The most dangerous trends in orthopedics and spine from 25 leaders

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The executives featured in this article are all speaking at Becker's 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference at the Swissotel Chicago.

As part of an ongoing series, Becker's is talking to healthcare leaders who will speak at the conference on June 15-17, 2023. The following are answers from our speakers.

To learn more about this event, click here.

If you would like to join as a speaker, contact Zoe McClain at

Question: What is the most dangerous trend in orthopedics and spine right now?

Adam J. Bruggeman, MD. CEO, Texas Spine Care Center (San Antonio): The most dangerous trend in orthopedics and spine right now is the continual erosion of autonomy and satisfaction with physician practice. Mental health issues are at an all time high with burnout being reported across all subspecialties. Some of this is due to the increasing amount of workplace violence as well as intimidation and inappropriate behavior by patients against healthcare workers. Consolidation of hospitals and physician practices has also contributed to a lack of satisfaction. The increasing burden of prior authorization and non-clinical duties have become overwhelming for many practices. 

Meanwhile, Medicare reimbursement continues to decline year-over-year. The short and long term ramifications of these changes cannot be understated. We need meaningful legislation to support the mental health of healthcare workers, tougher penalties on those who threaten to or actually harm healthcare workers, the repeal of the ban on physician owned hospitals, prior authorization reform, as well as long-term Medicare payment overhaul tying physician payments to an annual increase based on cost of providing care. These are lofty yet attainable goals if we can set aside our politics and endeavor to create a healthcare system that will become the model of quality and outcomes for the others to follow.

Corey Welchlin, DO. Owner, Center for Specialty Care (Fairmont, Minn.): The most dangerous trend in orthopedics and spine is allowing insurance companies to dictate our pay. We save them many thousands of dollars on each case being done in an ASC versus the hospital. We need a united process to argue our value.

Scott L. Blumenthal, MD. Orthopedic Spine Surgeon, Co-Director, Center for Disc Replacement, Texas Back Institute (Plano): The most dangerous trend is the term 'provider.' Physicians and surgeons being dumped into this overly broad term is yet another step to interfering in the physician-patient relationship. Ultimately, we are the only ones trained to advise patients to make the best decisions for their healthcare and health.

John V. Prunskis, MD, FIPP. Medical Director/Principal, DxTx Pain and Spine; CEO, Illinois Pain and Spine Institute (Barrington, Ill.): The most dangerous trend right now, not just in orthopedics and spine, is the continued erosion of physician reimbursement by CMS and Medicare. This year‘s cuts of over 4 percent on top of prior years cuts is offensive to physicians who risked their lives caring for patients during the COVID pandemic. It is offensive to physicians in the face of marked inflation caused by policies of the Biden administration. There is no other profession or group that has had its fees cut besides physicians. Every other profession has increased its fees.

Timothy Lubenow, MD. Anesthesiologist, Rush SurgiCenter (Chicago): One dangerous trend is the lack of third party coverage by commercial payers, including Medicare Advantage plans for several minimally invasive outpatient spinal procedures.

Mick Perez-Cruet, MD, MSc. Professor, Vice Chair, Department of Neurosurgery, Oakland University William Beaumont School of Medicine (Rochester, Mich.): The most dangerous trend in orthopedics and spine right now is loss of physician autonomy. This is due to independent private practices becoming too expensive to maintain while reimbursements for physicians services are being cut. As a result, private practices are forced to close and physicians are becoming hospital employees. This potentially moves physicians closer to a national healthcare system — the results of which can limit patient access to care, especially in higher cost areas of healthcare delivery such as orthopedics and spine surgery. 

One has only to look at our neighbor Canada to understand that national healthcare will result in less high quality orthopedics and spine surgery care and reduced access to specialty care. We all pay into the Medicare system. We all need to demand high quality healthcare when we need it. And elect individuals that support high quality healthcare.  

