AI, Ozempic and noncompetes: The trends to watch in 2024


As 2023 comes to a close and orthopedic and spine specialists, CEOs and administrators nationwide are setting their sights on 2024, there are a few key trends that the majority of industry professionals are focusing on. 

From the development of new artificial intelligence capabilities to the impact of glucagon-like peptide 1 receptor agonists on patients and physicians, here are the key trends that 27 musculoskeletal leaders are watching. 

Question: What are the top one to two healthcare trends you are watching right now? 

Andrew Lovewell. CEO at Columbia (Mo.) Orthopaedic Group: I continue to keep my attention on the staffing shortages that exist in critical roles in the healthcare space today. Obviously, anesthesia has been a hot topic discussion the last two to three years and I don't see that getting better any time soon. We have moved to a fully integrated model in our practice where the anesthesia staff are employed through our group practice. This created stability with insurance benefits, better contracts and a more marketable pay range. We are lucky to have the staff that we do in our ASC and are looking to grow our anesthesia service line in our market. Another trend that I am watching is the continued evolution of AI and large language models in the healthcare space. At this point, the jury is out on the full use case in many settings that we work in today. There is a lot of excitement and discussion about the future of medicine and the way it will look given this technological boom that we are experiencing. However, I don't look for things to change as rapidly as some are predicting. Healthcare has been one of the slowest adopters of evolving technologies or principles due to the regulatory burden and the cost curve that exists. If we could find a way to bend the cost curve on cutting-edge technologies, I would expect the deployment and use of AI and large language models to increase exponentially. In fact, as more companies develop AI, machine learning, and LLM I do believe we will see the cost burden lessen as things become more of a commodity in our space. 

Brian Curtin, MD. Orthopedic Surgeon at OrthoCarolina Hip and Knee Center (Charlotte, N.C.): Healthcare trends that have potential to really change the way we do our jobs on a daily basis include the integration of AI and quantum computing into decision-making as well as more individualized specific patient care. The rapidly occurring shift to the outpatient ambulatory care setting for most orthopedic cases is also likely to influence payers, patients and hospitals for years to come. Things don't necessarily move quickly in healthcare, but these trends are really moving the needle and forcing the field to prepare and adjust accordingly.

Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: The top healthcare trend currently that I am watching is the egregious behavior by insurance plans.  Many plans are hiding behind the Employee Retirement Income Security Act, which effectively allows them to do just about anything to our patients and get away with it. The medical determinations the insurance companies make, like not approving surgery, that lead to an adverse outcome for the patient not having the procedure, are basically protected. Clawing payments back, incorrectly paying line items and many other bad behaviors and the insurers thumbing their noses at the patients and physicians has gone unchecked since ERISA was enacted in 1974. What I predict is that this law will be scrutinized and revised so that patients can finally pursue their care and get what they pay for from their insurers. If a new era of accountability is not enacted, the current system will likely slow-motion implode and we will be propelled toward single payer, which will result in zero choices for our patients. 

Choll Kim, MD, PhD. Spine Surgeon at Excel Spine Center (San Diego): I am excited, hopeful and also a bit scared, for a wild and crazy 2024. There are three areas of profound interest to me. First and foremost is endoscopic spine surgery. I have been diligently working in this area for almost 20 years, but in the last two years, I have noticed a palpable change in the environment. There is now a small cadre of young spine surgeons who have embraced this technology, and have become evangelists. The field of endoscopic spine surgery is on the verge of a tipping point, and will soon be like knee and shoulder arthroscopy. Everything, everywhere, all at once. …The other two areas are social media and of course AI. Social media has dramatically changed my practice. While it has been a very effective way for patients to find me, its greatest impact has been on how I educate my patients, their families and their referring providers about spine issues. For my patients, information provided in a non-boring video format is far more engaging than printed material or content from an anonymous person, even if done professionally. It is second only to the personal one-on-one interaction. I plan on improving my social media program with the goal of providing meaningful content in an engaging way, without going off the deep end of the social media slippery slope. Finally, I am scared, but excited at the same time, about the potential impact of AI in medicine. The first example of its use for me would be to create an AI avatar of myself who could answer the multitude of highly redundant but important questions posed to me and my staff. This "Choll Kim AI" would be infinitely patient, perpetually available and never get tired of saying the same thing over and over again. I am looking forward to a wonderful 2024. 

Dan Chen, MD. Assistant Professor of Orthopedic Surgery at Geisinger Commonwealth School of Medicine (Scranton, Pa.): I'm watching how spine practices and hospitals will respond and adapt to decreasing insurance reimbursements. I think part of the solution will be to move more spinal procedures to the ASC setting. This practice migration will be supported by evolving minimally invasive solutions that can provide our patients with less postoperative pain and faster rehabilitation. 

