From higher reimbursement payments to better payment models for new procedures, here are the key changes orthopedic and spine surgeons hope to see from payers in 2023.
Question: What changes do you hope to see from payers in 2023?
Editor's note: Responses have been lightly edited for clarity and length.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: What everyone I think wants to see, is that the gaming and stretching doctors to their limits will ultimately result in payer demise. For the last 10 years, we have seen record profits from all the insurers. They are all jockeying to be the final purveyor of a nationalized healthcare system. Those who are advising the administration on what is good for the health of our nation are the same people ghostwriting pieces for the same insurers. They then cried out that "the cost of care was going up" and promptly got more subsidies from the government to fund their narrow network Medicare Advantage plan. They then posted record profits.
There is no magic solution to control costs, but allowing insurers to dictate how doctors treat patients, then not paying for the treatments, and then raising premiums for those patients and posting record profits will lead to their implosion and very likely a seizing up of our healthcare system. Without a doubt, many policy wonks and politicians will scramble to understand why it happened, when they were told what to do by these insurers, whose only motivation was shareholder profit.
Lali Sekhon, MD. Reno (Nev.) Orthopedic Center: I would like to see payers not let reimbursement be reduced in the same fashion that CMS reduced physician payments. Payers slyly peg payments to Medicare rates and take advantage of CMS decisions to reduce physician payments: "It's not me, it's them." The reality is that as publicly traded entities, payers have a primary fiduciary duty to shareholders. Their mission is profit. They will continue to delay, deny and defer. Their CEOs and boardrooms will continue to be paid handsomely. It's naive of providers to think they will behave otherwise. There is also no Santa Claus or Tooth Fairy, and in the same fashion, payers will never pay us more than they currently do.
Peter Derman, MD. Texas Back Institute (Plano): I hope that payers will "see the light" and increasingly appreciate the benefit of disc replacement over fusion in appropriately selected cases. While some progress has been made, we continue to struggle at times to obtain approval for multilevel or hybrid constructs, which are often the scenarios in which the incorporation of arthroplasty can make a huge difference to the patient. The fact that no FDA study has been performed for these situations is a matter of limited resources and not a reflection of a lack of clinical effectiveness. There are non-investigational device exemption studies supporting the use of arthroplasty in these settings. Approval for lumbar disc replacement continues to lag behind that of cervical arthroplasty. I hope for the benefit of our patients that this changes over time.
Thomas Loftus, MD. Austin (Texas) Neurosurgical Institute: In an ideal world, I would hope to see the pre-certification process eliminated completely. In the world we actually live in, I would at least hope for a paring back on the pre-certification process. The number of peer-to-peer phone calls continues to rise and the nature of the denials continue to become more arbitrary and non-scientific. There should be more value placed on the surgeon decision-making process and their interactions with the patient rather than the enforcement of random, ever-changing guidelines. It would be nice for payers to value patient outcomes and satisfaction over corporate profits.
Secondly, there needs to be a significant increase in reimbursement for all procedures to keep pace with the extraordinary inflation. We do not have the luxury of pass-through expenses in our collections, and therefore rely heavily on all payers keeping pace with inflation in order for us to remain solvent.