Six spine surgeons discuss declining reimbursements and what needs to change to mitigate the trend.
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: In your opinion, have electronic health records been worth the investment so far?
Please send responses to Anuja Vaidya at avaidya@beckershealthcare.com by Wednesday, May 7, at 5 p.m. CST.
Question: What are the most challenging reimbursement issues for spine practices today?
Neel Anand, MD, Clinical Professor of Surgery, Director, Spine Trauma, Cedars-Sinai Spine Center, Los Angeles: Approval for any procedure or surgery — there is a big block there. There is dichotomy in surgical reimbursement. Older techniques are sometimes reimbursed more than technologically advanced methods. Also, there is no reimbursement for expertise. Residents performing a procedure for the first time are paid as much as surgeons who have had years of experience.
Jack E. Zigler, MD, Medical Director, Texas Back Institute, Plano: Firstly, having the procedure accepted by the insurance company as a covered benefit. Many new technologies are not covered by major insurance carriers, who independently deem them "experimental and investigational," despite FDA approval and long-term published level I studies. Physicians and surgeons must demand that their professional societies fight against these capricious business decisions denying scientifically proven benefits to patients. An example is Aetna's positive coverage of lumbar arthroplasty for more than seven years, then its abrupt and unexplained 2013 policy reversal, now considering that same procedure as "experimental and investigational."
Secondly, passing the hurdle of individual case-by-case peer review. A common strategy by indemnity insurance carriers is to employ physicians, as either full-time "medical directors" or as consultants on an hourly or per-contact basis, who briefly review generally incomplete medical records, never examine the patient and then schedule a very short telephone contact with the treating surgeon where they repeat the company policy, point out theoretical deficiencies in the medical record and typically deny the case, offering the opportunity for further appeal per the insurance contract. This initial physician contact is frequently not a specialist in the area of concern, but merely a first-line gatekeeper to start an involved and time-consuming appeals process. An example is the new trend for carriers to deny authorization for segmental spinal fusion for mechanical back pain, falling back on antiquated criteria for gross instability that were initially developed in a post-traumatic model in the 1980s.
Thirdly, getting financially compensated commensurate with the work being done. Insurance industry reimbursements are often based on poorly collected information, whereby comparators for time, complexity and technical skill were often improperly chosen without good knowledge of the procedure being reimbursed. An example is the professional reimbursement for single level cervical arthroplasty that is typically 60 percent of the reimbursement for a technically easier single-level ACDF or reimbursement for lumbar arthroplasty at rates less than half those of an ALIF. These rates are determined unilaterally by the insurance carrier and contracting physicians are not allowed to balance-bill the patient for any additional fees.
Surgeons need to be smarter, and fight for evidence-based treatment options that should be available to patients, with reimbursement reasonable to the time spent as well as the intellectual and technical components of the procedure. As a profession, we have allowed others to determine policies that we as physicians should be making for our patients.
Individual doctors cannot get this done, but our societies, representing the specialists who have spent years in training, years in practice and years in scientific evaluation, need to be our voice. Specialty societies, such as the International Society for the Advancement of Spine Surgery, North American Spine Society, American Association of Neurological Surgeons and American Association of Orthopaedic Surgeons must play a more active role in demonstrating to the public as well as to our governmental representatives that the insurance industry should not be determining what procedures are approvable, nor which patients are appropriate, nor where reimbursements should be set, without the strong involvement and input of the only group gave up a decade of their life to training, who work in the trenches on a daily basis and who are uniquely equipped to make those decisions — the spine surgeons.
Ara Deukmedjian, MD, CEO, Medical Director, Deuk Spine Institute, Melbourne, Fla.: First of all, new treatments are universally being denied payment by insurance companies. How are advances in medical diagnosis or treatment going to occur if insurers are not paying for them? There will be no advancement of medicine without payer coverage of the new technology.
Secondly, established treatments are universally being denied payment by insurance companies. Can you imagine if tomorrow the U.S. military proclaimed that parachutes are "experimental" and not considered necessary for troops jumping out of airplanes onto the battlefield? Their basis for this is that no one has definitively proven parachutes are necessary through unbiased research. Their real reason for no longer providing parachutes is that the military is saving money. Now substitute spine surgery for parachutes and health insurance companies for the U.S. military.
We understand the reason our government wants to save money because we are $17 trillion in debt. Do we really understand why the health insurance companies want to save money? They are not in debt. As a matter of fact, the top five U.S. health insurers had record profit-making last quarter.
The more tests and treatment the insurance companies deny you, the more profit they make. Their profit and your health, however, are diametrically opposed and cannot exist in this world together. How can the insurer authorize spending money on your medical care when every dollar they spend takes away from their profits. This inherent conflict of interest did not exist in the past because doctors had full control of your medical testing and treatment, until now.
The rules have changed. So we now have a dilemma due to a difference of opinion, your doctor says the treatment recommended is medically necessary but the insurance company disagrees and claims the treatment proposed is not medically necessary. Put the control of your health back into your and your doctors' hands.
Brian R. Gantwerker, MD, Neurosurgeon, The Craniospinal Center of Los Angeles: Extensive delays of payment. The insurers have found new and fiendishly clever loopholes, not to mention outright fraudulent methods to slow your payments. What I see more of now is the company asking for the same information over and over again, for instance, W9s, operative notes and clinic notes that were already submitted for the authorization.
Richard A. Kube II, MD, CEO, Founder, Prairie Spine & Pain Institute, Peoria, Ill.: In an era when the numbers of challenges are vast, it is hard to pick just a couple. There are a few general categories however. One is the issue of authorization. Although a front-end issue, it is an important obstacle being placed by insurance companies. More resources are being diverted to this process and now with retrospective review coupled with claw-backs, it is becoming challenging.
Practices are placing detrimental reliance on those pre-authorizations and cash flow can see significant impact. Once procedures are complete, there is greater manpower required to follow up and appeal EOB — explanation of benefits — outcomes. Things that used to take minutes can take an hour or more on average.
Finally, there is the frank issue that is faced regarding overall lower payments for the same amount of work while the cost to deliver services increases by several percent per year. Together, these forces can produce a perfect storm for a cash flow crunch.
Sheeraz Qureshi, MD, Chief, Spinal Trauma, Icahn School of Medicine at Mount Sinai, New York City: The most challenging reimbursement issue for spine practices today is that the patient and the provider do not know what insurances will pay for, how much they will pay and what the patient's responsibility will be. This makes it increasingly difficult to provide patients with a high level of care because so many resources are spent both by the patient and by the physician practice on trying to understand what financial impact the care will create.
Increasingly, patients are paying larger amounts out of their own pocket for what they are led to believe is adequate coverage only to find out their deductibles are much higher, their out-of-pocket cost has increased and they have a smaller network of specialists that they can see. Ultimately, this will lead to an increased cost to society because patients are unable to access the high level of care they expect in a timely manner.
More Articles on Spine:
Hospital for Special Surgery Names Dr. Todd Albert Surgeon-in-Chief
Costs for SI Joint Disruption, Sacroiliitis About $270M Over 5 Years
The Robotic Difference: How New Technology Could Impact Spine