David Sohn, MD. Chief of Shoulder and Sports Medicine at the University of Toledo (Ohio) Medical Center: Physician burnout is a trend that we are seeing and trying to deal with.  Electronic medical records have not only made documentation and ordering more difficult but has also made the physician more available to patients, billers, compliance officers and hospital staff. It is not uncommon to have 75 requests in a day on top of the physician's normal workload. This has been cited as the No. 1 cause of physician burnout, and physicians are looking to see how organizations are dealing with it. Some organizations are supporting physicians by providing nurse practitioners who can answer the bulk of these questions and allow the physician to work "at the top of their license." Others are charging patients nominal fees for their MyChart questions. Still others are paying physicians for the extra time needed to answer all these queries. How organizations are choosing to support their physicians is a trend I am watching right now.

Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: One is the physician business model. Will providers continue to be in private practice, employees of a healthcare system, or involved with private equity? Furthermore, if the physician noncompete clauses continue to trend out of favor, I sense the whole physician employment model may be reset back to the private practitioner. Second is technology. As newer techniques evolve, e.g., robotics in orthopedics, will the U.S. healthcare system continue to pay for unproven technologies? The literature isn't definitive in terms of robots in total joints. Will the insurers pay for preoperative studies only required by these same technologies? Will hospitals purchase these same pieces of equipment?

Eric Schnapp. CEO of Mays & Schnapp Neurospine and Pain (Atlanta): We have been successfully rebutting the trend of escalating administrative burdens placed on providers. Rather than succumbing to the pressure and opting for hurried patient interactions, we have successfully countered this trend by implementing strategic administrative best practices, from billing, accounts payable, operations, human resources and marketing, to employing a dedicated EMR team to make the software work for our providers. This commitment to efficiency enables our providers to focus more on what our patients keep coming back for in ever-increasing numbers — the high-quality, personalized care we deliver.

Gregory Howard, MD. Orthopedic Specialist at Major Health Partners (Shelbyville, Ind.):  I like to keep an eye on new developments in healthcare, so narrowing the field to two will be an exciting challenge. These two trends immediately come to mind and I believe that both will be impactful in the short and long term.

1. Chronic subclinical inflammation management will drive the future of modern healthcare delivery — provided we all accept that we need to change. To this end, a growing number of physicians, scientific researchers, as well as the general public are becoming more aware of chronic inflammation being one of the most important causes of acute and chronic disease. Armed with this knowledge, a forward-facing healthcare community needs to adapt care delivery to reverse this insidious process.

2. Vertical integration of healthcare delivery systems. If one chooses to view the delivery of healthcare within the lens of a fair market economy, every part of the system will be harmed by the winnowing of choice and options for healthcare delivery, except for the owners of the vertically integrated system. Those harmed by a smaller competitive pool include providers of healthcare, medical specialty groups, hospitals, small or independent pharmacies, extended care facilities and most importantly the patients (who ultimately include all of us and our loved ones).

James Loging, MD. Orthopedic Surgeon at Palmetto Bone and Joint (Chapin, S.C.): In the dynamic landscape of healthcare, orthopedic surgery stands at the forefront of innovation and transformation. As we step into the future, two prominent trends are shaping the way orthopedic surgeons approach patient care and treatment methodologies.

1. Advancements in minimally invasive techniques: Orthopedic surgery has witnessed a paradigm shift with the evolution of minimally invasive techniques. Traditionally, many orthopedic procedures involved large incisions, leading to prolonged recovery times and increased risk of complications. However, recent advancements in technology and surgical approaches have paved the way for minimally invasive surgeries. MIS techniques, such as arthroscopy, robotic-assisted surgeries, anterior hip replacement and Jiffy Knee knee replacement surgery allow orthopedic surgeons to perform complex procedures through small incisions. This not only reduces trauma to surrounding tissues but also minimizes postoperative pain and accelerates recovery. The precision offered by robotic systems enhances the surgeon's ability to navigate intricate anatomical structures, promising improved outcomes for patients. The adoption of these techniques is not only driven by their clinical benefits but also by the growing demand from patients for procedures that offer quicker recovery and shorter hospital stays. As technology continues to advance, we can anticipate further refinements in minimally invasive approaches, making them increasingly accessible and effective in orthopedic surgery.

