What's worrying spine surgeons?


The spread of the coronavirus' delta variant, increasing prior authorization requirements are among the biggest concerns for spine surgeons in the coming months.

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 will CMS' 2022 proposal regarding payment and site-of-service changes affect spine care?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, Aug. 18. 

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

Question: What is your biggest concern as a spine surgeon over the next six months?

Richard Chua, MD. Northwest NeuroSpecialists (Tucson, Ariz.): My biggest concern over the next six months is the increasing COVID numbers related to the delta variant. Will this increase lead us, again, into difficulty with human resources (RNs, MDs, etc.), hospital resources (ICU beds, regular beds) and the ability to continue to perform elective spine surgeries?

In addition, I am very concerned about CMS' new policy for requiring prior authorization for surgeries that were previously not required for authorization or approval. This new requirement will continue to create delays in treatment for some patients. While it may be reasonable to require prior authorization for [anterior cervical discectomy and fusion] for single-level [herniated nucleus pulposus], what about the patient who has severe spinal cord compression and myelopathy? Waiting 14 days for prior authorization could be detrimental to the patient's outcome, and takes away some of the authority to decide best medical care from the patient-surgeon relationship.

Nitin Bhatia, MD. UCI Health (Orange, Calif.): My biggest concern over the next months remains the ongoing COVID-19 pandemic. The current quickly-spreading delta variant reminds us that we have not emerged from this world-changing disease, and that we do not fully understand or control the spread of the virus. With increasing disease numbers, healthcare institutions, and healthcare workers, may once again be overwhelmed, even though vaccines are widely available in our country. Both as a surgeon as well as a member of my community, I hope that we can all remain safe and make healthy choices while continuing with as normal a life as possible.  

Plas James, MD. Atlanta Spine Institute: My biggest concern is getting unvaccinated people vaccinated for COVID-19 because as it happens across the country, hospital beds are filling up causing spine surgeries to stop as there are no beds for surgery patients. Another concern is children getting COVID-19 by going back to school without wearing masks and bringing it home to their parents who then get sick. The world getting vaccinated is key to keeping us from shutting down nationally, especially in hospitals.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The looming Medicare cuts and the rise of the delta variant are top of mind. Firstly, the Medicare cuts initiated in the last administration show just how myopic CMS has become. There are few if any practicing physicians involved in the decision-making process for physician remuneration. They carry forward the fallacy that the cost of healthcare is due to physician fees (hint: it is not). And further, in the name of budget neutrality, they are not only willing to decrease patient access to care by making more physicians less likely to continue to accept new Medicare patients, but also willing to put in place arbitrary prior authorization mandates that add to bureaucracy and not to better care.  

As for the delta variant, the vaccines are here, hundreds of millions got their shots safely and it's time. The more the virus replicates, the more it can mutate, giving new — potentially dangerous — properties to the virus. We are only a few mutations away from decreased vaccine efficacy.       

John Dickerson, MD. Kansas Spine & Specialty Hospital (Wichita): One of my concerns is reimbursement continuing to decrease. Every year we see insurance companies cutting reimbursement while our expenses increase. Also, we are seeing an upsurge in the number of denials. Denial management within the practice eats up resources and, more importantly, it's not good for the patient.

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): The preauthorization process is currently broken. My biggest concern as a spine surgeon is the delay in care that is resulting from this broken process. Sometimes the guidelines do not make sense and there is not enough flexibility built into the guidelines to allow a patient to proceed with surgery if they do not meet criteria. Unfortunately, much of medicine — spine surgery in particular — is not so cookie cutter that we can make rules on who needs/doesn't need spine surgery.

Insurance companies and the major societies should come together to come up with a more equitable process to authorize surgeries/injections/imaging in spine care. This may entail the development of a peer-review process, similar to what is used for publications in academic journals. Alternatively, the insurance companies can yield decision-making to a third-party organization tasked with developing guidelines for preauthorization. It is interesting to see the variability in medical guidelines among the insurance companies. I've had instances where a patient was denied spine surgery by one insurance company. They enrolled in another insurance plan and were subsequently approved for surgery. This contradiction clearly is not good for delivering high-value patient care. 

Ali H. Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): My greatest concern over the next six months relates to the surge in COVID-19 infections and the impact this will have on patient care. While hospitalizations are increasing, this has a downwind effect on ambulatory surgery centers. We are seeing increasing restrictions on what is required to have clearance for surgery, requests for systems to withhold elective surgery in order to make resources available for inpatient care, and difficulties accessing primary care appointments for our patients. Increasingly, this is impacting our staff and personnel, as many vaccinated individuals are becoming infected and are forced to stay home and quarantine. Lastly, statewide mandates for vaccinations of frontline healthcare workers are leading some within the healthcare field to not get vaccinated and instead move out of state or change careers entirely.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): One of many concerns is the rising cases of the delta variant. I anticipate that we may need a third booster dose every six months or year. I am also concerned about the increasing coverage denial from the insurance carriers that may lead to delay in treatments. 

Commercial insurers are still reluctant to listen, acknowledge and accept evidence of advanced technologies despite having supporting evidence. For example, endoscopic spine technique, motion preservation, disc arthroplasty, etc.

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): I think the biggest concern over the next six months for all physicians, including spine surgeons, is the COVID-19 pandemic. All healthcare workers should work toward mandating universal vaccination and making sure that the government enacts appropriate masking and distancing protocols, so that the spread of the virus is minimized and vulnerable populations are protected.  

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