Thirteen spine surgeons share their outlook on the spine field in 2021 and what success will look like for their practice.
Note: Responses are lightly edited for style and clarity.
Question: What are you expecting from the spine field in 2021? What does a successful year look like for your practice?
Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): I anticipate advances in enabling technologies that allow procedures to be informed in a less invasive, more efficient and reproducible fashion; ideally in an outpatient setting. These technologies include augmented reality, enabling precision, less-invasive procedures and looking forward to robotics evolving to truly solve technical challenges in an efficient manner rather than being adopted for marketing purposes.
In terms of my practice, a successful year includes COVID becoming a more manageable situation with resumption of more normal interactions with patients, colleagues and friends. I anticipate my outpatient practice expanding even beyond XLIF, TLIF and ADCDFs/TDR that I currently regularly perform in our ASCs.
William Taylor, MD. University of California San Diego: In my opinion 2021 will be a year of continued expansion for appropriate technology. This will allow us to shorten recovery time, improve outcomes and shorten surgical times. These improvements will come based on reduction in complications and decrease in reoperations from issues that can be rectified or prevented prior to leaving the OR. In addition, improved outcomes will be based on our use of artificial intelligence to help in patient selection. This will not only be based on entering appropriate patients in preoperative education and rehab, but lead to a decrease in the use of narcotics. That will allow us to select and individualize operative procedures that are appropriate for specific patients. Intraoperatively, the continued use of robotics, navigation and augmented reality will allow us to avoid some routine issues that have caused reoperations, infections or neurologic injury.
Success of our practice will be based on our ability to include this expanding technology in the appropriate setting, and working with stakeholders to ensure that it is used properly and effectively to provide increased value. Patients will continue to demand that we understand, implement and provide procedures that utilize the latest technology to improve their outcome.
Lali Sekhon, MD, PhD. Reno Orthopedic Center (Reno, Nev.): This year has been a challenging year for everyone and stability would be a nice way to enter 2021. We are immediately facing possible elective surgery closures and most of us are hoping that the COVID vaccine will alter the downward spiral of healthcare and the community. I expect a couple of things:
1. Pressure on reimbursement. We are already starting down the gun barrel of an almost 10 percent reduction in reimbursement for surgeries from CMS, with commercial payers to follow suit. With most practices running at greater than 50 percent overhead, this does not augur well.
2. More new technologies. Navigation, implant materials, bone graft substitutes, robotics and augmented reality.
3. More questioning of new technologies. The question that hospitals and healthcare systems will ask about these new technologies is where the value lies. I see more and more questioning by health systems on the introduction of new technologies with some demonstration of the value they bring over "easier for the surgeon" or "surgeon preference." A lot of hospitals see some of these technologies as marketing stunts with entry level benefits.
4. The aging population. More Medicare recipients will need care. The case mix will continue to tilt away from commercial payers.
5. Consolidation of groups or organizations. Power in numbers.
6. The importance of ancillaries to the survival of private practice groups.
7. Challenges for small spinal implant companies as hospitals reduce vendors for savings.
8. More transparency in terms of payments/reimbursement.
9. Gainsharing/co-management agreements between hospitals and surgeons becoming more prevalent.
10. More outcome data on surgeons and hospitals for consumers.
Overall, 2021 may be challenging. We are fortunate to have somewhat recession-proof careers and are in a better position than other sectors of society, but with so much money spent at a state and federal level on COVID relief, reducing payments for Medicaid and Medicare are in the pipeline. The hamster wheel is going to get driven faster for less.
Jonathan Gottlieb, MD. Minimally Invasive Spine Center of South Florida (Miami): I anticipate that 2021 will continue to challenge the country for innumerable reasons, and the field of spine surgery is certainly not immune. In addition to the direct impact of COVID, the vitriolic political environment and uncertainties surrounding the extent to which the government will manage healthcare in the future will likely temper any substantial growth efforts in our field. Additionally, many people have either lost insurance, lost their jobs, or face incredible out-of-pocket expenses that limit their interest and ability to undergo treatment unless it is an absolute emergency. I am hopeful that we will have some modicum of control over this disease and that the expansive cognitive dissidence gripping our country will also mitigate over the next several months. At that point, we may begin to see some return to normalcy in our practices and in the field as a whole.
We have been fortunate and able to maintain the practice without any personnel losses. However, the financial setbacks are real and cannot be tolerated indefinitely. Our reserves position was favorable at the onset of the pandemic and really reaffirms the need to plan for lean times. Lessons from this experience should never be forgotten. Private practices, already an endangered species, will not survive unless we incorporate what we have learned and evolve before it is too late. We would define 2021 as a return to 75 percent of pre-COVID volume.