2. Personalized and regenerative medicine: The era of one-size-fits-all healthcare is gradually giving way to personalized and regenerative medicine in the field of orthopedic surgery. Recognizing that each patient's condition is unique, there is a growing emphasis on tailoring treatment strategies to individual characteristics, including genetic predispositions and lifestyle factors. Advancements in regenerative medicine, such as stem cell therapy and tissue engineering, offer promising alternatives to traditional orthopedic interventions. These approaches aim to harness the body's natural healing mechanisms, promoting tissue regeneration and repair. From treating osteoarthritis to addressing ligament injuries, regenerative techniques hold the potential to revolutionize the field and provide more sustainable, long-term solutions for patients. The integration of AI and machine learning further contributes to personalized medicine by analyzing vast datasets to predict patient outcomes and recommend tailored treatment plans. This data-driven approach enhances the precision of diagnosis and enables orthopedic surgeons to make informed decisions, optimizing patient care. In conclusion, the landscape of orthopedic surgery is evolving rapidly, driven by innovations in minimally invasive techniques and the shift toward personalized and regenerative medicine. These trends not only underscore the commitment to improving patient outcomes but also reflect the adaptability of orthopedic surgeons in embracing cutting-edge technologies. As we continue to witness breakthroughs in these areas, the future of orthopedic surgery holds exciting possibilities for both practitioners and the individuals seeking their expertise.

Jeffrey Moore, MD. Orthopedic Spine Surgeon at SonoSpine (Oklahoma City): The top healthcare trends I am currently watching are reimbursement cuts and the utilization of new technology. These are acutely linked in the spine world. We are seeing how reimbursement cuts are affecting surgeons' practices and the different approaches they are taking to tackle this issue. While at the same time, we are seeing a burst of new expensive technology such as advanced imaging, navigation and robotics. These new exciting technologies are not cheap. It will be very interesting to see how reimbursement cuts may affect a surgeon's utilization of these expensive technologies. Cost effectiveness studies will become paramount to justify the purchasing and utilization of these fancy tools. 

Joe O'Brien, MD. Medical Director of Minimally Invasive Orthopedic Spine Surgery at VHC Health (Bethesda, Md.): 1. Physician ownership of ASCs and hospitals are trends to watch moving forward. 

2. Joint ventures with forward-looking hospital systems are also a desirable business construct. The current administration is looking closely at noncompete provisions. The elimination of noncompete clauses in healthcare could completely reverse the trend of falling physician reimbursement. It would be a huge benefit to those looking at hospital employment. 

John Brady. CEO at Fox Valley Orthopedics (Geneva, Ill.): From the operation of an ASC perspective, and given the large increases in anesthesia expense, providers and facility leadership need to consider alternate models for delivery of this service, including CRNA-only models. Ensuring clinical quality and patient safety should be the priorities, but as more ASCs shift to this type of model, they should be able to better control overall costs and avoid or minimize costly management stipends charged by anesthesia groups. The other area of focus is the aggressive reduction of operational waste in practices. Leveraging "lean" and "agile" thinking are critical in order to ensure efficiency and optimize practice output. Medical practices have become far too complex to operate with an old-school small practice mindset. Administrators who are able to standardize operations and eliminate unnecessary activities and expenses will be the most successful.

John Prunskis, MD. CEO and Medical Director of the Illinois Pain & Spine Institute (Elgin): The top two healthcare trends right now I am focusing on are healthcare artificial intelligence and the effects of GLP drugs. Regarding healthcare AI, I currently serve as an advisory board member to two firms. The first is Hippocratic AI, which is working on developing what is essentially a large language model generative AI virtual nurse. The second is St. Augustine, Fla.-based Flagler Health+, which is working on optimization of care in patients with painful spine and other painful conditions. Each of these two companies are involved in different aspects of healthcare AI. The second trend I'm focused on is the effect of the GLP drugs such as Ozempic and Manjaro and their effects on multiple industries.

Joshua Rosenow, MD. Director of Functional Neurosurgery at Northwestern Medicine (Chicago): I am closely following the effects on access to care due to the continued reductions in Medicare physician reimbursement. We may have finally hit the tipping point where a substantial number of physicians in independent practice can no longer afford to see Medicare patients. Similarly, I am watching the ongoing struggle to improve the prior authorization process. There are multiple proposals circulating, and legislative relief may be possible. We need to continue to advocate on our patients' behalf regarding these issues to preserve access to the care they require.   

Justin Bundy, MD. Orthopedic Spine Surgeon at Augusta-Aiken (S.C.) Orthopedic Specialists: I am watching consolidation, both from surgeons and industry. I am watching shortage management solutions including anesthesia/CRNA providers, supplies and supply chain issues. Lastly, I am watching migration from inpatient hospital settings for spine and orthopedic procedures. 

Katherine Wojnowich, MD. Sports Medicine Specialist at Bayfront Health St. Petersburg (Fla.): The top healthcare trend I'm watching in the world of nonoperative sports medicine would be biologics and regenerative therapies and their application to a variety of musculoskeletal conditions. The world of biologics is extensive and continues to grow, and their addition to standard treatments for a variety of musculoskeletal conditions have become more widespread. That being said, regulatory concerns as well as payer reimbursement have historically limited their application more broadly. As research grows showing non-inferiority to standard practice and that kits/collections systems bring the cost down, I would suspect certain practices to start appealing for insurance coverage.

