10 Top Issues for Spine Surgeons After the Supreme Court Upheld Healthcare Reform


At the end of June, the Supreme Court upheld the individual mandate for the Patient Protection and Affordable Care Act of 2010, which aims to reform the healthcare system in America. The Court upheld ACA but struck down the provision of mandatory Medicaid expansion, leaving this decision to the individual states.
Here, spine surgeons and industry experts discuss the top 10 issues with PPACA for spine surgeons and how the Supreme Court's decision will impact spine surgery in the future.

1. Increased pool of patient coverage
. Since the individual mandate was upheld by the Supreme Court, more patients will be covered either by a Medicaid expansion, purchasing third party payor insurance or another form of government program. The coverage expansion has a rippling impact on all physicians and surgeons because it will add more patients to into the healthcare system without necessarily increasing the number of medical professionals available to treat them.

"The PPACA will attempt to enlarge the insurance risk pools to include coverage of the healthy, low risk population which should make insurance for high risk, sick and elderly more affordable by spreading the cost of healthcare over a larger population of premium paying beneficiaries," says Ara Deukmedjian, MD, founder of Deuk Spine Institute in Melbourne, Fla. "I believe everyone deserves exceptional healthcare as a basic human right and I believe that is also how the President saw it when his administration drafted this legislation. By restoring and preserving health to all Americans we as a nation can focus on working together to bring our nation back to its greatness in the eyes of our countrymen and other nations."

These patients required care before they were insured and the new legislation aims to pay for this care already being given in a more efficient manner. "There are 32 million Americans not insured and they are currently coming to emergency rooms for care," says A. Nick Shamie, MD, co-director of UCLA Comprehensive Spine Center. He is also president of the American College of Spine Surgery. "Even though they don't have insurance, we take care of them. Now they will have some type of insurance — whether that's a government or private healthcare company."

This increase will likely impact elective procedures, such as many spine surgeries, because insurance coverage will be more focused on life-threatening conditions. "Much of what we do in spine is not life threatening; it's to improve quality of life," says Dr. Shamie. "As a result, I think patients who want to get specialty and elective care will have higher premiums or pay for their surgery themselves. There are some procedures that aren't covered by government or insurance companies, so patients who want those will have to pay out of their own pocket."

2. Lower reimbursements for spine surgery. Spine surgeons and physicians across the board have been reporting a reimbursement decline for the past several years, and this trend will likely continue throughout PPACA implementation. "One of the major flaws in the new law is the fact that the majority of newly insured patients will receive their coverage through the Medicaid program," says Jeffrey Lobosky, MD, associate clinical professor of neurological surgery at the University of California San Francisco. "In most states, reimbursement for Medicaid is dismal and thus it won't address the concerns of surgeons who see their incomes declining nor of patients who lack access because so many physicians have had to limit the number of Medicaid patients in their practice. If the plan remains to pay for this expansion of care by reducing reimbursement to physicians and to hospitals by the Medicare program we will soon see our senior citizens finding access just as difficult as it is for the Medicaid population."

The forced Medicaid expansion across all 50 states was struck down, which means each state will be responsible for covering patients by their own plan. "The Supreme Court effectively deferred the decision on Medicaid expansion to the states, and Medicaid is fully half of the insurance expansion," says Stephen Jenkins, senior vice president of Sg2. "States whose politics and fiscal situation support expanding Medicaid will do so. States whose politics and fiscal situation don't support Medicaid expansion won't."

The more expensive procedures, including those with new technology, will likely be out of reach for the average patient. "The ongoing struggle that remains is how we are going to pay for healthcare improvements, and ultimately which ones are the best value for the government and third party payors," says Thomas Schuler, MD, founder and president of Virginia Spine Institute in Reston, in a presidential address for the Spine Research Foundation. "Unfortunately, improvements which are best for individual patients will be lost in the healthcare debate. The decisions that are being made today, and will continue to be made in the future, are based purely upon economics."

3. Rationing healthcare means less spine surgery.
In addition to expanding coverage to all Americans, the passage of PPACA also means insurance companies won't be able to turn away patients based on pre-existing conditions; as a result, insurance companies are assuming higher risk for covering sicker patients. Since spine surgery is often elective — to improve the quality of life instead of to keep a patient alive — some of the dollars going into spine care now could be re-directed to more life-threatening conditions and specialties.

"Lowering the patient's blood pressure, making sure the heart is working well and providing diabetes and cancer care will all take precedence over elective care," says Dr. Shamie. "We will have to ration the care we provide such that people can have as much as possible and to give the benefit to the society as a whole. We have a multi-tiered healthcare system in this country already, but this will make it more apparent because in the past specialty care was at least partially covered."

As reimbursement for specialty care is cut or denied, a greater number of spine specialists may stop seeing the lowest-reimbursing government payors, or accept only cash-pay patients.

