7 Thoughts on How President Barack Obama's Re-Election Impacts Spine Surgery


Eight leading spine surgeons discuss how President Barack Obama's re-election will impact spine surgery and what spine surgeons can expect from the Patient Protection and Affordable Care Act in the future.
Dr. Andrew CordoverAndrew Cordover, MD, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Ala.: The re-election of President Obama will have many effects on the healthcare industry, surgeons and spine care. One of the main concerns I have as a healthcare provider, particularly in the area of spine care, is providing care for an older population under the evolving yet troubled Medicare system. President Obama has defended the program and I hope, as a surgeon, that he can help build up the Medicare program to better serve the aging population in this country.

Another change that will come from President Obama's re-election includes reforming unresolved issues that affects both patients and surgeons. For patients, this includes better access to quality care, healthcare coverage and affordable prescription medication. For surgeons, one of the main issues is finding a way to provide better care to an aging population at a reduced cost. This includes finding a solution to strenuous approval processes for patient care and reimbursement. A patient should never wait for vital care because it must go through an approval process.

Moving forward, Republicans and Democrats need to work together to create a patient-based system that makes access to care easier for those who need it the most.

Thomas Errico, MD, President, International Advocates for Spine Patients:
What's clear is that the re-election of President Obama ensures the ongoing implementation of the Affordable Care Act (ACA). Some of that is good (elimination of pre-existing condition exclusions, elimination of lifetime benefit caps, inclusion of tens of millions of people into the healthcare system), and some of that is bad (the unchecked power of the Independent Payment Advisory Board, the uncertainly around guaranteed benefits in state health exchanges, and declining physician reimbursements).

What's unclear is how the ACA can simultaneously expand access to care for millions of people while purportedly controlling costs. It seems that to significantly control costs, something has to give. Will they reduce physician reimbursement? No one seems to be in any hurry to scrap the flawed Medicare Sustainable Growth Rate, which means Medicare reimbursement will decline 27 percent next year. Will they cut costs for drugs, devices and hospital care? Those things are clearly on the
chopping block.

In the short term, the device tax and the implementation of the Independent Payment Advisory Board will adversely impact investment into innovative technologies, and likely curtail physician reimbursement. Those two elements do not bode well for spine surgeons and their patients. Our organization - International Advocates for Spine Patients — remains vigilant to ensure that implementation of the ACA does not unnecessarily restrict patient access to medically indicated spine surgeries, nor unduly dis-incentivize investment in innovative and life-improving medical technologies.

Brian R. Gantwerker, MD, Spine Surgeon, The Craniospinal Center of Los Angeles: With this election, we as physicians cannot close our eyes and hope the Affordable Care Act will go away. We need to catch up with what we should have been doing since itsDr. Brian Gantwerker passage — which is figure out how we can stay viable and continue delivering quality care.  

Regardless of whether or not you voted for the President, we have to operate within this new framework. I think three things now need to be done:

1) Create a coalition of spine surgeons and pain specialists;
2) Come up with a plan regarding how we want to remain independent practitioners and NOT hospital employees;
3)  Secure our reimbursement security through lobbying and our spine and pain management coalition.

We are antiquated in our dogmatism. It's time to wake up, create a plan and ACT.

Dr. Steven GarfinSteven Garfin, MD, International Society for the Advancement of Spine Surgery President:
The re-election of President Obama has potentially both positive and negative implications for spine surgeons.

His re-election virtually insures that the Affordable Care Act (ACA) will not be repealed anytime soon, and that means millions more Americans will have insurance and be able to pay for necessary healthcare, including preventive services, and surgical and non-surgical treatment of acute and chronic conditions. Additionally, the ACA promises an environment where administrative costs and hassles of dealing with insurers will be
reduced. Finally, surgeons have an opportunity to play a leading role in new delivery systems to improve care and reduce costs, including accountable care organizations and state-based health exchanges.

It is also theoretically more likely that President Obama will protect public investments in medical research and public health, which will ultimately lead to an improved environment for innovation and emerging technologies that can improve patient lives.

On the negative side, the ACA contains provisions that may be beneficial to the overall population while punitively punishing the needs of individual patients. For example: an increased focus on, and massive funding of, comparative effectiveness research that draws large, population-based conclusions may reduce or eliminate a surgeon's ability to treat an individual patient based on that patient's specific needs, desires and values.

Another provision of ACA, the Independent Payment Advisory Board has virtually unchecked authority to reduce healthcare costs, and will have as its primary focus physician reimbursement levels, and a reduction in federal spending for pharmaceuticals and medical devices.

