The most dangerous trend in spine surgery


Ten spine surgeons reveal the trends in healthcare that could have a negative impact on spine surgeons and care delivery in the future.

Timothy Witham, MD. Johns Hopkins Bayview (Baltimore): The usual issues, mainly insurance companies dictating the way we care for patients and limiting the opportunities for patients to receive certain treatments.

Mick Perez-Cruet, MD. Michigan Head & Spine Institute (Southfield, Mich.): Restricted vendor access and lack of appropriate payment for medical devices by our large healthcare providers. This eliminates smaller companies with innovative products for our patients and has a detrimental impact on healthcare innovations that benefit our patients.

Jason Huang, MD. Baylor Scott & White Medical Center (Temple, Texas): There are so many things going on in healthcare — the opioid crisis, increasing economic pressures on doctors, hospital closures, countless new emerging technologies, acquisition and merger of major medical device companies, health policy reforms, etc. It is easy to get loss in this environment or lose our focus entirely. As physicians, the most dangerous trend is to lose focus on our single most important goal: making our patients healthier and better and serving our patients. The lack of focus on patients, but too much emphasis on technology or profits, in my opinion, is the most dangerous trend in medicine.

Thomas Loftus, MD. Austin (Texas) Neurosurgical Institute: By far the most dangerous trend is insurance treatment denials. There seems to be a trend to limiting patient spine care using arbitrary rules and regulations by the insurance company. While there may be an immediate cost saving for the insurance companies, the costs to the patient in additional doctor visits, lost wages, and the ultimately higher likelihood of pain medicine addiction are significant. The greatest danger is that these arbitrary guidelines created by insurance companies override the medical judgement of the treating surgeons. That will never lead to better care for the most important person in the equation: the patient.

Khoi Than, MD. Duke Spine Center (Durham, N.C.): I am really interested in the subject of graft materials in anterior cervical discectomy and fusion. I did research on this at OHSU and will continue to do so at Duke. We looked back at all one-level ACDFs done at OHSU, and the rate of pseudarthrosis when PEEK was used compared to structural allograft was five times higher with PEEK. This was published in the Journal of Neurosurgery: Spine, and our article on multi-level ACDFs will be published soon with essentially the same findings.

The problem is that surgeons can bill more using PEEK than structural allograft. If you perform a multilevel ACDF, you can charge for the structural allograft just once but you can charge for the PEEK cages at each level. That is a potential motivator for using PEEK and I'm interested in exploring that further.

There are hundreds of thousands of ACDFs performed in the U.S. per year and we are potentially negatively impacting those patients if they are not healing and require additional surgery. That is a dangerous trend and it has been going on for decades, unfortunately. I'm hoping to be part of changing that.

Ashutosh Pradhan, MD. Ascension St. Vincent's Riverside (Jacksonville, Fla.): I am concerned that there is a race to the bottom to control cost without necessarily evaluating patient benefit. We should all be good stewards of our healthcare system. In a race to improve our cost structure, I think we are eliminating opportunities for new technology and burdening physicians with documentation requirements that seem unnecessary. In addition, it seems like I am spending more time on the phone with insurance companies for patients I have documented appropriate conservative treatment.

Gregory Lekovic, MD. California Hospital and Medical Center (Los Angeles): Headwinds abound, mainly in regulation and reimbursement. By far and away the most dangerous trend in healthcare is proposed legislation to combat 'surprise billing': the leading legislation will place the burden of payment for "out-of-network" (which in this context should read: "under-insured") patients on surgeons and other hospital-based specialists, who will in turn have to seek subsidy from hospitals in order to survive. This will also strengthen the negotiating hand of insurers with regard to all doctors, bolstering narrow network plans and lowering physician reimbursement across the board.

Kevin Foley, MD. Semmes Murphey Clinic (Memphis, Tenn.): I believe the most dangerous trend in healthcare has been the tendency of too many physicians not to get involved in the management of the field. Delivering quality patient care can be time-consuming and exhausting, but we ignore the management of healthcare delivery at our peril and ultimately, to the detriment of our patients.

Dale Horne, MD. Neurosurgeon (Cincinnati): Complacency and cutting corners by surgeons, physicians and staff, often due to the increased regulations and time demands, is dangerous. Practice and hospital administrations must respect that quality care requires time with patients. Furthermore, unless a surgical emergency exists, patients should be given the option of conservative measures and stable conditions should be followed. Just because we have the technology to perform a surgery does not mean we should.

Kristopher Kimmell, MD. Neurosurgeon (Rochester, N.Y.): I think that, rather than working for positive reform and improvements in care delivery within their systems, many surgeons engage in 'bare minimum' activities, i.e. the least amount required to get their work done. Alternatively, there is a lot of gamesmanship practiced by surgeons. There have been surgeons that find loopholes in coding or reimbursement policies and deliberately alter their practice in order to maximize reimbursement. This is not always what is the best and right thing for the patient. Inevitably these loopholes are closed, and surgeons may move on to a new technology or procedure.

I think that we need to move away from a view of trying to extract maximum reimbursement from every patient and procedure and move toward demonstrating our value to healthcare systems and payers from a more holistic perspective. We do add value and contribute to our healthcare systems in multiple ways. But we have to be aware of these benefits and leverage them to our advantage while also delivering the best possible care to our patients.

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