Dennis Crandall, MD, medical director of Phoenix-based Sonoran Spine, has experience at the cutting-edge of spine surgery and practice development.
In addition to his responsibilities with Sonoran, Dr. Crandall is the chairman of the Sonoran Spine Research and Education Foundation, co-chair of the public relations committee for the Scoliosis Research Society and a clinical professor at the University of Arizona College of Medicine-Phoenix. He also serves as head of spine education at Phoenix-based Mayo Clinic-Arizona Orthopedic Surgery Residency Program.
Here, Dr. Crandall discusses his thoughts on seven key areas of spinal innovation development and where he sees the best opportunities for future technology advancement in the value-based care environment.
Note: responses have been lightly edited for clarity and length.
Question: What technology and techniques are most exciting for you in the future?
Dr. Dennis Crandall: Here are my thoughts on seven key areas.
1. Biologics: New bone graft options with real basic science and clinical data supporting their use; Pain control alternatives that minimize opiate use; Osteoporotic bone strengthening through injectable products and pharmaceuticals; Bone graft delivery technologies for the interbody space; Alternatives to BMP with similar efficacy in achieving arthrodesis.
2. Biomechanics: "Smart" implants that measure load forces; Bone-friendly surface technologies for cage design; Bone graft-friendly expandable interbody implants; Computer modeling of interspace and implant stresses; Computer modeling of adjacent segment degeneration factors and potential solutions.
3. Biomaterials: Dissolvable spinal implants; Surface technology for interbody cages.
4. Diagnosis: Low-cost MRI scanners and technology; Lower cost radiographic imaging with 3D capability.
5. Surgical performance: Robots are on the rise and will continue to command attention because of their potential uses; Power tools that decrease the work surgeons do or make the work go faster; Efficient case and tray design for decreasing hospital sterile processing; Improved intraoperative neuro-monitoring techniques that are more consistent and reliable.
6. Deformity: MIS techniques; Addressing the big problem of proximal junctional kyphosis through computer modeling, implant design, construct design and biomaterials testing.
7. MIS: Non-fusion technologies for spondylolisthesis.
Despite continued and increasing pricing pressures placed on new (and existing) spine technology from the payers every year, creative diagnostic and surgical technologies continue to advance. That is a little surprising.
Q: How do you evaluate new technologies and techniques?
DC: In the current era of cost-conscious healthcare delivery in spine, I look for technology that will make a difference in the actual outcomes for my patients. The insurance companies and other large data collectors are tracking every outcome and complication my patients have and comparing that to how much the care I provided cost to achieve that outcome.
As a result, I look for things that make my surgeries faster, get my patients up and functional quicker, achieve reliable fusions, are associated with fewer complications and make a difference in patient-reported outcomes. New technology must help to solve a clinical problem in a way that is at least as effective as what is used now, without introducing new complications. Depending on how well it performs in these areas, payers/hospitals/surgeons will assess the appropriateness of the price, and the price must not outpace the benefits. In my area, only truly disruptive technology commands a price premium across the market.
Q: Is your practice moving toward value-based care? How does new technology fit in, whether you're taking cases to a hospital or outpatient surgery center?
DC: In Phoenix, we are very heavily managed care, with close scrutiny by both payers and hospitals. ASCs with surgeon investors are under incentive to limit technology to value-based options. Hospitals are holding meetings to provide surgeons with cost and profitability feedback in order to apply not-so-subtle pressure for cost containment. Gain share arrangements that incentivize surgeons to partner with hospitals to lower costs are common. Bundled payment plans are becoming more popular. Unless surgeons move toward not accepting insurance or Medicare, they are being forced into participating in value-based care.
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