Finally, both government and commercial payors are beginning to exert downward pressure on utilization of high-cost services (like spinal surgeries), coupled with a reduction in reimbursement rates for physicians' services.  Public and private payors, spurred by provisions in the ACA, have increased their reliance on so-called "evidence-based medicine." In theory, this makes sense; of course physicians should base their clinical decisions on all available evidence. The challenge in spine surgery is what constitutes evidence; while payors insist that the best evidence only comes from randomized controlled trials, spine surgeons understand that RCTs are oftentimes impossible to conduct in surgical scenarios. This results in a far greater scrutiny of spine
procedures once considered the standard of care, and forces surgeons to continually justify the care decisions they make.

We remain hopeful that the implementation of the ACA will not adversely impact our patients' access to medically appropriate care.

Dr. Stephen HochschulerStephen Hochschuler, MD, Founder, Texas Back Institute, Plano: The re-election of President Obama means ObamaCare will remain in place. Unfortunately there is so much within this 2,700 page document that only time will tell what impact this will have. I personally have great concern for patients and physicians. Neither, for various reasons, had any significant input to this healthcare legislation.

The AMA, as usual was asleep at the wheel. Both patients and physicians, I believe, will experience new regulations which will restrict choice. More likely than not, bureaucrats will make regulatory decisions without the knowledge or input of treating physicians.

Through the years The Texas Back Institute has trained more than 100 fellows, many of whom still have significant debt. Although I personally thoroughly enjoy the practice of spine surgery my concern for the Millennium surgeon is what's mentioned above. There will be many more challenges to face. Hospitals will continue to purchase physician groups.

Accountable care organizations will initially try to play a major role. I believe insurance companies, hospital companies, plaintiff malpractice attorneys, drug and implant companies will initially make more money. Physicians, on the other hand, will work longer hours with increased documentation, increased overhead costs and less take home pay. I also believe that as Medicare and Medicaid grow, physicians will try to limit access but the government will pass a law that requires such care or one will lose their license.

What alternatives might help adjust this scenario? More surgery will be done on an outpatient basis. With this in mind, physicians would do well to supplement their income by ownership in surgi-centers. In addition another physician-owned model which not only helps control implant costs by removing the middleman, similar to I-Tunes, Amazon and Netflix but also contracts for "bundled payments" and "episodes of care" should be considered. Eventually this could become a physician-owned insurance company.

Perhaps my last consideration, especially in those states that have NOT had malpractice reform is for physicians to investigate an offshore, physician-owned insurance company that only settles legitimate cases for a legitimate fee.

How this will play out in the long run is yet to be determined.

Dr. Charles MickCharles Mick, MD, North American Spine Society President: It is time for all stakeholders in healthcare to look beyond self interests and to work together and implement the Democratic experiment in healthcare reform. Nobody knows the end result, but all of us know that healthcare reform is needed. We need to improve care coordination and quality, and we need to reduce costs. The Democrats have won, and we have been given a message that the public wants to move forward with their plan.

Some aspects of the ACA are superb. For example, giving insurance to everybody, not being able to take insurance away if you get sick and being able to move from job to job and take your insurance with you. There are other aspects that will need to be modified and improved, for example the Independent Payment Advisory Board.

A. Nick Shamie, MD, American College of Spine Surgery President: It's very difficult to predict how any healthcare change would impact spine surgeons. One thing is for certain: The healthcare system will change in this country. We have aDr. Nick Shamie growing population and an increased demand for healthcare in this country. The costs have continued to escalate year after year and we need to reign in the costs of healthcare especially in our current economic environment. As physicians, we should all expect decreased pay from government and private payors per each patient care delivered. Specialty and elective care will not be reimbursed as well as it is today. Patients will have to pay out of pocket for elective care (much of spine surgery falls under this category). I believe all of this will translate into an increase in efficacious outpatient minimally invasive procedures with lower per-procedure costs that patients can pay for out of pocket.

Dr. Jeffrey WangJeffrey Wang, MD, UCLA Spine Center: Although the election process will definitely influence the future of healthcare and certainly spine surgeons have been very interested in the outcome, in reality, there are changes that have been set in place for some time that would likely have been implemented, regardless of the election results. Placing more demands on the surgeons and certain requirements in the near future would likely have been mandated. I think the fact that President Obama was re-elected means that the process may be more transparent in the sense that many surgeons were preparing for the changes that he set in place, and now we know that he will likely push these forward.

However, healthcare is changing and will continue to change, regardless of the outcome, and we need to make sure that we understand these changes, prepare for these changes and try to anticipate the changes that will likely come in the future. Clearly there is a need for more efficient spending of healthcare dollars and a requirement to show evidence to support our treatments. And, improving patient care and outcomes will be a top priority.

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