The 2016 presidential campaign trail: Key thoughts, challenges & issues for spine surgeons


The 2016 presidential elections are still a year away, but candidates have been jockeying for the top spot for months already. While the most debated issues for many campaigns focus on the economy, immigration, cyber security and terrorism, expect healthcare to take center stage as the sea of candidates dwindles into two frontrunners on either side.

“The candidates right now are trying to position themselves for popularity and exposure,” says John Finkenberg, MD, NASS Advocacy Council Chairman and president of the National Association of Spine Specialists. He practices at Alvarado Orthopedic Medical Group in San Diego. “They are being coached on healthcare to only go three questions deep: Do we need a universal healthcare system? How do we pay for it? Do we need an insurance mandate? Whether we need to repeal and replace or just tweak current healthcare law never gets discussed, but in reality that’s one of the most important issues for how the country will move forward.”


Republican candidates are more likely to advocate for repealing healthcare reform while democratic candidates vouch for changing certain aspects of the law. However, a full repeal and replace is unlikely regardless of who wins the presidency.


“The only chance for full healthcare reform repeal is if the Republicans controlled the House of Representatives, Senate and presidency and the likelihood of that isn’t high, so I’m looking for the candidates to tweak a third of it through defunding and other changes,” says Dr. Finkenberg. As a result, when planning for the future providers can assume the ACA framework will be intact.


“The central provision around which all of the ACA is based is the concept of coordinating and controlling more of the care by primary care physicians,” says Alan Hilibrand, MD, Vice Chairman of the Department of Orthopedic Surgery/Co-Director of Spine Surgery at Rothman Institute/Thomas Jefferson University Hospital in Philadelphia, President of the Cervical Spine Research Society, NASS Advocacy Council Member and Chair of Communications for the American Academy of Orthopaedic Surgeons. “While that’s not necessarily a good thing for spine surgeons, I think it illustrates the need to get out the message about the effectiveness of our treatments and their ability to return people to work and improve the quality of life. And we need to prove moreover that our procedures and innovations are durable.”


The largest orthopedic and spine specialty societies already have efforts underway to collect data and show how effective surgical treatment can be for the appropriately selected patients. Physicians are publishing their data and research in medical journals and helping develop protocols for treatment in the future.


A few of the other key issues candidates and Congress are talking about include:


● Repealing the Independent Payment Advisory Board
● Changing the employer mandate
● Repealing the medical device excise tax


“Where the candidates need to go from here on out is to talk about ways they think they can modify healthcare law to save the popular parts and modify the parts that aren’t successful,” says Dr. Finkenberg. “If you look at individual candidates, I think Dr. Ben Carson has the obvious advantage for looking from the physician’s standpoint on how healthcare works and has an impact on his patients. But he doesn’t have a corner on the market. Hillary Clinton on the democratic side has spent a huge amount of time researching healthcare as well.”


There are several issues and positions for surgeons to consider at the ballot box next November. However, the issues poised to have the biggest effect include the individual mandate, Medicare reform and competition among providers and payers.


1. Individual mandate: Some favor continuing the individual mandate while others would repeal. Pay attention to alternatives for the individual mandate in case of repeal and consider how access to care would change compared with the current situation.


2. Competition: Consider whether the policies would encourage or discourage consolidation in the healthcare system, from provider to payer consolidation. Certain policies drive independent physicians to hospital employment, and hospitals to join health systems, which could affect the quality of care. Among payers, some candidates support market competition beyond the health insurance exchanges while others move more toward a single payer system.


3. Medicare: The sustainable growth rate will need repair in the coming years, and whether Medicare can continue is up for debate. CMS is also moving more toward value-based payments and penalizing providers that don’t report their quality data.


“Whether a Republican or Democrat becomes president in 2016, we’ll see some modifications to the ACA that will affect Medicare and payment for physicians will change because the penalties will set in over the next few years,” says Dr. Finkenberg. “If you aren’t able to participate in EHRs, reimbursement will drop somewhere between 2 percent and 8 percent. That will have a profound affect on Medicare dollars and bend the curve.”


Medicare is also moving toward value-based, risk sharing payment methods. Earlier this year, the Medicare program unveiled plans for bundled payments for hip and knee replacements, and spine may not be far behind.


“I think they are going to come out with a similar type of comprehensive plan for certain types of back procedures,” says Dr. Finkenberg. “If they put a ceiling on a one- or two-level fusion, it will be interesting to see how surgeons approach the bundle. NASS thinks it's coming and we’d like to be part of that discussion rather than be handed a decision.”


Private payers likely won’t be far behind after Medicare begins spine bundled payment for straightforward procedures, such as decompressions, anterior cervical discectomy and fusions as well as single-level lumbar fusion and discectomies.


“I think we as surgeons need to find out what our costs really are--what our implants cost, what OR time costs, hospital charges for the inpatient stay and anesthesia charges,” says Dr. Hilibrand. “We should be prepared for the hospital to say the bundle is a flat charge for the ACDF and we’ll give the surgeon a small percentage. The surgeon can argue their portion is worth more, but they need to know what everything else costs so they can know where to help save money.”


Most candidates just have personal experiences with the healthcare system. That’s why it’s imperative for healthcare providers to educate their representatives and support legislators who are working toward improving healthcare for patients.


“In the world of spine surgery, there is a perception among the lay medical public that spine surgery, even if it works, doesn’t last,” says Dr. Hilibrand. “This isn’t something that we’ll be able to change with 20-year outcomes in clinical trials. It will take a lot of marketing by spine surgeons to make that point. There are negative stereotypes out there and we have to change that perception or there will be other physicians who prevent us from seeing patients.”


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