Bradford Currier, MD. Mayo Clinic College of Medicine (Rochester, Minn.): COVID and politics dominated every aspect of our lives in 2020. The Dec. 13 electoral college vote and the FDA's vaccine clearance were propitious events that hopefully foretell a semblance of normalcy for 2021. Some positive changes will carry over from the pandemic, like more telehealth visits, fewer in-person administrative meetings, more online education and more attention directed at preventing infections, including getting rid of ties at work. Technical advances drive the spine field, and there are numerous candidates for disruptive technologies in 2021. Artificial intelligence, machine learning, robotics, image guidance, virtual reality, augmented reality and digital microscopy represent some of the advances that will potentially improve our field's ergonomics, safety, efficiency and outcomes. Lowering costs should be a top priority, but regrettably, that is not likely to happen in 2021.
The first virtual Cervical Spine Research Society conference concluded last weekend. It was a tremendous success and is still my favorite meeting of the year, but I hope that we can go back to face-to-face educational conferences next year. Fitting to the 2021 question was an excellent symposium during the CSRS meeting on "Using Big Data for Cervical Spine Management." Joe Schwab, MD, gave an illuminating talk titled, "Machine Learning And Spine: Is It Here Or Is It Hype?" He discussed the Gartner Hype Cycle1. A successful year will separate the wheat from the chaff of technological "breakthroughs" to get us to the slope of enlightenment and plateau of productivity of the hype cycle and focus on improving patient care and cutting costs. Let's hope that we also see the end of COVID and partisanship.
Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): Next year will be a transformational year in spine surgery. Both physicians and medical device companies will have to adapt to a new normal. The trend towards outpatient spine surgery will only be accelerated by patient demand as well as insurance companies and Medicare encouraging more cases to be done in an outpatient facility. Increasingly, I am getting a number of calls from physicians asking for guidance on how to do awake spine surgery as more patients are asking for it. I recently helped guide a physician in Chicago to perform an awake spinal fusion after his patient asked him for the surgery to be performed using this protocol.
Medical device companies will have to adapt to this new normal and offer services to surgeons to help them transition their practice to the outpatient space. This will include not only minimally invasive tools but also digital training tools, AR/VR technologies to train surgeons and staff, along with digital tools that will allow surgeons to do remote patient monitoring postop.
William Rambo, MD, and AnnMargaret McCraw, CEO. Midlands Orthopaedics & Neurosurgery (Columbia, S.C.): While COVID-19 and a new presidential administration are unpredictable variables facing the delivery of spine care in 2021, we remain optimistic that clinical advancements coupled with market pressure will yield positive results for patients and other purchasers of care as well as spine surgeons. Currently, 34 percent of all spine surgeries performed by our physicians occur at our ASC offering excellent outcomes and dramatic cost savings. Recognizing this value, insurance plans and self-insured employers continue to expand coverage for advanced spine procedures in the ASC setting, so we expect this volume to increase in 2021.
Facilitating this increase are ongoing advances in intraoperative imaging and perioperative pain management, including Enhanced Recovery After Surgery. Our group recently included eight spine surgeries in the bundled surgery menu on our website. All spine bundles include the surgeon and assistant fees, ASC facility fee, implants, anesthesia and 90 days of routine follow-up care. As healthcare purchasers clamor for price transparency, we expect 2021 to bring us more patients, self-funded employers and their third-party administrators who appreciate our easily accessible pricing menu.
Finally, as the burden of data collection is continually reduced by technology improvements, registry participation and reporting of truly meaningful surgical outcome data becomes easier. We expect to enhance our quality tracking and reporting capability in 2021. Overall, a successful year for our practice includes abundant opportunity to set ourselves apart as providers of choice who offer healthcare purchasers enhanced value through excellent surgical outcomes, exceptional patient experience and fair, transparent pricing.
Scott Boden, MD. Emory University Orthopaedics & Spine Hospital (Atlanta): A successful 2021 will see a return to above pre-COVID patient/procedure volumes (some catch up on deferred care), and maintaining some of the innovations that were accelerated as a result of the pandemic, such as telemedicine. Helping patients realize that the insurance they purchased will not cover the modern therapies, especially with regard to biologic injections and cartilage replacement, that they desire and deserve.
Domagoj Coric, MD. Carolinas Medical Center (Charlotte, N.C.): I am expecting a slow transition back to a semblance of normalcy with the availability and distribution of the COVID-19 vaccines. There will be a continued trend toward consolidation in hospital systems (our affiliated hospital, Atrium Healthcare, is proceeding with a merger with the Wake Forest University system), payers, industry and surgical practices. The pandemic has accelerated the transition to telehealth and virtual medicine as well as increasing the amount of spine surgery being delivered in the ambulatory setting. The continued adoption of MIS techniques will also accelerate the trend to outpatient and ambulatory spine surgery.
