How will the payer landscape evolve by 2026? 4 surgeon predictions

Payer Issues

The payer landscape in orthopedics is constantly shifting due to the growth of value-based care and the increase in hospital-employed physicians. Four surgeons told Becker's how they see the payer landscape changing in the near future.

Ask Orthopedic Surgeons is a weekly series of questions posed to orthopedic surgeons around the country about clinical, business and policy issues affecting orthopedic care. We invite all orthopedic surgeon and specialist responses.

Next week's question: What do you see as the next true game-changer in orthopedics?

Please send responses to Carly Behm at by 5 p.m. CDT Tuesday, Oct. 12.

Note: Responses were edited for style.

Question: How do you anticipate the payer landscape evolving in your market in the next five years?

David Jacofsky, MD. The CORE Institute (Phoenix): The payer landscape in orthopedics will continue to evolve. There remains a strong interest by payers and CMS to drive the continued shift from volume-based to value-based care. Historically, episodic-based, or procedure-based, bundled payments were the main focus in the orthopedic arena. Although this will continue, there are a few problems with this model that are driving payers to consider other options.

First, bundled costs within a single episode can improve while total spend for the musculoskeletal procedure in a market paradoxically still may increase. Secondly, the proverbial "race to the bottom" causes stakeholders to lose interest in the program as the opportunity for savings deteriorates over time. Finally, there is some frustration and pushback, since the facilities and practices that made early investments into value-based cultures may be punished with the lowest target prices in a market against which they now must compete.

In response, there appear to be three models that are starting to gain the growing attention of payers. Condition-based bundles that reward providers for care around a diagnosis, rather than a procedure, allow providers to be rewarded for improving care coordination, improving the wellness of the community, and eliminating unnecessary procedures and waste; and allow measurement over longer periods of time than during an acute or 90-day bundle. Payers are also realizing that, in many markets, risk managed by ACOs and primary care physicians often seems to underperform in mitigating the upward trend in spend for the 25 to 30 percent of ICD-10 codes tied to musculoskeletal diagnoses. Therefore, for musculoskeletal groups with the infrastructure to manage claims, analytics to manage and measure providers and facilities, and the experience to price insurance risk, there is a growing opportunity to carve out this risk from the primary risk-bearing entity and share those savings with the PCPs.

Finally, as claims systems are improving, there are opportunities for providers to develop clinically integrated networks to bear full global risk on the entire musculoskeletal spend for an entire group of insured members for a payer on a per-member-per-month or percent-of-premium basis. Although this strategy requires the largest investment in infrastructure and a very experienced team with deep insurance background and knowledge, it also presents the greatest future opportunity for physicians to move up the proverbial food chain in healthcare. The future is bright in value-based care for those who wish to embrace it.

Ammar Saymeh, DPM. Director of Foot and Ankle Medicine at NJ Spine and Wellness (East Brunswick, N.J.): There are several trends to take into account when anticipating the constant evolution of the payer landscape. Partnership opportunities between various companies and medical groups will be key to doctors and patients alike. This will assist in improved care and expanding the roles of various providers. Value-based care through analytics will assist in predicting and improving patient outcomes. This data will ultimately reduce the cost of treatment for patients long term. These new trends in the payer landscape will assist in advancing care for patients.

Robert Peinert Jr., MD. Orthopedic Surgeon in Harlingen, Texas: I expect that Medicare and commercial insurance will continue to rein in fees for and increase the number of hoops that we will have to jump through in order to bring a patient to surgery. This will be in concert with a national effort on behalf of the government to provide marginal care to the masses at the lowest cost. This will not occur to Congress' own healthcare programs, nor will this reduce the seven-figure salaries of the insurance executives.

Adam Bruggeman, MD. Texas Spine Care Center (San Antonio) and CMO of MpowerHealth (Addison, Texas): The number of physicians currently employed and looking to be employed by hospitals continues to increase. This spells a significant problem for affordability of healthcare, as costs have been shown to dramatically increase when physicians become hospital employees. This also tends to encourage surgeons to move their cases to hospitals over jointly owned ambulatory surgery centers. Insurance companies have also now been given the gift of unilaterally determining prices through the new No Surprises Act interpretation by HHS. Over the next few years, we will have a good idea of where this is headed, but the significant uncertainty based on these two factors makes it nearly impossible to understand what insurers will be doing in the near future. The hope is that insurances will understand the significant importance of maintaining independent practice.

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