Payers in spine surgery: A changing dynamic

Payer Issues

CMS and commercial payers are trending toward bundled payments as the healthcare industry shifts from fee for service toward value-based care, while the notion of a single-payer system continues to be tossed around but is unlikely to become a reality in the near future.

Four spine surgeons discuss emerging payer trends in the markets that they operate.

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. Becker's invites all spine surgeon and specialist responses.

Next week's question: What spine technology do you expect to take off in the next five years?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CST Wednesday, March 2.

Editor's note: The following responses were lightly edited for style and clarity.

Question: How has the payer landscape evolved in your market over the last five years? What do you expect in the future?

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): The market is constantly changing in California. There has been a relative balance of managed care, private payer and government payer systems. Attempts have been made to go to a one-payer system, but failed again this year in the California State Senate. I do not anticipate that will change in the near future.

What we are seeing, however, is the progressive trend toward bundles and moving on from there to globalizing care. It is approaching the spine market quickly. We have begun a program with several payers to globalize our payment, including the surgical center, physicians involved, anesthesia, surgeon and assistant, as well as all costs of the event of care. This program has become very popular with the payers and is expected to expand quite quickly in the commercial market.

Ultimately, the managed care market will likely move to the same type of scenario, whether that is instituted through hospitals or clinical groups, in an effort to mitigate the risk by having a global event with a known price tag and quality outcome. The movement will happen first through the payer groups on a fee-for-service basis and is likely to migrate from there to the managed care structures.

Patrick Roth, MD. New Jersey Brain and Spine (Oradell): Insurance companies are increasingly demanding evidence of physical therapy or other conservative treatments prior to authorization for imaging and intervention. While this may appear to protect patients, it is really to limit the cost of care. Imaging is perceived as leading to procedures (and it often does), but imaging is often essential for diagnosis — and when properly evaluated — can actually limit procedures. The challenge is that clinicians have an incentive to treat and insurers have an incentive to limit treatment. Thus there is misalignment with the patient who simply wants to feel better.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: In the past five years, we have seen multiple payers post quarterly profits in the tens of billions. Especially during the COVID-19 pandemic, insurers posted record profits. Patients unfortunately have not gotten better coverage and are paying more out of pocket than ever. Patients are dissatisfied with how much they pay and the healthcare system in general. In the next five years, there will likely be an accelerated movement toward a single-payer system unless insurers decide to stop inflating premiums and pointing the finger at physicians, whose pay rate is flat or has decreased over the past 10 years. 

Congress continues to listen to the refrain from the insurance lobby while the payers rake in the ducats. Perhaps if the right people get in their ear, we can fix this rapidly disintegrating system. I predict if Congress continues to push physicians out of independent practice, they will wonder aloud why they haven't saved more money. All the while, hiding in plain sight in the coffers of insurers.

Richard Kube, MD. Prairie Spine (Peoria, Ill.): There is an increasing level of education within the self-funded, self-insured payer groups. They are beginning to understand bundled payments and the tremendous value of ASCs. They are also finding they have power to contract and step outside the typical BUCA (Blue Cross and Blue Shield, UnitedHealth Group, Cigna, Aetna) world and get true transparent pricing. They are realizing they can function essentially as cash customers, and that empowerment will lead to savings. Cash bundled case rates are on the rise.

Marly Dows-Martinez, MD. PM&R specialist, Resurgens Orthopaedics (Atlanta): Sadly, payer trends continue to decline in terms of reimbursements, but also in terms of procedure approval. Payers continually make changes to their guidelines by adding hurdles for patients to cross, requiring more stringent patient follow up and more detailed documentation. Payer policies seem less based on level 1 evidence and more on administrative bureaucratic job security. We, as physicians, must encourage the publication of level 1 evidence and encourage our various specialty societies to provide unified fronts to commercial and governmental payers. 

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