Thomas Scully, MD. Neurosurgeon, Northwest NeuroSpecialists (Tucson, Ariz.): The most dangerous trend, and it is one that has been ongoing, but is accelerating rapidly, is denial of surgeries or imaging by insurance companies. Just this week I had a lumbar fusion denied on a patient that has undergone multiple epidural steroid injections, facet blocks and three months of chiropractic care. Her imaging demonstrates a full centimeter of offset at L4/5 with spondylolysis. She has 6 mm of movement between supine and standing imaging.  Her everyday activities are impaired. Yet, her insurance company is demanding six weeks of physical therapy now prior to authorizing any form of surgery. 

We are short of the number of physicians needed in our community. Patients wait to get in to see us. Then, we tell them they have to do weeks of conservative treatment. It would be great if they could do the conservative treatment prior to their appointment. This is then magnified when we finally get someone who has exhausted a great deal of non-surgical treatment and they are impeded by their insurance company.

Sanjay Patra, MD. Neurosurgeon, Spectrum Health Butterworth Hospital (Grand Rapids, Mich.): The most dangerous trend is health systems not being aware of the value of spine care being provided to their patients.

Ravi Bashyal, MD. Vice Chair, Patient and Provider Experience and Director, Outpatient Hip and Knee Replacement Surgery; Clinical Assistant Professor, Orthopedic Surgery, University of Chicago Pritzker School of Medicine Northshore University Health System: The most dangerous trend in orthopedics in my opinion is the continued devaluation of historically successful procedures, such as hip or knee replacement by both Medicare and commercial payers.

The continued reduction in reimbursement for these proven procedures, especially in the face of inflation and standard cost of living increases, means patients will have decreased access to high quality orthopedic care to restore their mobility and well-being.

Ramy Elias, MD. Orthopedic Surgeon, Center For Advanced Orthopedics & Sports Medicine (Auburn Hills, Mich.): I would say the most dangerous trend is private equity taking over independent orthopedic and spine practices. This inevitably limits patient choices and interferes with the doctor-patient relationship. In addition, the costs to the healthcare system go up and oftentimes the quality and access to care decline.

Harel Deutsch, MD. Co-Director, Rush Spine Center (Chicago): I think in the past, hospitals provided some oversight over credentialing of surgeons and what surgeries they could perform.

Now with an increasing number of  spine surgeries in surgi-centers, that credentialing oversight can be missing. The result is that some doctors, such as anesthesiologist pain doctors, are doing spine surgeries that they are not adequately trained to do. Procedures that are not widely accepted are being done without proper vetting. This opens the door for poor outcomes, complications, and medical fraud. Credentialing of surgeons at surgical centers needs to be taken more seriously. 

Jacob Rodman, CMPE. CEO, Raleigh Neurosurgical Clinic (N.C.): I honestly think the most dangerous trend in orthopedics and spine right now is the inability for patients to receive the care they desperately need. More and more roadblocks are going up every day through administrative actions that are further separating the doctor from the patient. Patients are either not receiving the care they need or delaying it due to administrative burdens the payers are placing on patients and health systems. 

William Tally, MD. Specialist in Minimally Invasive Treatment, Athens Orthopedic Clinic (Ga.): I see two trends that worry me. The first is the continued progress toward hospital  bureaucrats making decisions to our exclusion — minimal vendor contracts being the most obvious. Hospital management limits new technology and cost by having middle bureaucrats say no. 

The second is the worsening trend for insurance, Medicare included, to ration healthcare.  Obviously it’s not worded that way as it would cause immediate pushback — but how else would you characterize the worsening trend of surgical delay by avoiding approval or denial? It's an unending stall tactic by requesting an ever growing listing of the patients care and history be elucidated. They have all that information, but by putting the burden on providers they avoid outright responsibility for delays. That is rationing under another name. 

