If things continue as they are, however, and if the government passes more laws that are aimed at destroying private practices, such as the ACA, fewer and fewer physicians are going to be willing to keep up the fight.

William Taylor, MD. Director of Spine Surgery at UC San Diego Health System: Pressures from payers will continue to stymie delivery of innovative care; this occurs through non-approvals and roadblocks to new procedures. Many institutions consider only costs that are partitioned into unchangeable sectors (operating room, hospital, instrumentation). They fail to see savings in other budgets and don't consider improved patient outcomes in decision-making.


Dr. Thomas Schuler: Data collection will lead big data and payers and industry to standardize payments and availability of devices. The problem comes from a negative impact on customized care. This data collection will lump care and not individualize it. In cancer therapies, the shift is toward customized treatment for specific genetic markers. Spine will go the opposite direction, with current attempts at data collection and payers' current desire to decrease utilization of essential treatments.


Dr. Christian Zimmerman: There will be a renewed interest in postoperative management and extramural services, such as home health and physical therapy, to assist patient recovery. Surgical approval rates (locally) have plateaued due to increased awareness of presurgical accomplishments or failure to significantly improve with conservative measures. Most large health systems have justifiably cut costs of implantable instrumentation to levels equitable to all companies with standing contractual agreements. Negotiations centered on further cuts may come with prospective agreements.


Dr. John Finkenberg: The best opportunity for spine surgeons should be to get more involved with their societies. Your career will pass by before you notice, and the accumulated national/international knowledge our colleagues have must be shared for the ultimate benefit of our patients.


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