"It's going to be difficult to find physicians willing to treat [Medicare and Medicaid] patients, and this is already happening," says Dr. Schuler. "The reason these reimbursements have deteriorated over time is that more people are using Medicare and Medicaid."

4. Independent Payment Advisory Board has not been repealed.
The Independent Payment Advisory Board remains a chief concern of medical providers as a provision of healthcare reform. IPAB was devised by PPACA to evaluate treatment guidelines and suggest Medicare reimbursement using evidence-based medicine research. "Most patient advocacy organizations and nearly all professional medical societies oppose IPAB due to its unrestricted power to impose draconian cuts to health expenditures, including physician reimbursement and drug and device expenditures," according to a response statement released by IASP.

If IPAB is setting the guidelines for Medicare and Medicaid reimbursement, private payors may soon follow suit. Another concern of many healthcare professionals is the make-up of IPAB: 15 members appointed by the president and subject to Senate confirmation that include political leaders, not currently practicing physicians.

"Two burning issues that relate to surgeons is the Independent Payment Advisory Board which is given the power to slash reimbursement with only a modest physician influence and malpractice reform,"says Dr. Lobosky. "Almost all physicians' organizations and most Republican lawmakers strongly oppose the current make-up of the IPAB and are working to repeal it. Tort reform has been given nothing but lip service by the current administration yet is a major concern to most surgeons. We'll have to wait and see if there is any movement on these two important issues."

However, the focus on research and evidence-based guidelines may also have a positive impact on some aspects of spine care. "We need to provide evidence for everything that we do because truthfully there have been some treatments or procedures that we’ve offered our patients without solid evidence supporting them," says Dr. Shamie. "We have to become more responsible in providing scientific evidence supporting our treatments. That is easier said than done because it is very costly, and sometimes not feasible for various reasons, to conduct a good study to prove what we do works."

5. Evolving patient-physician relationship as coverage denials increase.
Almost everyone agrees healthcare spending is out of control. Currently, America spends 18 percent of its GDP on healthcare, and if this number continues to grow it threatens to consume funds for infrastructure, education and defense. In an effort to curb healthcare spending, the government and payors have established coverage guidelines that limit whether the patients will have their procedures covered based on indications instead of the surgeon's recommendation or patient's treatment desires.

"One of the significant barriers to curing chronic back and neck pain, aside from incorrect diagnosis or improperly executed 'correct treatment' is denial of care by the patient's health insurer," says Dr. Deukmedjian. "Unfortunately, the PPACA does nothing to stop the insurers from adding more medical tests, medications or treatments to their list of 'medically unnecessary' or 'experimental' care. Every doctor has encountered these denials on a daily basis in their practice and the insurers have successfully driven a massive wedge between the doctor and patient relationship, effectively destroying it."

The guidelines are often modeled after research suggesting treatment pathways for the average patient with a spinal condition. However, not every patient is the same and these strict guidelines have no room for variation, which leaves patients who are outliers untreated.

"The problem is this research at best is a suggestion of what works for many patients," says Dr. Schuler. "It does not answer what the solution or treatment is for any outliers. This is where the problem arises. Patients that fall outside common presentations are being denied care by third party payors."

As a result, these guidelines take viable options for treatment away from the surgeon and patient, straining their relationship. "It is the physician's knowledge, experience and understanding of scientific data, combined with the patient's individual and social needs, which allows the two of them to develop the optimal treatment," says Dr. Schuler. "Evidence-based experts and political appointees are not the answer to the best treatment options for an individual or for all Americans."

6. Evidence based medicine means less access to spine care.
The focus on evidence-based medicine, lower reimbursements and growing patient population means there will be less access to care for all patients. Strong evidence based studies are few and far between for spine surgery and conducting new high caliber studies present several difficulties, most prominently funding and study design. Most studies are currently funded by industry members and require a placebo, or "sham" procedure, to compare with the surgical patients.

"Not only is [performing a sham procedure] impractical, but it is completely unethical," says Dr. Schuler. "Furthermore, without performing the complete surgical dissection involved in a given surgery, a sham incision would not produce comparable surgical morbidity."

Another issue with creating evidence-based guidelines are those who are reviewing the evidence; there are strong studies with conflicting results that either recommend for or against surgery, and committees can selectively choose which studies to cite in their guideline decisions.

"In discounting many outcome studies that have already confirmed the effectiveness and success of a given therapy, patients are subsequently denied access to life changing treatment," says Dr. Schuler. "There are many reasons that a reviewer would choose to discredit a procedure."

7. Comparative effectiveness research won't always yield the best results.
Research is important in the medical field, but not all patients will fit into the path determined most successful by research analysis. Every human is different and brings different variables into treatment, whether they are part of the research or outside of it.