Brian R. Gantwerker, MD, FAANS, FACS. Neurosurgeon, The Craniospinal Center of Los Angeles: The most dangerous trend in orthopedic and spine surgery is by far and away the cutting of reimbursements. If you could draw a timeline in reverse, one would see that a lot of the current trends, including loss of access to the specialty by patients, the acquisition of practices by both hospitals, insurers and private equity firms, all kind of lead back to reimbursement.

For the last 20 years, the centers Medicare has decreased reimbursements for are mostly, if not all spine surgeries. This was done in the name of cost cutting and simultaneously demanding better and more reproducible results. Unfortunately, many of our thought leaders in an effort to appease the unreasonable bureaucrats of this organization, made quality improvement a velvet hammer. And while we were all trying to do better, and have better outcomes — we accepted less money in return. I believe the acquiescence to this downward pressure, and a race to the bottom is ultimately the current and past most dangerous trend in our field. 

My sincere hope is that physicians in general can organize and push back and show that we have not saved money and healthcare by cutting physician reimbursements, as they are a relatively small piece of the pie. As always, the cost of insurance, medications and hospital bills remain the largest cost centers. 

Pharmacy benefit managers are basically working in legalized kickback schemes to enrich Big Pharma. Hospital CEOs are making well over seven figures each year while not supporting the very people that keep the lights on. Also, if you see the tens if not hundreds of billions of profit the insurers are making on such ineffective and wasteful plans such as Medicare Advantage, while simultaneously receiving large subsidies from the government, there is little doubt where the following money leads.  

Corporate welfare has always been the enemy of cost saving in healthcare. Ultimately, I believe hospitals will become too big to fail and will require further handouts. I am not sure where that leaves our patients, but it isn’t pretty. 

Eric Mehlberg, MD. Pain Medicine, Comprehensive Pain Specialists (Broomfield, Colo.): The most dangerous trend is payers picking and choosing — and sometimes intentionally ignoring — the most current science to support their non-coverage of treatments. This is driving patients to pursue more dramatic options namely opioids and extensive surgery. A few examples come to mind: total disc replacement, Medicare no longer covering SIJ RFA and basivertebral RFA.

B. Bus Tarbox, MD, MBA. President, Columbia Orthopaedic Group (Mo.): The most dangerous trend in orthopedics today is the encroachment of insurance companies into the patient-physician relationship. Over the course of the last several years, insurance companies have increased the number of preauthorizations and denials. This has resulted in a significant increase in peer-to-peer reviews. Insurance companies are now making medical decisions without any medical liability for treatment. This encroachment and increased preauthorization and peer-to-peer review burden has delayed care and ultimately hindered the care of the patient. If physicians are not patient advocates and spend the extra time doing this work for their patients, they will not get the care they need or the medications that have been prescribed. 

As this workload has increased and has entered into the clinical space, insurance companies then brag about their multimillion-dollar quarterly profits. This is not because they are making good investments, this is just denial of care. Unfortunately, the unintended consequence of this increased burden has allowed for the ability for private equity to now migrate into healthcare as physicians are burnt out. Now with private equity entering into the field, physicians have now given up some autonomy to determine the appropriate care for the patient due to pressure from the private equity firm to meet quotas as opposed to delivering great patient care. 

Carmen Quatman, MD, PhD. Orthopedic Surgeon, The Ohio State University Wexner Medical Center (Columbus): The most dangerous trend is the continued ability of payer source driving clinicians ability to order appropriate tests and procedures. Continued regulations of denials and peer reviews are critical to allow for patient quality and safety. Without appropriate coverage and lengthy denial processes, patients can have precipitous decline in health and potential long term harm.

Riley J. Williams III, MD. Professor of Orthopedic Surgery, Attending Orthopedic Surgeon, Hospital for Special Surgery, Weill Cornell Medical College (New York City): The most dangerous trend is primary repair of anterior cruciate ligament injuries in young pivoting sports athletes.