There will be a return to physical meetings even as surgeons and industry continue to take advantage of virtual interactions. I anticipate the first major physical spine meetings — the International Society for the Advancement of Spine Surgery in May and the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint section on spine and peripheral nerves in July — will be well-attended as a welcome relief from COVID fatigue and isolation.
Innovation trends will continue with advances in intraoperative navigation, including more sophisticated robotics and AR platforms. Spinal arthroplasty will continue to evolve with the impending FDA approval of a third cervical artificial disc device, the Simplify Disc, for two-level cervical disease, and two other devices — Baguera-C and Synergy — in active IDE study. Lumbar arthroplasty may see something of a renaissance as the Tops lumbar artificial facet pivotal IDE study completes enrollment and the Balanced Back posterior lumbar artificial disc launches its pivotal IDE trial. Core fusion technologies should also benefit from pent-up demand as the pandemic recedes in the second half of 2021.
A successful 2021 will entail navigating the continued fallout of COVID-19, including the spectre of a second widespread elective surgery slowdown. On top of the myriad medical challenges brought by the pandemic, surgical practices must also deal with looming CMS cuts. In what can only be described as impeccably poor timing, neurosurgical practices are looking at a cut of 6 percent due to changes in Medicare's physician fee schedule. Success will ultimately be determined by the physical health of our medical providers as well as the financial stability of our practice.
Raymond Gardocki, MD. Vanderbilt University Medical Center (Nashville, Tenn.): I expect endoscopic interbody fusion to grow significantly. I also expect that outcomes data will be collected, showing higher fusion rates and less subsidence due to better visualized disc prep and less endplate violation. Look for new instrumentation advancements and technique refinements that make this procedure feasible for more surgeons to perform outpatient and awake one- and two-level lumbar fusions. I think this will lead to more mainstream acceptance and use of endoscopic spine surgery. A successful year for my practice would be doing all of my posterior one- and two-level thoracic and lumbar cases endoscopically by Christmas 2021.
Thomas Loftus, MD. Austin Neurosurgical Institute (Texas): It's difficult to predict 2021. The response to COVID has been stifling to surgeons and their patients across the country. New Medicare rules with decreased payments and new prior authorization requirements are only going to limit patient access to their health care even more. I am hoping there will be more pushback by spine surgeons on the newer regulatory and pricing burdens in 2021. Innovation is likely to be slow due to limited meeting and social interactions among surgeons and scientists in 2020. A successful 2021 would be hopefully recovering some of the financial losses accrued in 2020 by restoring access to patients and healthcare delivery in general.
Mick Perez-Cruet, MD. Michigan Head & Spine Institute (Southfield, Mich.): I expect to see continued growth in the spine field in 2021. Increasingly, patients suffering from spinal disorders are recognizing the benefits of outstanding spine care in achieving a better quality of life and getting them back to an active lifestyle. This is being achieved through advancements in minimally invasive spine surgery and a better understanding of spinal disorders. Large collaborative spine surgery patient-generated data pools such as the Michigan Spine Surgery Improvement Collaborative, a Blue Cross Blue Shield-initiated program, are showing us the true benefits of spine surgery care in improving the lives of our patients.
Continued constructive analysis of patient outcomes and procedures that work to produce optimal patient outcomes will lead the spine field in 2021. A successful year would involve continued growth and prosperity through the provision of outstanding, compassionate and affordable spine care. Our ASC continues to grow as we bring more cases to the outpatient setting.
Philip Louie, MD. Virginia Mason Medical Center (Seattle): Next year will be a huge relief, in that 2020 will be finally over! Unfortunately, similar challenges will persist. Working in a large medical center in a large metropolitan city, we are faced with large volumes of surgery cancellations and in-person clinic visits due to the pandemic. Our first challenge will be to coordinate, maximize and support patients through extended conservative measurements. Reassuring patients on the safety and efficacy of providing surgical care will be paramount. As such, I think spine providers will need to turn to new methods of patient engagement and mobile health options. This includes using mobile technology for health education, treatment adherence, chronic disease management and remote monitoring of health conditions.
Given the wide range of applications and the increasing popularity of smart devices, mHealth has the potential to transform the way healthcare is delivered. However, similar to the introduction of telemedicine, we will need to learn to adapt and trust a new technology that may create increased work burden during the early stages. New modalities and programs that take us out of the comfort zone — away from the traditional model of providing care — can be challenging.