'Practicing medicine is an art, not a cookbook': What we heard in July

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Spine and orthopedic experts and leaders in July spoke with Becker's Spine Review on topics from smart knee replacements to bundled payments.

1. "The proposed decrease in the Medicare Physician Fee Schedule for 2023 (i.e. the relative value unit conversion factor) will very likely have an adverse impact on timely access to care for nonemergent orthopedic conditions in the Medicare insured population (approximately 60 million people), at least in the near term. Issues surrounding the proposed decrease are analogous to the problems encountered with the sustainable growth rate that led to annual emergency congressional funding of CMS payment cliffs. Understandably, there are numerous pieces to this economic puzzle (an aging population, a projected end date for the Medicare Part A Trust Fund, healthcare consolidation/integration, changing value-based care models, expensive tests and treatments and patient and clinician expectations). I support the voices of leaders in our medical and surgical societies to avoid a decrease in the Medicare conversion factor. The Medicare Access and CHIP Reauthorization Act of 2015 may need an overhaul." —David Kalainov, MD, of Northwestern Medicine in Chicago, on CMS' proposed physician pay cuts.

2. "The limitations in smart implants in orthopedics is identifying the right data at the right time and having it delivered in real time back to the right person so a timely clinical decision can be made that can impact patient outcomes. That is not an easy feat, but smart implants do have the benefit of removing patient compliance issues as well as optimized data integrity from being implanted in a fixed position rather than placed on skin surfaces." —Peter Sculco, MD, of New York City-based Hospital for Special Surgery, on smart knee implants' setbacks.

3. "It will be difficult for an independent practitioner, as they do not have infrastructures or supportive systems like the bigger groups or hospitals. I have been collecting outcomes on my patients to prepare for this. However, we have to have a fair price, as there is no one-size-fits-all. Practicing medicine is an art, not a cookbook. We have to consider each patient regarding their comorbidities. We also have to weigh what technique, implants, biologics, navigation, etc., are utilized for surgery. If value-based care was truly value-based, commercial payers and CMS would not continuously look to pay less for the same or better outcomes." —Issada Thongtrangan, MD, of Microspine in Scottsdale, Ariz., on how spine surgery will develop in an era of value-based care.

4. "The concept of bundled payments sounds great. Reward those who are most efficient. This might work in joint arthroplasty where the surgeries are more uniform. However, spine has such variability in the procedure that it’s hard to compare a TLIF to another TLIF. They need to be extremely specific. Another part of bundled payments that was shown to be flawed in arthroplasty was the payments should also be based on patient demographics. Pay less for the chip-shot patients, but pay more for those that multiple studies have shown will have a higher chance of complication and readmission." —Chester Donnally, MD, of Addison-based Texas Spine Consultants, on bundled payments in spine surgery.

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