Albert Wong, MD. Neurosurgeon, Cedars-Sinai Medical Center; Neurosurgeon, DOCS Health (Los Angeles): The most dangerous trend is for the younger generation of surgeons to be heavily dependent on technology. While navigation and robotics have decreased the required skill level for spinal instrumentation, the dependence on technology can lead to a loss of understanding of spinal anatomy and surgical technique.  

Not uncommonly, some hospitals do not have the newest navigation or robotics. Or sometimes the equipment is unavailable or out of service. Similar to when GPS is unavailable, a driver should still be able to navigate their way home with a basic road map. Surgeons should maintain their ability to troubleshoot and perform surgeries when the newest technology is unavailable. 

Katherine Wagner, MD. Neurosurgeon, Ventura Neurosurgery (Calif.): I am concerned about insurance companies demanding peer-to-peer authorizations, constant clarifications, and generally interfering with my ability to provide safe and efficient care for my patients.

Zeeshan Tayeb, MD. Owner, Pain Specialists of Cincinnati: One of the most dangerous trends from my perspective being an interventional physiatrist and in the space of regenerative and optimization medicine is operating on those who are not in the best of health. 

Over a 100 million Americans have a chronic medical condition and are in pain for some reason or another. Billions of prescriptions are being filled for different conditions, ailments or both. The majority of these prescriptions mask the symptoms and extend life, but are not enhancing the quality of life. Furthermore, when an individual like this undergoes an operation or procedure, the outcome is typically suboptimal. 

Going back to basics, nutritional and hormonal optimization alongside some exercise would make a drastic difference in mitigation for these types of operations and procedures, or at the least improve outcomes.

Troy Morrison, DO, FAOAO. Orthopedic Surgeon, Citizens Memorial Healthcare (Bolivar, Mo.): The most dangerous trend in orthopedics and spine today is the growing lack of accountability for payers. Unfortunately, policy makers and our national associations have contributed to a lack of competition and oversight for insurance companies. This environment has left hospitals, physicians and most importantly the consumers completely powerless.

Daniel Mulconrey, MD. Orthopedic Surgeon, Midwest Orthopaedic Center (Peoria, Ill.): There will always be 'dangerous trends' as we continue to care for the spine patient in the post-pandemic era. One major concern in 2023 is the constriction of the workforce that is altering all aspects of patient care.

Difficulties with patient access to care, inpatient and outpatient nursing, and anesthesia are a few examples of this workforce issue affecting surgeons and patients across the United States. 

A dangerous trend would be for spine surgeons to become complacent in their approach to the care of the patient. We need to continue to stay vigilant with regards to quality, access to care and patient satisfaction. These workforce restrictions place pressure on the spine surgeon and treatment teams. These issues create an obstacle which can make the delivery of the best care difficult. 

Prior to the pandemic, many of these basic aspects of patient care were presumed and accepted. In 2023, the spine surgeon will need to refocus on the delivery of care and strive for patient satisfaction and quality in the post-pandemic era.

Joshua M. Rosenow, MD, FAANS, FACS. Director of Functional Neurosurgery, Professor of Neurosurgery, Neurology, Physical Medicine, Rehabilitation, Northwestern University Feinberg School of Medicine (Chicago): The most dangerous trend in spine surgery may be overenthusiasm for the ASC setting for spine surgery. We have certainly learned much about how to do many types of spine surgery safely in the ASC setting. However, we need to not box ourselves into a corner with this enthusiasm such that we lose the flexibility from insurers to decide that certain procedures can only be done in an ASC. Physicians need to have the ability to choose the right procedure for the right patient in the right clinical environment.

William T. Pennington, MD, MHA. Orthopedic Surgeon, The Orthopedic Institute Of Wisconsin (Franklin): Labor shortage with increased cost of labor and decreasing reimbursement has led to a crisis in maintaining clinical staff levels at optimal numbers to provide high quality care safely at many facilities. This crisis is affecting independently owned organizations as well as those facilities owned by the large health organizations.

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