Insurance companies and the ramifications of the COVID-19 pandemic are some of the issues at the forefront of spine surgeons' minds. Here, six surgeons discuss the biggest obstacles to the specialty going forward.
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: How do you envision the spine field one year from now? What will be different and what will remain the same?
Please send responses to Alan Condon at firstname.lastname@example.org by 5 p.m. CDT Wednesday, Sept. 30.
Note: The following responses were lightly edited for style and clarity.
Question: What is the biggest obstacle facing spine providers in the modern landscape?
Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Insurance companies are the biggest obstacle facing spine providers today. Our ability to diagnose problems, employ minimally invasive surgical techniques, and restore and maximize quality of life for our patients has never been stronger. Unfortunately, onerous processes of preauthorization, denials of care, and pointless and exhausting peer-to-peers have inundated spine surgeons' offices with unnecessary work [and] increased overhead costs, and ultimately left patients shortchanged due to unreasonably denied or delayed care.
Furthermore, an emphasis on maximizing profits by prioritizing low-cost care — irrespective of quality — has driven reimbursement rates down, put a squeeze on practitioners and limited patient options for treatment. Until spine surgeons retake control over their practices, patients and decision-making independence, insurers will continue to minimize our role and limit our ability to push the field forward.
Jeffrey Wang, MD. USC Spine Center (Los Angeles): The largest obstacle right now is how to continue our educational activities and surgical training, given the lack of the ability to travel to academic meetings, teach new surgical techniques and learn research advances. Although much can be done virtually with webinars and virtual education, surgical techniques require hands-on and laboratory training, which is best accomplished in face-to-face settings. I am excited about potential virtual reality and augmented reality, in perhaps allowing us to develop new ways of surgical education. However, this needs a lot of work and there is no substitute for live teaching in hands-on cadaver courses.
John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): There are two major obstacles facing spine surgeons today as I see it: The first is the need to better advocate for new technology for our patients in a market that constantly wants to cut and contain costs. These new technologies will make surgeries safer and more predictable, but in some situations come with necessary upfront capital expenses. The second is our need to advocate for fair reimbursement. As CMS continues to decrease specialists' reimbursement in favor of other specialties, it is important that we speak up about the value we provide and the risk that we take on in doing so.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): The biggest obstacles facing spine providers and most physicians in the modern landscape of the U.S. healthcare system are declining reimbursements and burdensome and ever-increasing regulations by government agencies and private health insurers. I get paid significantly less to perform the same spine surgery procedures now as I did when I first started practicing in 2010, even though now I perform such procedures more efficiently, less invasively, and with better patient outcomes and satisfaction.
In the meantime, the salaries of my staff, rent costs, insurance costs and supplies costs are only going up. If the overall healthcare costs are going up and my payment rates are going down, where does all that money go? To make matters worse, CMS is planning to cut reimbursement for surgical procedures by approximately 11 percent on Jan. 1, 2021. If this trend continues, patients will face longer waits and lower access to spine care as more surgeons will not be able to be in-network with their insurance plans because of such low reimbursement rates.
The ever-increasing burdensome regulations that are imposed on spine surgeons by CMS, state medical boards and the private insurance companies require the physicians and their staff to spend more time on administrative tasks to stay compliant and to obtain prior authorizations. This time could be better spent providing the actual patient care and improving quality of such care. Most of these regulations are not designed to help the patients, but are instead aimed to limit the amount of care provided, regardless of whether the patient needs that care or not.
Colin Haines, MD. Virginia Spine Institute (Reston): In my opinion, spinal healthcare has advanced more than almost any other aspect of medicine over the last decade. This tremendous growth has in large part been tied to economics. If companies continue to have a financial incentive to innovate and develop new products, as has been the case recently, then we will keep improving exponentially. However, concerns over bundled care models, declining reimbursement and an increasingly more difficult authorization process for surgeries have made the business of spine more challenging. To continue to improve, there needs to continue to be an incentive to improve.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: The continued creeping of insurers into the space between physicians and patients. We, as physicians, have been completely lax in terms of keeping the payers out of the relationship. Now, we are seeing them doing peer-to-peer reviews for follow-up CT scans for fusions done for dens fractures. Forms are sent to my office demanding enumerating the manufacturer, model and make for each implant correlated with a CPT code. So again, due to complacency, we have seen more insinuation into the medical relationship space. If we, as a specialty, want to continue to practice in a safe, compassionate and effective manner, it is time we extracted the same from payers in our professional relationships.