Spine surgeons' biggest threats headed into 2024


The spine field has exciting innovations and opportunities for surgeons to improve patient care. But there are also roadblocks holding surgeons back from truly delivering the best care possible for patients.

Independent spine surgeons are seeing financial challenges from workforce shortages, high labor and supply costs, and pressure to invest in new technologies. The most significant challenge in 2023 has been the burden of increased prior authorizations and insurers requiring more approvals before surgeons can render care.

At the 20th Spine, Orthopedic and Pain Management-Driven ASC Conference in June, a panel of spine surgeons shared their experiences with prior authorizations and changing payer policies.

"[Prior authorizations] seem to be an ever-moving target," said Carlos Bagley, MD, chair of the department of neurosurgery, co-chair of the neurosciences division and co-medical director of the Saint Luke's Bloch Neurosciences Institute in Kansas City, Mo. "It creates additional challenges for efficiency and just good quality patient care."

Ernest Braxton, MD, a surgeon at Vail-Summit Orthopaedics & Neurosurgery in Vail, Colo., agreed.

"The biggest holdup in getting patients to the OR used to be getting pre-op clearance, a medical reason, but now the biggest reason is insurance preauthorizations," he said. "The usual threats always loom over the horizon. I think they're very real existential threats of decreased reimbursement, erosion of our contracts, which just makes it harder for us to maintain private practice."

Frank Phillips, MD, a spine surgeon at Midwest Orthopaedics at Rush and director of the division of spine surgery at Rush University Medical Center, has also seen payer challenges ramp up in the last year.

"The payers have the deck stacked in their favor," he said. "We all know we fight those battles on a one-on-one basis for illogical denials … Years ago they would say we didn't have evidence for what we do. We've done a really good job over the last 20 years of providing a lot of good evidence and good data, but it doesn't seem to have much effect."

These challenges are evergreen, and Dr. Braxton's team surveyed the landscape and found a new opportunity to drive patient care. Surgeons can despair, he said, but that isn't very fun.

"Instead of wallowing in self-pity and despair, we're seeing newer opportunities," he said. "I happen to live in a place where there's a lot of medical tourism and we're focusing more on getting people who are out of state and even international to get care out in Colorado."

He has developed strong patient relationships that "transcend geographical boundaries'' as patients choose to travel and see him for degenerative conditions. He sees relationships with insurance companies and investment in improved technology as well as the site of service changing more to the outpatient setting.

The transition to more outpatient spine surgery could mean more alignment, or more contention, between hospitals and surgeon groups.

"The venue of care and how we pay for [new technology in spine] is critical as we move more to outpatient facilities," said Dr. Phillips. "I think that now the relationship between hospitals and ASCs is becoming more and more challenging as hospitals see their cash cows moving away. I think those are the things we're going to deal with over the next five years."

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