How emerging spine surgeons, value-based care can win

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Hyun Bae, MD, has his eyes on the evolution of outpatient spine surgery and value-based care. And one key element to their trajectories will be physician control.

Dr. Bae is one of the leaders for Los Angeles-based Commons Clinic's new Center for Spine Economics, Outcomes & Research. The center is investing $100 million over the next decade and will introduce a center of excellence program for spinal restoration. 

He spoke with Becker's about why spine surgery is best fit for the outpatient center and his outlook for value-based care in the industry.

Note: This conversation was edited for clarity and length.

Question: What are your top goals with the new center?

Dr. Hyun Bae: Improving patient care is our biggest goal. It's really patient care and delivery and how to do that in the most effective and efficient way. Ultimately this is about the spine, and we do feel that spine surgery is making a big push to the outpatient setting because our new technology and minimally invasive surgery is allowing that. It's really trying to deliver the best care in a local setting by the physicians that you would get at major academic institutions. So it's the best physicians, best care in a local, very friendly setting that's basically all patient centric, oriented toward efficiency and quality.

Q: Are there any interesting projects that you have on the horizon that you're excited about?

HB: One of my biggest focuses is more non-fusion and motion preservation technology. It's more about spinal restoration than fixating and fusing the spine. And a lot of those technologies, which some of them have been around for 20 years that just haven't really been adopted, but a lot of those now are coming through the pipeline. I think these motion preservation technologies can be best delivered in the outpatient setting. It shouldn't be done in the hospital because we're not fusing patients, and fusion is a very morbid procedure. But what's amazing is if you're trying to restore the spine and the physiology of the spine and the fact that the spine moves, it actually in itself is easier and it's less invasive. All these newer procedures are geared really for fast recovery, minimal invasion, and we don't want to fuse the patient. We don't want to brace the patient. We want to get the patient back to being active. For us that's a big focus. It's really kind of a paradigm shift in spine surgery. 

If you fuse a 40-year-old, and sometimes you have to, it's a very episodic care. The problem is what happens in the long term. For us we really want to focus not on just the episodic care, but really what happens in the long term. So for a 40-year-old if you fuse the patient, certainly there's an impact. If you're able to do a procedure where you don't have to fuse the patient, there's less of an impact. You're mitigating the fusion impact, which is fantastic. 

It's certainly a good argument. But conversely that argument is the same for a 60-year-old. I actually think 60-year-olds can benefit more. The impact for a stiff spine where you can restore motion in a 60-year-old is way greater than a 40-year-old, because the 40-year-old can really compensate. A 60-year-old can benefit more from motion-preserving spine surgery because you can take a stiff spine and you can make it mobile. 

All of this type of thinking is not best done in the hospital. A lot of these new technologies are going to be driven in the outpatient center because the hospitals don't want to pay for them, and there may be some insurance issues. They may be too expensive in the hospital, and we're going to be able to do this much better, much more efficiently in the outpatient center.

Q: How would you describe the state of value-based care in spine today, and where do you see it heading in the next decade?

HB: There's two things about value-based care. One is trying to drive down costs. We want to be able to deliver the most quality of care the most efficiently. That is really done by having the physician in control so there's truly value-based care. A value-based care is we really want to drive down costs and be very efficient and make sure that we deliver great quality. But how do we do that? 

We want to do it with the physician in control. Not the hospital in control and not other third parties in control, but really the physician in control who takes ownership and somewhat, we say, the risk. I'm not sure if that's the right word for it. But value-based care is typically tied to bundles. So there's a certain fee or a metric that we're trying to get to. The best way we can do that is really trying to have the physician take ownership. The physician and the patient are both equity holders and making sure that we make the right decisions for the patient. That drives the best quality, the best outcome and hopefully we can actually save the cost of their healthcare system.

Q: What advice would you have for other independent spine surgeons who might be having trouble keeping afloat with economic headwinds? What advice would you have for them to still be able to deploy this type of value-based payment model and thrive?

HB: Well for a young spine surgeon it is pretty difficult. We're seeing that most of our young spine surgeons are getting hired by hospitals. I think that is just the trend. If you asked what would be the most advantageous for independent physicians, obviously they have to maintain control of this health pathway. 

It's a battle because hospitals want to maintain control, and we know that the care delivery model for most spine surgery now is best in the outpatient center. Eighty percent of spine surgery can be done in the outpatient setting. Now it's a matter of who controls that. 

I think that's where I would focus. The downsides are it's very hard to negotiate contracts as an independent physician. You have to have some type of leverage like hospitals do when they're negotiating contracts, so that's very difficult. But I think that your leverage that you have is that you typically are in control of the healthcare choices. If you can maintain that and get into a value-based bundle, whether it's a surgery center, or joint ventures with hospitals — if you can somehow maintain that control and participate —I think that would be the best recommendation.

Q: You mentioned this trend of young surgeons going toward hospital employment. What do you think it would take to reverse that trend and encourage young spine surgeons to go into private practice?

HB: I don't know. I think that that's tough right now. I think that for a young spine surgeon, the best thing that they can do is join a very powerful, independent, well-run physician group. There are many out there. But that's where I would say they would do the best. If you said, "I'm a young spine surgeon. I just want to go out and hang a shingle by myself." I think that's okay. But you probably would have to do that in a very underserved area, where you can have some leverage because you're coming in and there's really not much spine care around and you can use that. Otherwise, I think that that's very difficult. I think the best bet for a young spine surgeon, if they do not want to join a hospital-based practice, is to find well-run independent physician groups ,and I would say that you know they have their own building, their own ancillary, their own surgery center, whatever it may be. But they really manage this independent practice quite well for the future.

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