From risk-sharing payment models to increased scrutiny placed on hospital surgeons and expanded data collection and integration, six surgeons predict how the specialty will change as healthcare shifts from a fee-for-service model toward value-based care.
Question: How do you anticipate spine surgery will develop in the era of value-based care? What payer trends are you anticipating in your market?
Oren Gottfried, MD. Duke University Health (Raleigh, N.C.): Every surgeon will be required to not only look at their own quality data, objective patient satisfaction, patient-reported outcomes and costs daily compared to benchmarks and peers, but to improve and maintain it at a high level. Surgeons will be required to follow evidence-based and practice guidelines for concordant care. There will be heavy scrutiny by hospitals to limit their surgeon outliers for quality or cost. Currently, indications for surgery are surgeon based. In the future, we will all follow standard, evidence-based indications for every high-value, low-cost surgery, and low-value, high-cost surgeries will not be allowed.
Also, we will have to prove to payers with historical data that our surgeries demonstrate efficacy with low costs and durable outcomes. In the current model, all you have to do is complete a checklist to get authorized for surgery, but in the future, you will have to demonstrate success with your prior outcomes to get value-based contracts to see more patients.
Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): The key to the future of spine surgery is data collection. Integrating sources of data to one consolidative set that can be analyzed will be critical. The future of spine surgery will be dependent on it. Quality-driven, cost-efficient decision-making will prevail. No longer will simple authorizations be adequate to determine decision-making for the type of surgery. The cost of the procedure and the patient-derived outcome will drive the system. The era of out-of-network and fee-for-service will soon end. HMO limitations have failed to provide the right answers for quality-based service availability to the patient.
The shared-risk model in a value-based system will look at cost and quality outcome of the surgical decision to determine reimbursement. As spinal surgery involves complex decision-making for a proper choice of the type of intervention, full sets of data to determine the cost and quality outcome will be needed. This is needed across an entire population seen (i.e., all patients seen in the clinic as well as those operated on), diagnosis codes, case selection and treatment choices. The event-of-care data with cost, complications, readmissions, etc., will all need to be included with the patient-derived outcome system for follow-up.
This will determine a baseline for value in the value-based care system and requires that the data from all of these varied sources be consolidated into a working database with the establishment of a baseline. The decisions derived from this data will drive the future generations of decision-making and teaching.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I think value-based care will likely only work in certain markets. I predict that most insurers will end up turning their business models towards administration of direct care contracting. I really don't see payers being able to continue to do business as usual in the current marketplace. Direct-to-employer contracting is a model that will work better for patients and physicians in being able to control cost and eliminate the unnecessary and often detrimental presence of the middle-market people. In a more direct-care model, companies will really see the value provided by excellent surgeons and their treatments. I see only more trouble and the loss of revenue with the continued participation of insurers, as they will likely soak up whatever savings provided by the surgeons and increase costs to the insured.
Overall, I think value-based care is detrimental to patient care. Like everything in life, you get what you pay for. That being said, reasonable remuneration for a well-done surgery should have a certain price range, but certainly a surgeon performing a successful thoracolumbar fusion should be paid more than the price of fixing a car bumper. What that price should be could be driven by market forces, if they were ever allowed to be enacted.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The highlights of value-based care are an emphasis on prevention and wellness; a focus on improving outcomes; integration and coordinated care; and the investiture in practice transformation. These are core tenants of most specialty practices, especially complex spine care in larger health systems. The real challenges I see are the enlarging un/underinsured populace as a result of the pandemic and its toll on the healthcare dollar. Currently, privatized surgical centers disallow Medicare/Medicaid insurance participants and with projected governmental cuts next year, the result will deepen this divide further. Payer trends seem to be more centered on patient flow and surgical approvals as backlogs continue to grow with staffing issues being foremost. Locally, the throughput of insurance claims are more surgically accommodating.
Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): It will be difficult for an independent practitioner, as they do not have infrastructures or supportive systems like the bigger groups or hospitals. I have been collecting outcomes on my patients to prepare for this. However, we have to have a fair price, as there is no one-size-fits-all. Practicing medicine is an art, not a cookbook. We have to consider each patient regarding their comorbidities. We also have to weigh what technique, implants, biologics, navigation, etc., are utilized for surgery. If value-based care was truly value-based, commercial payers and CMS would not continuously look to pay less for the same or better outcomes.
Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): Value-based care as a business model has been challenging in spine surgery. It has been more successful in joint replacements with the bundled payment program. Unfortunately, we are seeing a lot of payers putting in work to deny spine surgery via the pre-authorization process. Many of the criteria they use to approve spine surgery changes — there has to be better uniformity in this process.
Spine surgery as a field will be able to achieve greater value as more cases move into surgery centers. I am starting to get a lot more phone calls from ASC management companies and a few payers to determine how to implement awake spine surgery in their centers. The adoption of outpatient spine surgery will be market driven — this is how the field will develop in the era of value-based care.