How the payer market is evolving in 4 spine surgeons' markets


The relationship between spine surgeons and major payers has been complicated over the years. Four spine surgeons shared their perspective on the payer market where they live.

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: With CMS pay cuts declining, would dropping Medicare patients ever be a consideration? If so, what would be your last straw?

Please send responses to Carly Behm at by 5 p.m. CDT Wednesday, Sept. 6.

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

Question: How is the payer market evolving in your region?

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: In our market, managed care continues to try to call the shots. Whether it's some big box plan or Medicare Advantage, it never ceases to amaze me the bill of goods they sell our patients. Our staff are extremely adept at explaining patients' insurance to them, which to me seems perverse. Many patients don't realize what they've signed up for until they try to get care and realize the only thing they are saving is the plan's own money and making their shareholders and C-suite gobs of money. 

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): Self-funded, self-insured employers are starting to wake up to the idea of direct contracting for service. In our market, small, self-funded businesses regularly pay 600 percent of Medicare for in-network spine surgery. Based upon the EOBs we have been able to acquire, we have saved businesses on average $80,000 per surgery when they direct contract with us rather than going through their existing BUCA TPA-driven plan. This is money that falls directly to their bottom line.

Rojeh Melikian, MD. DISC Sports and Spine Center (Newport Beach, Calif.): Historically, too much of the healthcare spend in spine has been focused unnecessarily on fixing surgeries with poor outcomes. Thankfully, this is changing due to two major trends. First, more surgeons are adopting leading-edge, minimally invasive techniques that give their patients better outcomes both more safely and quickly. Second, some of us are also taking leadership roles in working closely with payers to optimize site of service for elective spine care. We're prioritizing quality, minimally invasive surgeries over bigger, traditional procedures and bringing them into the ASC setting. As a result, the cost savings is spread between payers, providers and patients.

This is also helpful in encouraging payers to increase patient access to quality specialists. Who a patient chooses as their health insurance carrier should not be a limiting factor in receiving quality care from leading experts.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): This healthcare payer market is locally driven; however, the largest payer in our state is United Healthcare, leaving one perplexed as to control and pricing. The indisputable drubbing that healthcare suffered under the pandemic is seemingly slow in its return to pre-pandemic or near normal-numbers from fluctuating payer mixes. labor constraints, salaries and expenses and the learned process of navigating surges and volumes. Medicare/Medicaid volumes have certainly expanded, but the majority of these patients are currently under new legislation to provide new work programs all the while being directed towards larger healthcare systems. 

Overall, spinal surgery reimbursements are lower than five years ago duly affecting capital purchase, hospital employment contracts and certainly morale.

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