Connect outcomes to payment — How value-based care must evolve in spine


Five spine surgeons discuss flaws in current value-based systems and offer solutions to make the models more effective for spine providers and patients.

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 spine technologies should ASCs invest in over the next three years as cases accelerate toward the outpatient setting?

Please send responses to Alan Condon at by 5 p.m. CDT Wednesday, July 7. 

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

Question: What needs to change for value-based care to be more attractive for spine providers?

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): The original value-based programs were started by CMS in renal disease, hospital purchasing and readmission, reduction of hospital-acquired conditions and developing of a physician value modifier. Benchmarking to these standards is important to the outpatient ASC world particularly for spine and other high-acuity cases, but the model of implementation still needs to be developed. It centers on careful and accurate data collection; benchmarking against known hospital standards (while showing the ASC model exceeds these); diligent case costing and pricing transparency; and linking this to quality markers and outcomes analysis. Most important, it's reducing this to a digestible model that the patients can understand. The ASC model is set to develop and push forward the limits of new, value-based models. It is up to us to document the information and provide it to the payers and patients in a meaningful package.

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): For our healthcare system to truly move toward a value-based system, outcomes will have to be linked to payment. Incentives drive behavior. Unfortunately, surgeons who achieve better outcomes are not rewarded appropriately. The reasons for this are multifactorial (third-party payer system, universal agreement on an appropriate surgical outcome). The goal of a value-based healthcare system is to achieve an outcome that is meaningful for the patient. If the provider is incentivized to reach that outcome such that it gives them a competitive advantage, more surgeons will try to innovate around the delivery of spine surgical care. Ultimately, this will advance the field, further deliver value for the patient and take unnecessary costs out of the system.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Value-based care is based on the faulty assumption that cheaper is better. Personally, I have dedicated myself to its deconstruction. It is harmful to practice, patients and is antithetical to good medicine. You cannot get a Maserati at a Yugo price. There is yet to be a study demonstrating cheaper is better in spine. The false equivalency of using cheaper materials and cookbook medicine to arrive at as good an outcome as a pricier, more thoughtful treatment being 'better' is based on the fallacy that doctors are the drivers of cost in medicine. Once we stop allowing the powers that be from trying to squeeze blood from a stone, we can better take care of patients. Physicians are being let go in favor of less-trained midlevel individuals in an effort to save money, and it permeates not only into primary care, but also medical and soon surgical specialties. Value-based care ends up driving up costs when things have to be re-done, and when hospital systems churn their way through surgeons, getting increasingly less experienced (and likely less expensive) surgeons to do the quality of work that only an experienced surgeon can do. Once we physicians stop acting like Lando on Bespin when Vader tells him that he is 'altering the deal,' we stand a chance to preserve the quality of our craft.  

Andrew Hecht, MD. Mount Sinai Health System (New York City): Value-based care today remains only for the most simplistic of problems. Value-based care does not account for bigger procedures, complex problems or sick patients. Spine surgeons must be careful about avoiding a race to the bottom under this term 'value.'

John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): Value-based care attempts to categorize patients into neat little buckets and provide physicians with as little money as possible to care for those patients. In theory, this incentives physicians to save money, but in reality it over-simplifies the whole patient. Especially with spine patients where all 'fusion' patients or all 'deformity' patients are not the same. Unless insurers and the government are willing to use significantly more buckets for spine patients, this type of system will dramatically underpay for select patients and ultimately drive many surgeons away from caring for these people. This could contribute to the sickest patients with real varsity-level problems losing access to care. In the end, the insurers (including the federal government) save money and the people who have been paying premiums or taxes could lose access to care, even though the procedures they need are technically covered. I think we should be careful about which side of this we want to find ourselves.

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