Developing a payer strategy in spine with Dr. Brian Gantwerker

Written by Alan Condon | November 07, 2019 | Print  |

Brian Gantwerker, MD, is a neurosurgeon specializing in the treatment of brain tumors, as well as degenerative diseases and injuries of the spinal cord.

Dr. Gantwerker has been in private practice for nine years as president and CEO of The Craniospinal Center of Los Angeles in Santa Monica and Encino, Calif. 

Here, he discusses how his relationships with payers changed in the last decade, tips for negotiating contracts and practicing with the financial risks associated with independent physicians.

Question: How has your relationship with payers transformed over the years? 

Dr. Brian Gantwerker: It's much worse now because payers have cracked into the Medicare Advantage market and they're applying the same tricks and rules and baseless guidelines that they were doing on the commercial side with Medicare patients. For example, I had a patient who had a C2 fracture who was healing well in a collar. However, in order to monitor progress, you have to get interval CT scans every four to six weeks for about three or four months. Medicare Advantage plans refused to approve a follow-up CT scan with the reasoning being she didn't have a spinal cord injury, which was ridiculous. First of all, an MRI would be the test of choice if she did have a spinal cord injury. Second of all, it was obvious that they were just trying to delay the scan, which would endanger this patient's wellbeing just to save a couple of dollars. 

It has gotten worse. Because of that I have to think very hard about what insurances I take because I have a certain quality of medicine I want to practice and these insurances — now that they've gotten into the Medicare market and started to buy practices — are dictating how physicians are ordering tests and managing conditions all in the name of better medicine, but we haven't seen that data. I think the problem is that people are equating saving money with practicing better medicine but that's just not true.

Q: What are your key considerations when whittling down what insurances to take on?

BG: One thing to consider is what industries are around you in the area. Here in California, we have the Writers Guild of America, Directors Guild of America and the Screen Actors Guild and they contract with Blue Cross Blue Shield. It's really a self-insured plan but there's a lot of lives out here that are covered by that. Geographically, if you're located in Los Angeles you may want to consider being contracted with them. Conversely, if you go 15 miles north there's a very dense number of HMO patients. You have to look closely at your contract base and develop a good relationship with the regional manager for the payers, because you will inevitably run into mechanisms in order to slow down your payments. That regional manager could potentially help you and be an advocate for you to get paid. 

Conversely, if you're practicing in a mostly retirement community like Boca Raton, Fla., you want to stay contracted with Medicare. Certainly, if you want to set up your practice in South Florida where there's a lot of people over the age of 65 and collecting Medicare, you would not want to drop Medicare because it would make it very difficult to start. 

The other consideration is if you have any preexisting relationships. For example, if you're starting your own practice and you're part of another group practice, you may want to approach the payer and tell them. You could use that as a jump-off point to negotiate a similar rate that to the one you were getting from the original group. 

Q: How challenging were your initial payer negotiations given that you were not part of a group before setting up your practice?

BG: I chose to do it the hard way and negotiate my own rates. It worked out fairly well in the beginning. We signed contracts with a lot of local payers — anybody who was offering a Medicare rate or slightly above with a reasonable amount of remuneration — and it worked out quite well. You need to have a pretty affable personality and be willing to go back and forth a little bit. But if that's not your thing, there are companies and consultants that offer those services. To me it doesn't make monetary sense to do that considering the negotiations are relatively short. The main thing is the enforcement of your contract and making sure you're getting paid at the proper rate, which is probably a bigger challenge than getting the initial contract. 

Q: The financial risk can be a lot higher for physicians in private practice. How do you manage your practice with that in the back of your mind?

BG: I think practicing with the fear of being sued is very hard, and I think all of us to some extent do that. You have to get a good feeling from both the patient and your treatment plan. If your "spidey senses" start tingling, then chances are something is amiss. I try to have a very open dialogue with my patients both before and after surgery, I set expectations in as honest a way as I can. I always tell patients nobody knows exactly what will happen but rest assured that we will manage it together, and I think they appreciate that. 

Every surgeon is different in how they practice but I think if all of us can have an open dialogue with the patients, ensure they know what to expect and their questions are answered, that might lead to less malpractice. There are some people who are motivated to sue because they are angry at someone or something, but studies have shown that physicians who are open, approachable and have good relationships with patients tend to get sued less. 

More articles on spine:
Dr. Sergiy Nesterenko opens spine clinic in Texas
California hospital adds 7 neurosurgeons to curb patient leakage
Drs. Nic Gay, Kerisimasi Reynolds team to form Silicon Valley Orthopaedics

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