5 Spine Surgeons on How Congress Should Proceed With Healthcare Reform


Here are five spine surgeon leaders discussing how Congress should proceed with healthcare reform. Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses. Next week's question: How often do you practice defensive medicine?

Please send responses to Laura Miller at laura@beckershealthcare.com by Wednesday, August 1, at 5pm CST.

Q: How should Congress move forward with healthcare reforms?

Dennis Crandall, MD, Founder and Medical Director of Sonoran Spine Center, Mesa, Ariz.: Repeal Obamacare, and replace it with specific reforms that are popular and that we can afford. Change incentives for patients and care providers. Allow for competition among insurance carriers. [Implement] malpractice reform.

Ara Deukmedjian, MD, Founder, Deuk Spine Institute, Melbourne, Fla
.: They need to bring true competition to the health insurance marketplace. Right now true competition does not exist. In a free market with "legitimate" competition you will always see cost decline and value increase. In the private health insurer industry we are seeing the exact opposite of this, hence competition is non-existent and collusion must be occurring. Basis for this opinion, firstly costs continue to rise. Every year the premiums for health insurance plans rise 10-15 percent, deductibles rise, copays rise and coinsurance rises. The cost of healthcare is rising every year across market "competitors" (private insurers) in the way of higher premiums, copays and deductibles.

Secondly, the value of health insurance benefits is declining (in spite of higher costs to the consumer). This is evident as more denials for services, testing and treatment now than ever before. More and more standard testing and treatments (such as new medications or surgeries) are being labeled as "experimental" and "medically unnecessary" hence not covered as a benefit. Patients insurance plans offer less benefits for physical therapy, chiropractic and rehabilitative medicine every year. Doctors and hospitals and all healthcare providers are seeing declining payments for services despite increasing costs to us to provide the care. Insurers are taking more money in on the front end but paying out less and less each year to providers (hospitals, doctors, pharmacy, therapy, etc.) because they unilaterally reset our payments to lower levels and have dramatically increased their denial activities year over year. Every year, Americans with private insurance are being robbed more and more of basic healthcare as these benefits are cut by insurers in efforts to rake in bigger profits.

In summary, because the consumer's cost of private health insurance rises each year but the quality of benefits decline each year, competition must NOT exist in this market. Instead we see private insurers with record profits being posted each quarter and the health of our nation is abysmal. American people are being cheated out of their health benefits. This is Congress's most pressing healthcare issue in my humble opinion. Give healthcare back to the people.

Michael Hisey, MD, Medical Director, Texas Back Institute, Plano:
First, congress needs to fix some obvious and relatively easy issues that weren't addressed by the PPACA.  

The SGR needs to be fixed or scrapped.  This continued threat of decreased payments for treatment of our Medicare population is decreasing access to care for those most in need.

Tort reform needs to be a part of any complete healthcare reform.  We have shown in Texas that reasonable reforms can continue to protect patients and decrease malpractice premiums.

Options for purchasing insurance across state lines need to be considered.  This would allow competition and would have the potential to drive down insurance premiums.

In my mind, the hardest issue to address is the disconnects between the money being paid for healthcare, the person recommending the care, the patient receiving the care and the effectiveness of the care. In a free market model the patient would shop for care and make choices based on cost and expected results. Currently, treatment recommendations are made with little sensitivity to cost. Costs for diagnostics, implants and treatments are more closely tied to what the market will bear than to the cost of delivery.  Until the incentives can be aligned, it will remain almost impossible to control the costs.  

Gain-sharing concepts like ACOs, PODs and physician-owned hospitals have the potential to align the incentives of the payors and those recommending the treatments because a portion of the savings would be realized by those making the recommendations.  Another way to address cost is to motivate lower cost delivery of implants and pharmaceuticals.  As it stands now, there is little motivation for drug and implant companies to deliver lower cost but equivalent products because the higher cost products are much more profitable.  New products are developed and are priced not by what it costs to develop and produce them, but by what the competing products are priced. There is little if any economic incentive to drive costs down. We know that they can deliver the products for less, though, because when the same products are sold outside of the US they can be delivered for a fraction of the cost. Some of this difference may be due to liability issues, but most is simply what the market is bearing.

The areas of our health wherein we have control need to be self-supporting. This could include smoking or obesity which can increase the cost of care for individuals and are largely under the individual's control. I'll use smoking as an example: It is not fair for non-smokers to bear the burden inflicted on the healthcare system by smokers. It would be possible, but unpalatable to fund the difference by an increased insurance premium for smokers. It might be cleaner to fund the problem from the source. Tobacco is already heavily taxed, but these funds have been diverted to many unrelated projects. The money raised by tobacco taxes needs to be used to offset the incremental costs of smoking to the insurers, both private and public.

It should be obvious, more and better care can't be delivered for less cost without significant increases in efficiency and without some decreases in income to healthcare providers.  

Whenever there is change, there is opportunity for those who are forward thinking to mold the future. In this case, the future of healthcare delivery.

Raj Rao, MD, Director of Spine Surgery, Medical College of Wisconsin, Milwaukee:  Congress needs to understand that physicians want to provide the best care possible for their patients, and as all Americans, would prefer that this be done in a cost effective fashion. Physicians account for less than 10 percent of overall Medicare expenditure, while facility fees continue to consume a large slice of the Medicare budget. Specialty care is what has kept American healthcare the beacon for patients from all over the world and Congress needs to do its utmost to ensure that high quality specialty care continues to be available for our patients. Physicians from all specialties should be more actively solicited in development of reforms that make sense, quality measures that actually mean something to the specific disease process and in the development of deliver mechanisms that benefit patients.

Paul Slosar, MD, President, SpineCare Medical Group, San Francisco Spine Institute:
Personally, I don't think the US can actually afford the current plan (CBO estimates climb from $940 billion to $1.96 trillion) so it will likely eventually either collapse under its own weight, or have to be redone again. I believe it would be more successful if the lawmakers passed a few specific laws to address the problems with pre-existing condition exclusions, the un/underinsured and tort reform. The majority of the system (which overall functions reasonably well, but is expensive) could be then reworked by tax reforms and gradual shifting of more financial control to the individuals (free market forces with back-up catastrophic coverage). This would allow better cost control and more effective interactions between patients (who would control more of their spending) and doctors (who order the expensive tests).

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