"The basis of evidence-based medicine, as well as comparative effectiveness, is to scientifically prove what treatment is best," says Dr. Schuler. "A significant problem with this concept is that one cannot general for all patients."

8. Practice management regulations and expenses. Over the last several years, government regulations on independent medical practices have made it increasingly difficult for surgeons to strike out on their own. A physician recruitment survey from Merritt Hawkins shows that only 1 percent of their assignments last year were for solo physicians while 63 percent were for hospital employment, up 7 percent in one year.

Consolidation within the industry and hospital employment has been a concern for many physicians, including spine specialists. Surgeons coming out of training are increasingly signing hospital contracts while more experienced surgeons are tempted to sell their practice and go under the employment umbrella as a result of the government regulations making it increasingly difficult to run an independent practice. An additional concern for physicians is technology upgrade. Physician practices are now encourage — and soon will be required — to meet meaningful use requirements. Many practices have begun to work toward this goal by implementing electronic health records systems.

"I think physician practices should prepare for transitioning to EHR if they haven't started that process already," says Clarie Marblestone of Felton Nelson. The problem for many practices with EHR is the cost; most systems are expensive and purchasing one at a time when reimbursements are declining becomes challenging.

There are additional issues with implementing the system beyond the initial cost. Physicians and employees must take time to train on the system and fully transfer their records from paper to the electronic system. Finally, if the practice's electronic system doesn't interface with the local hospital's system, surgeons will continue to have trouble transferring the data and patient records.

However, surgeons who do using EHR systems to track their patients, outcome and quality could see increased efficiency in the office visits and collect information about their patients' successes. If surgeons can show they achieve better outcomes, or provide a higher quality of care than others in the market, they could have negotiating power with insurance companies and a strong marketing point in the future.

9. Partnering with others for healthcare delivery.
In the wake of healthcare reform legislation, several new types of partnerships emerged to increase efficiency and improve quality of care. These partnerships include accountable care organizations, alignment with hospitals and bundled payment agreements. Many of these partnerships are still in their infancy and the role of specialty care within them remains undefined. However, one theme continues to arise: innovative partnerships between different providers and healthcare stakeholders are encouraged under the new legislation.

"Since PPACA is now going forward, physician practices could partner with Accountable Care Organizations," says Ms. Marblestone. Many providers, including specialty care physicians and hospitals, have been hesitant to engage in ACOs or other alignment models because they didn't want to invest in a new venture that could possibly become irrelevant if healthcare reform efforts came to a halt. The slow release of guidelines for ACOs also played a part in the reluctance to participate. "We'll be hearing a lot more from the Department of Health and Human Services about implementation and what the actual law directs. They have left out a lot of details about how PPACA will be implemented, but I think we can expect to see a lot more from them now that PPACA has been upheld."

In it's response to the ruling, the International Advocates for Spine Patients "applauds provisions of the [Affordable] Care Act that increase patient access to primary and specialty care and efforts to better coordinate care (and thus save money) through Accountable Care Organizations and State Health Exchanges."

The independent groups that are able to survive in today's market are often larger groups that provide a full spectrum of spine care and partner with local hospitals.

"The biggest transformation underway in our industry is driving more accountability to providers and asking them to assume risk for their performance across the continuum," says Mr. Jenkins. "That did not hang on today's ruling. Those forces are unstoppable."

There have been a few examples — most recently in Michigan, California and Tennessee — where joint replacement surgeons and groups have partnered with insurance companies for bundled payments. Bundling payment means the provider assumes an increased level of risk for the patient's outcome because the insurance company pays a flat rate for the procedure and postoperative care regardless of unforeseen complications or infections.

10. Stifling innovation in the spine market.
The spine device and implant market has enjoyed an explosion of technology over the past several years, with minimally invasive techniques and biologics leading the way. Surgeons are now able to perform better procedures for their patients to recover more quickly than in the past, but the future of innovation remains unclear. New technology is often more expensive and a cost-conscious healthcare environment may not support important advances.

For device companies, one of the biggest concerns with PPACA is the upcoming medical device tax. In response to the Supreme Court's ruling, IASP said it "remains concerned about the medical device tax contained in PPACA, as we fear it will limit device companies' ability to invest in newer, improved technologies that can benefit patients and may lead to job losses as well."

Going forward, it may only be those who can afford to pay out-of-pocket for new technology who support these advances and receive better care. "The luxury of advanced care we have been providing has to become more limited now," says Dr. Shamie. "We have to do some rationing because we have more people needing the same care and less resources and financial remunerations for resources. If patients want a new procedure that isn't covered by the insurance company, they have to find another way to pay for them."

More Articles on Spinal Surgery:

The Most Important Issues Facing Spine Surgeons: Q&A With ISASS President Dr. Steven Garfin

20 Spine Surgeon Leaders in Advocacy Efforts

Healthcare Reform Upheld: AAOS President Dr. John Tongue Responds

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