Spine care delivery will look very different in 5 years: 10 surgeon insights


From multidisciplinary spine centers to the continued growth of telehealth and rapid migration to the outpatient setting, 10 surgeons outline how spine care delivery will evolve in the next five years.

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: What procedure(s) are you considering migrating to your surgery center?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, March 31.

Note: The following responses were lightly edited for style and clarity.

Question: How do you see spine care delivery changing in the next five years? 

Colin Haines, MD. Virginia Spine Institute (Reston, Va.): 2020 was a year of evolution for healthcare. New challenges bring new opportunities for innovation. Because of the concerns about in-person healthcare delivery during the height of the pandemic, our field has rapidly evolved to incorporate telemedicine. This has been revolutionary for multiple reasons. The speed and efficiency overall are tremendous — patients now have access to medical experts at their fingertips. 

Public health experts have long stated that we have a physician distribution challenge in America. Now, we can have patients who live in regions without high-level spine care connect to us over the internet as opposed to having to travel long distances for their initial visit. Also, patients who are challenged by taking time off work or caring for their children can receive care from the convenience of their office or home. In essence, patients are now more than ever able to get their spine condition addressed as the geographical barriers to entry are eroded.

Telemedicine is not without its negatives, however. Quality spine care is so much more than a history and imaging review. An in-person physical exam by a spine surgeon is paramount for accurate diagnosis and treatment — a critical step that cannot be achieved over the internet. Regardless, I firmly believe that telemedicine is a critical development that I integrate into my practice and has expanded my reach to those who need it the most.

Burak Ozgur, MD. Hoag Neurosciences Institute (Newport Beach, Calif.): I believe spine care delivery should be delivered more by way of comprehensive multidisciplinary teams. In this way, there's more opportunity for collaborative treatment and providers to learn from one another, ultimately improving outcomes. I also expect there to be more accountability to objective patient outcomes. We need to see what treatments yield better results and improved functional outcomes.

Brian Gill, MD. Nebraska Spine Hospital (Omaha): Spine care will continue to evolve over the next five years with a greater emphasis on moving procedures to outpatient settings. It is already happening at an exponential rate, especially with CMS dropping nearly all spine-related inpatient codes and moving them to outpatient. This will move many procedures from a hospital setting to an ASC setting, continuing the ongoing trend. Techniques and protocols will continue to evolve to facilitate the progression of spine care to an outpatient setting. I am a strong proponent that providers need to have a vested interest in the care of their patients as it helps to drive efficiencies, controls costs and provides superior outcomes. In turn, this creates value to insurers, employers, and most importantly, patients. 

There will continue to be cost scrutiny and downward pressure on reimbursement for spine procedures. I recently saw where bundled payment models resulted in roughly a 10 percent savings in several surgery types. Insurers will continue to scrutinize spine surgery indications which may delay or prevent care from being delivered. I think bundle payment models will continue to gain traction as well as other models that will result in cost savings.  

The one silver lining of the COVID-19 pandemic was the widespread adaptation of telehealth. The emergency declarations temporarily suspended some of the telehealth requirements, making it more accessible to patients and providers. Telehealth has been around for some time, but it has had limited use due to many constraints. I think that telehealth is here to stay and will continue to increase as a percentage of overall patient visits.

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): As patients become more sophisticated in researching their care, they will look for data on their provider's outcomes.  Increasingly, surgeons should set up a mechanism to collect their surgical outcomes, and ultimately be able to publicly display that data. In addition, patients will want to receive their care in Centers of Excellence. Having all their spine care providers under one roof, in a one-stop shop, will be desirable and convenient. Patients will realize that coordination of their care will be easier if all providers are under one roof.

Richard Kube, MD. Prairie Spine (Peoria, Ill.): With the rising costs of healthcare in general, healthcare consumers will be searching for options that provide value. Many procedures, including those required for spine ailments, can be done safely in an ambulatory setting. The streamlined and efficient nature of ASCs makes them well equipped to provide high value for the services rendered. I believe these market forces will continue to incentivize more care to be provided in the ambulatory setting, including spine surgery.

Peter Derman, MD. Texas Back Institute (Plano): The pandemic gave us all an unanticipated crash course in telemedicine. While in-person office visits are now again the norm, virtual visits remain an attractive offering for certain patients. These include those who must travel great distances for care; those with responsibilities at work or home that make it difficult to take time away; and those for whom travel is difficult due to physical limitations. Certain routine postoperative visits and imaging follow-up appointments are also quite amenable to telemedicine. As we increasingly demonstrate the value of telemedicine through research publications, I am hopeful that payers and regulators will break down existing barriers to allow more widespread utilization. Rather than being limited by their local geography, patients should be able to seek the care of leaders in the field from the comfort of their homes. 

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: Down the pipeline, spine care delivery will be increasingly hybridized with more motion preservation, augmented reality/virtual reality, robotics, endoscopy and telemedicine. We are seeing more spine care also being moved to the surgery center in an extended-stay modality. By 2026, I think we will see a very different payer landscape as well. Whether for better or worse, there might be a single payer and/or bundled payment system. I do not think this will necessarily be a good thing.

The reason being, part of what makes spine surgery so important is the positive effect it has on patient lives. The impact of being without pain, or being much relieved, and being able to return to work and their family life is utterly undervalued by the payers. Unless something changes, and both physicians and patients push back, despite all the innovations and amazing technology, unless someone makes the payers actually pay for it, patients will not enjoy its benefits. 

Adam Bruggeman, MD. Texas Spine Care Center (San Antonio) and CMO of MpowerHealth (Addison, Texas): Spine care delivery will clearly shift toward the outpatient setting as payers see cost savings and providers have greater opportunity for ownership in surgery centers. Trends are shifting toward employment models and consolidation of practices as we see hospital systems, private equity and insurance companies continue to employ a greater percentage of the workforce. Also pushing this trend is the growing attitude of physicians who prefer to avoid the ever-growing practice management requirements and increasing burden of preauthorization associated with payers.

Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The surgical expectation of early discharge is already the accepted norm for those who are capable following spinal surgery. The length-of-stay issue and patient education surrounding the pandemic has been an accepted shift of practice, resulting in temporary unit creation, focal physical and occupational consultation and early readiness for discharge. Diagnoses that are complex to treat such scoliosis, deformities, remote fractures, or intracanal tumors of the spine, coupled with systemic illness, will remain challenges even in the best health systems and providers.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): I expect there will be more spine cases being done in outpatient settings. There will be more adoption in motion preservation and endoscopic spine surgery on both sides, the surgeons and the insurers. I predict we will continue to see the growth in robotics, navigation and artificial intelligence.

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