From decreasing reimbursements to widening physician scope, here is what six spine surgeons say are the biggest threats to their profession.
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: Which spine innovations/surgical techniques will see the fastest adoption in the next two to three years?
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Editor's note: Responses were lightly edited for clarity and length.
Question: What’s the biggest threat to spine surgeons in 2023?
Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): The ASC environment — run by and for physicians — has proven to produce superior outcomes, quality and cost-efficiency. And yet the biggest threat spine surgeons face today is the loss of autonomy as corporations try to control our futures.
With insurance companies unwilling to negotiate on an individual level and all lending power going to the hospital conglomerates, there is a lack of power among practitioners. Unfortunately, this works against the insurers, with higher hospital prices, and pushes the practitioner into an employment model.
Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): Increasingly, other providers are doing procedures that are not effective in an unregulated fashion. The poor outcomes may give all spine surgery a bad name.
Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (Livonia, Mich.): It is now more important than ever that spine surgeries only be performed by expert spine surgeons. We are currently living in an age where non-physician health professionals are trying to push the boundaries beyond the scope of their training. Likewise, physicians that are not surgically trained in the spine (surgically trained spine surgeons being only neurosurgeons or orthopedic spine surgeons) are trying to involve themselves in surgical procedures of the spine when they do not have the proper training to do so.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Spine surgeons are facing a constant barrage of tribulations from every conceivable direction. But the biggest threat by far is bad healthcare policy created by wonks who do not fundamentally understand medicine and the business of taking care of patients. From setting reimbursement policy based on charges instead of reimbursements, to assuming basics about how physician employment works, it is obvious one of the main reasons healthcare is going down the tubes is from bad policy. There is a root assumption things cannot get better until costs are contained. While we see insurers reap grand profits, their allies, and in some cases mouthpieces, continue to advise policy to the bureaucracy to cut physician reimbursements. As we see that is only about 6 percent of the healthcare spend, and insurance is over 40 percent it is still befuddling to most why things still cost so much in healthcare. When you drill down and get to the policy advisers' root assumptions, you start to realize why things continue to not improve for either the doctors or patient access.
Bow Hansen, MD. UCI Health (South Orange, Calif.): One of the biggest opportunities for spine surgeons is also one of its biggest threats in 2023. Technology has dramatically changed how spine surgery is planned and performed. More and more spine surgeons use intraoperative navigation for screw placement. This aid enables spine fusion surgery to be safer and more precise. However, it also allows trainees to go through residency and fellowship without a thorough understanding of spinal anatomy and critical landmarks. Their ability to take over when navigation is incorrect or not available is increasingly lost. Robotics may exacerbate this problem by removing the trainee further from even choosing the correct screw trajectory during the operation. Lastly, algorithms that enable the spine surgeon to supply the patient’s preoperative imaging studies and receive an operative plan remove the surgeon even farther from needing to understand the indications and tradeoffs for a particular surgical approach. The threat to spine surgeons, especially ones in training, is the inability to create an operative plan or to carry out that plan safely without this technology. Additionally, it may enable any doctor to perform spine surgery just as well as a surgeon fully dedicated to spine surgery.
A similar situation is occurring now with GPS navigation and the move toward self-driving cars. Fewer people plan their trip by looking at a physical map, as opposed to entering the starting and ending locations on a computer (or their car's GPS). Cars are also able to drive themselves in more and more challenging scenarios. The detailed knowledge of London's streets that taxi drivers decades ago needed has become obsolete. Soon, it is possible that rideshare drivers may be replaced by autonomous cars.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): By far and away the biggest threat is reimbursement to both providers and hospitals. Decreasing revenue affects production, staffing and efficiency. Clawing back from the reverberations of the last three years is interminable. Coupling these tribulations with shrinking capital budgets have stagnated innovation and progress in this field. The politics of administrative medicine is melancholic where optimism used to be the norm.