Kostas Economopoulos, MD. Assistant Professor in the Department of Orthopedic Surgery at Mayo Clinic Arizona (Phoenix): Currently, my attention has been on the effects AI and machine learning have on healthcare and research. AI is transforming how we think about disease and treatments. Just as importantly, research is being transformed by AI. 

Mark Vorherr. CEO of Mayfield Brain and Spine (Cincinnati): There are many important trends to manage, and the keenest among them are those that impact patient access. We have our attention on legislative matters. Specifically, HR 2474 [Strengthening Medicare for Patients and Providers Act] and the potential to turn back further cuts to the CMS physician fee schedules, and the SITE Act, which would create site neutrality reimbursement for physicians. Both could significantly improve patient access.

Michael Burdi, MD. Orthopedic Surgeon at Community Orthopedic Medical Group (Mission Viejo, Calif.): 1. Robotic trends. 

2. The move of procedures to outpatient facilities and ASCs. 

Nikhil Verma, MD. Professor and Director of the Division of Sports Medicine at Midwest Orthopaedics at Rush (Chicago): 1. AI: Very interesting topic. The truth is that AI is not "intelligent." It is simply a very fast and efficient and powerful way to search and apply data. The problem is, if you put bad data in, you will get bad data out. What we are missing in healthcare is large amounts of outcome driven data in large populations. We have small samples from research, but we don't track all patients to follow their outcomes. This is a huge limitation no one is talking about. 

2. Population health/Medicare Advantage: We have seen this move before. It's called an HMO. Are we really saving money or are people just learning to use the system to generate more profits? I fear the second is the answer.

Peter Passias, MD. Orthopedic Spine Surgeon at NYU Langone Health (New York City): The emergence of artificial intelligence as a tool for patient selection, surgical planning and execution, and prediction of outcomes, as well as customizing our treatments on the individual level. 

Qusai Hammouri, MD. Spine Surgeon at NYU Langone Health (New York City): I am fascinated by the integration of AI in medical practices and the personalization of healthcare through patient-specific surgical guides and implants. The use of AI in diagnostics and treatment planning is revolutionizing the way we approach patient care, making it more accurate, efficient and equitable. At the same time, the arrival of custom-made surgical guides and implants, tailored to each individual's unique anatomy, is a significant leap toward more effective and less invasive treatments. These innovations not only excite me, but signify a new era in precision medicine that holds a lot of promise for improved patient outcomes and personalized care.

Rebecca Urban. System Director of Orthopedics at Summa Health (Akron, Ohio): A few trends that we are keeping an eye on is the evolving changes in the process for navigating insurance authorizations and reimbursement. Further direction from payers to help shift strategies while also showing the importance of high-value and low-cost care. We continue to focus on providing high-touch and innovative care to our patients while staying true to our mission. The continued development of our surgical service lines, ensuring we have the most efficient processes and utilizing our resources most effectively.  

Reuben Gobezie, MD. Director of the Gobezie Shoulder Institute (Cleveland): The most important trends that we are seeing in the healthcare marketplace revolve around the need to make providers and payers align on healthcare delivery with the goal of reducing the total musculoskeletal spend for payers/employers. The perpetually escalating musculoskeletal spend is driven by several key factors that can be influenced to drive value for all stakeholders. These factors include improper steerage to ER/urgent care centers for non-emergent musculoskeletal problems, lack of standardized care pathways that lead to over utilization of imaging and/or surgery. Our practice is working with a technology platform, Genie Health, that is enabling our providers to drive value-based contract negotiations because we have the ability to triage patients at "the top of the funnel" and maximize the effective delivery of virtual care. Genie Health is a platform designed to enable providers in musculoskeletal to offer a 360-wrap-around care platform using assessments for prevention, remote monitoring and PT telehealth for treatment, and a "digital front door" for triage of patients/employees with "intention to treat." Our ASC is a tool used by our practice to provide high quality value-based services that circumvent high cost hospital-based MSK care. The ASC is a key part of the value proposition providers can offer payers and an important part of the "alignment" strategy between the payer and provider in this new era of healthcare where total cost of musculoskeletal care is the focus. 

Robert Tatsumi, MD. President of Oregon Spine Care (Tualatin): Our leadership team continues to focus on payer relationships and improving reimbursement for spine surgeries. It is important to communicate with your payers on a regular basis and collect data that demonstrate cost effectiveness, improved outcomes and lower complication rates.

Thomas Schuler, MD. Spine Surgeon and Founder at Virginia Spine Institute (Reston): Technological advancements in spine are changing the evolving physician's treatment paradigm. Disc replacement in the neck and low back are an incredible opportunity to better help patients and slow iatrogenic problems that arise from spinal fusions. Regenerative medicine likewise is a game changer, since spinal motion is preserved and function is restored non-surgically. Outcomes research will ultimately demonstrate superiority for these treatments in properly selected patients.

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