How value-based care is changing in spine: 9 surgeons weigh in

Practice Management

Nine spine surgeons discuss opportunities and inefficiencies in value-based programs and project how care models will evolve.

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 is the most exciting technology in spine?

Please send responses to Alan Condon at by 5 p.m. CST Wednesday, April 28.

Note: The following responses were lightly edited for style and clarity.

Question: How do you see value-based care developing in spine in the next two to three  years?

Alexander Vaccaro, MD, PhD. Rothman Orthopaedics (Philadelphia): In the next two to three years, value-based care will change due to the rise of popular bundle payment scenarios and the beginning of population health management paradigms. Bundle payments today should be reflective of diagnosis-related groups, which can vary drastically. The average DRGs for cervical and lumbar surgical cases vary significantly, from $11,000 to over $100,000 for the same diagnosis, yet these differences in costs are not reflected in current CMS bundled payment reimbursement schemes.

Value-based care must better align with specific CPT coding, as there is great variation in surgical procedures, especially in deformity surgery, where number of levels or complexity is not factored into bundle reimbursement. Costs also vary dramatically across locations, yet the impact of geography on reimbursement is not fully factored into CMS bundle cost. Lastly, technology advancements, which may result in improved patient outcomes, is actually penalized financially, as it is considered an additive cost, which is actually counterproductive to value-based healthcare.

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): Value-based care is developing very rapidly in spine. We have set up a global payment model where we perform a case for a set fee. We receive one price-negotiated check from the insurer and pay the surgeon, the assistant, anesthesia, center implants and any bills that result from that event of care. You have to know and be very comfortable with your case costing to do so, and know how few variances from the norm you have.This technique of billing has been very popular with insurance agencies, and we now work with the major four insurers in the state of California, with this now representing the majority of our billing. The patients love it.

One copay or deductible paid once, and then they are literally out of the billing cycle, signing a piece of paper when they arrive, saying that they will not be billed by anyone — complete transparency to the end. If you are experienced and contain your costs, there is a good profit to be made in this, but it requires efficiency of care and repeated good outcomes. We have not extended this yet to other outpatient areas, such as imaging and pain management blocks, but our next step is to incorporate those into this global management system. This transition of billing all in network on a global basis has caused a very rapid expansion of cases within our structure over the last two years, and we expect it to continue to do so. I believe you will see it start to move across other centers very rapidly over the next two to three years. 

James Mok, MD. Northshore Orthopaedic & Spine Institute (Skokie and Des Plaines, Ill.): In the short term, I believe the major changes will be in site of service and documentation. There will be a major shift in spine surgery to the outpatient setting, whether it be ASCs or hospital outpatient departments, because they are lower cost. As providers get a handle on value-based care programs, there will be stricter emphasis on documentation and coding to fully capture the complexity — and therefore risk adjustment — of a patient's care. Neither of these represent a big change in surgeon behavior, but they set the stage for what comes next, when value-based care gets bigger. That's when surgeon practice patterns may be challenged.

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): The traditional definition of value is quality over costs. While this definition will always stand true, there will be an evolution on what it means to deliver value-based care. As more information becomes available online, patients will seek medical care that is convenient, reasonable cost, high quality and a good experience. Delivering medical care won't be enough for providers. Spine care providers will have to ensure they are able to meet the other value propositions (convenient care, reasonable cost, high quality, great experience).

Richard Kube, MD. Prairie Spine (Peoria, Ill.): As costs continue to rise, the self-funded, self-insured businesses are becoming educated regarding cash-bundling options. As this occurs, more cases will move to ambulatory settings. With the groundwork laid by the folks at Surgery Center of Oklahoma City, and the advent of groups like Health Rosetta, more people are becoming aware of value options they never believed existed. It is frequently cheaper to fly an employee out of town to a place like Surgery Center of Oklahoma City or our facility, Prairie SurgiCare, to have surgery and fly home than it is to have that treatment done in one's hometown. 

Our compilation of local explanations of benefits has shown an average of $80,000 saved per each spine surgery performed for employees of self-funded, self-insured health plans. This is a great opportunity for those businesses struggling with rising health costs. Likewise, it is a great source of savings for local and county governments, along with many unions. Health-sharing groups like Samaritan Ministries and Sedera also benefit from the value found when using these value-based providers. Increasing numbers of cases will move into these arenas, and we will see small hubs develop where these free-market health delivery concepts are thriving.

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: I believe that value-based care was and is a nebulous, ill-defined, and generally failed effort. What is becoming apparent is that value-based care was a thinly veiled attempt to justify lower reimbursements. We have to see the touted transparent benchmarks for "making the grade." Call a meeting with the stakeholders, and ask them: "What does value-based care in spine surgery look like?" A room of furrowed brows and quizzical looks will fall over the crowd. What is it? What is it worth? The lack of definition and tangible goals is the reason it continues to not work. If value-based care was truly value-based, the payers and CMS would not continuously look to pay less for the same or better outcomes.  

Andrew Hecht, MD. Mount Sinai Health System (New York City): Value-based spine care has been on the horizon for many years. Spine surgeons must organize and provide leadership for the most basic procedures and push back against complex procedures being included in any type of bundle payment or value-based model.  

Burak Ozgur, MD. Hoag Neurosciences Institute (Newport Beach, Calif.): We all have to care for the total value of treatments and outcomes. The big picture must be taken into consideration. Included in this is the proper diagnosis and effective treatment, which includes a multidisciplinary collaborative approach across all spine disciplines such as pain management, physiatry, physical therapy, neurology and surgery. We all should be held more accountable for objective patient outcomes. The cost of care should be taken into consideration with these objective outcomes, and thus the value of effective care is more appreciated.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): 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 the outcomes on my patients to prepare for this in the future. 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 in what technique, implants, biologics, navigation, etc., are utilized for surgery.

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