2 payer tactics making life hard for spine providers — Drs. Robert Bray and Srdjan Mirkovic weigh in

Alan Condon -  

Spine surgeons are finding it increasingly difficult to get commercial payers to pay for spine-related inpatient services, and changing preauthorization hurdles continue to plague the specialty.

During Becker's 18th Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, two spine surgeons discussed the biggest challenges facing their practices and how they are addressing them.

Below is an excerpt from the conversation, slightly edited for clarity. To view the full session on demand, click here

Question: Outside of the pandemic, what are the major challenges for your practice?

Srdjan Mirkovic, MD. Northshore Orthopaedic & Spine Institute (Chicago and Skokie, Ill.): The major challenge has been getting surgeries approved or getting imaging studies approved, at least in Illinois. We've seen an increased reluctance to pay for spine-related services, so we're spending more time on different sorts of peer reviews. It goes down to authorizing or not authorizing MRIs, fighting through the MRIs, getting them approved and then justifying surgeries. Obviously, that is very time-consuming.

One of the things that we're also seeing is that some of those services get turned down very close to the surgery, which is a huge inconvenience to the patients and to providing healthcare in general. We would certainly like to see that a little bit more streamlined, but among all the challenges right now, I think there is a higher chance of delivering care in a timely fashion based on payers' comfort in paying for the services.

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): I think we have two major challenges. One is the staff and nursing shortage. There's so many nurses being so heavily taxed during the pandemic. Maintaining and trying to deal with the staffing with the rapid increase in volumes has been a difficult challenge. Hopefully that will stabilize more in the future.

Our other challenges are getting the payers to understand over the last few years the differences in complexity. It's much easier with hips and knees because of these sort of yes or no decisions. But with spine, it's such a complex field, and there's so many decisions to be made — so many ways in which a surgeon can handle the case. It's been standardizing those to a fashion that allowed us to take it to a different payment level.  

It really requires knowing your variability and knowing your case costing down to the penny what things cost, but also knowing the variability amongst your surgeons — which surgeon uses which implants, how many implants or biologics they use, utilization rate — and linking all that to their outcomes. So, you really have to dive in very deeply to both your staff and your surgeons, but once they're a part of it, then you get that buy-in and understand that process. It was a little rough putting that in place over the first few years, then getting enough data to show the payers that it worked and now getting them on board. In our state, at least, they have expressed tremendous interest in expanding it now.

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