MIS, value-based care and more: Trends spine surgeons should follow

Spine

From evolving surgical techniques to developments in healthcare pay, seven spine surgeons shared trends they advise their peers to keep an eye on.

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.

Editor's note: Responses were lightly edited for clarity and length.

Question: What’s one trend that every independent and/or employed spine surgeon should be following?

Wael Barsoum, MD. President and Chief Transformation Officer of HOPCo (Phoenix): One of the most impactful trends that spine surgeons should follow is the increased emphasis on outcomes-based payments among health systems and payers. In fact, CMS has indicated that its intention is for all providers to take on some downside risk by 2025. Furthermore, they have stated that they plan to have at least 50 percent of their contracts to be part of a value-based care arrangement.

Commercial payers have also begun to follow this trend, so spine surgeons must be prepared to pivot away from many of the traditional fee-for-service models. For instance, in 2022, HOPCo partnered with Florida Blue to create a clinically integrated network of community physicians and facilities treating musculoskeletal conditions to participate in a musculoskeletal outcomes management program and risk-shared incentives. One of this program's largest areas of emphasis was creating a comprehensive low back pain program.

In order to move into these more value-based contracts, spine surgeons need reliable and accurate data. This includes outcomes data, claims data and decision-making data. Historically, it has been challenging for surgeons to get accurate and up-to-date data. However, some companies in the market specialize in capturing this data and have robust IT infrastructures. For example, we have invested over $100 million in our data platforms to ensure that our partners have access to the most timely and accurate data so that they can enter into these value-based programs in a way that is most advantageous to them.

Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): One trend every spine surgeon should be following is marketing to the public. Growing up with a family of restauranteurs, I often heard, "you can have the best pizza around, but if no one knows it then you'll never last." Believe it or not, this same concept is applicable to spine surgery. Mass marketing involves having a sophisticated and educated public relations specialist or team of specialists with a finger on the pulse of social media, public perception and popular developments in the given region of practice. There is an art to highlighting what unique qualities you offer to the public and being able to share those talents with patients that need your services. The world needs our talents, it is our responsibility to educate them that we can help.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: As an independent spine surgeon, I feel everyone should be following the trend of prior authorizations. The arbitrary denial of routine tests and clearly indicated surgeries should concern everyone. There are several congressional bills being looked at, and I encourage all those affected to support them. The more insurance companies are held accountable and the less physicians abrogate their fiduciary duties to their patients, the more patients will benefit. I would expect, unless pushback is made, the ever-changing and double-secret guidelines the insurance companies use to deny common sense treatments will grow and become ever more opaque. 

Srdjan Mirkovic, MD. NorthShore Orthopaedic & Spine Institute (Chicago, Skokie, Ill.): The one trend to follow is the evolution of minimally invasive surgery and the continued efforts for it to result in better outcomes for a greater number of spinal disorders. Additional research is needed to determine which patients benefit most from same-day minimally invasive surgeries and which conditions are best suited for outpatient surgical care without compromising outcomes.

Recent research suggests readmission rates are greater for same-day minimally invasive surgeries than for those who had an overnight stay. Though same-day MIS for uncomplicated disc herniations can benefit patients, further research is needed to determine to what extent other more complex spinal disorders — including stenosis and scoliosis — may benefit. Additionally, more thorough understanding is needed of which patient population and spine disorders will benefit the most from MIS without increasing complication rates associated with inherent visual and possible 2D plane orientation limitations.

MIS shows great promise given the possibility of greater pain control and quicker recovery, as evidenced by the current positive clinical trend; however, we should temper our enthusiasm until further clinical research and outcomes become available.

Emeka Nwodim, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Every independent and/or employed spine surgeon should work to transition more surgeries to the outpatient or ASC setting. In addition to practicing medicine, spine surgeons should understand and master the business of medicine.

Alexander Butler, MD. Lenox Hill Hospital (New York City): I am certainly not alone in enjoying the constant stream of trends and changes that characterizes modern spine surgery. I think the pace of evolution is what has drawn many of us to pursue this specialty. We find ourselves amidst broad leaps in technology including augmented reality, robotics, endoscopy and predictive analytics; these promise to shape the future of the field. While remaining up to date and actively contributing to this development is critical, I think it is important to remain mindful of how this process affects the care we provide day to day. 

To that end, one trend I try to keep in mind is that patients' awareness of the remarkable advancement taking place cannot keep up with our enthusiasm as surgeons. As the breadth and complexity of procedural options availabe to us grow, so does the differential in understanding. In my experience, 90 percent of patients simply want the best outcome possible, a priority that is agnostic to specific techniques or technology. As industry enthusiasm, market dynamics and our own excitement and curiosity encourage continual incorporation of enabling technology into practice, each surgeon must maintain their own balance between progression and ultimate quality of their craft for every single case. 

Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): The biggest clinical trend that every spine surgeon should be following is minimally invasive spine surgery. MIS techniques in spine surgery, especially in lumbar fusions, have been shown to be safer for the patients with lower blood loss, shorter hospital stays, lower risk of infections, less postoperative pain and quicker recovery. Despite such significant clinical benefits, MIS techniques are still not as widely adapted as one would expect. Likely causes are the significant learning curve of the new techniques that would require a surgeon to take time out of busy practice, potentially increased exposure to radiation, need for investment in additional technology such as intraoperative CT scanners or robots, and lack of any additional reimbursement for a more complex surgery. The patients, however, are becoming more and more aware of the minimally invasive spine surgery and will seek out spine surgeons who offer MIS techniques and better clinical outcomes.

The biggest practice management trend that all spine surgeons as well as all clinicians should be following is the ever-increasing takeover of medicine by corporate and government entities (which are frequently intertwined). The surgeons are seeing more and more of their capacity to provide appropriate and timely treatments and to be reimbursed appropriately being taken away from them by people and institutions that do not have appropriate medical training and do not prioritize patient well-being. Spine surgeons should make maximum efforts to preserve their autonomy and ability to provide the best possible care for their patients.

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