CMS, Ozempic and more: 5 spine, orthopedic surgeon concerns in 2024


From noncompete clauses to GLP-1 weight loss drugs, several evolving policy and clinical issues are affecting spine and orthopedic surgeons headed into 2024.

Here are five topics physicians are watching closely:

Noncompete clauses

Independent spine and orthopedic practices are watching developments in noncompete clauses. Across the U.S., several states have targeted noncompetes, and the FTC in 2023 proposed an outright ban on them. The majority of physicians — 87% polled by Doximity — support the FTC's proposed noncompete ban.

Noncompetes have been a point of contention at some practices in the last year. A practice in Michigan, for example, settled a lawsuit with surgeons over a noncompete.

"Noncompetes can put independent practices into a tough spot if surgeons don't examine contracts thoroughly," Bruce Prager, MD, of Orthopedic Center of Arlington (Texas).

"If the hospital becomes the owner of the practice it can be in several different forms: own the entire practice 100 percent or own some portion of the practice — the non-physician employees, the lease and the EMR," he told Becker's. "Either way the physician loses control and needs to have some safeguard in effect. This could be some contract that covers a certain number of years. The physician needs to make sure there is no noncompete clause. If not, then the hospital can unilaterally force the doctors to move at the end of the contract leaving them with nothing but their names."

GLP-1 weight loss drugs

GLP-1 weight loss drugs like Ozempic and Wegovy rose in popularity starting toward the end of 2023, but spine and orthopedic surgeons are both intrigued and wary of the effects they could have on the industry. 

Studies are already underway for the immediate and long-term effects of the weight loss drug. An already projected uptick in total joint replacements could come sooner as people lose weight with the drug, experts predict

Then there's also consideration on how the drugs could affect anesthesiologists at spine and orthopedic practices. 

"The downside of these medications is that it delays gastric emptying, and that's how it helps make you lose weight because you feel fuller," Max Courtney, MD, chief of joint replacement at Rothman said. "But some of our patients may need to skip a dose or they need their NPO time [before surgery] to be longer. Our anesthesiology colleagues are actively doing research into the effect with the anesthesia. We're doing active research. We have several studies ongoing at the Rothman Institute looking at the effect of these medications after joint replacement."

Shift to outpatient spine care 

Evolving spine surgery techniques and technologies are making more spine surgeries feasible for the outpatient setting. Along with the patient benefits of being able to recover from surgery at home the same day, ASCs can offer an opportunity for surgeons and practices to diversify income channels.

"I expect that 2024 will continue to be a difficult environment for surgeons as well as orthopedic and spinal implant companies," Peter Whang, MD, of Yale University School of Medicine in New Haven, Conn., said.  Considering the looming cuts in Medicare reimbursement for our services in the setting of increasing expenses, we are facing significant headwinds that make the practice of medicine almost untenable for surgeons and our industry partners alike. In response to these challenges, I believe that we will see an even greater shift of orthopedic and spinal procedures to the outpatient setting in an attempt by surgeons to establish more diverse income streams while providing more cost-effective care. Likewise, I anticipate that there will be further consolidation in our industry as more companies grapple with the stark economic realities of our healthcare system."

CMS woes and whether to keep Medicare patients

CMS' final rule for the 2024 Physician Fee Schedule and Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System cuts overall physician pay 1.25%, and the conversion factor will be $32.74, a 3.4% dip from 2023. At the same time the country has seen the highest medical practice cost inflation since 2000 with a 4.6% increase in the Medicare Economic Index.

For neurosurgeons, the reimbursement rates for common procedures fell by 11.2% between 2002 and 2021, according to a May 4 report from Medscape. For one procedure, excision of a cerebellopontine angle tumor via removal of skull bone, Medicare reimbursements fell 24.3%. The rates rose for only two neurosurgery procedures in that same time period.  

Because of declining reimbursements, some spine and orthopedic surgeons have made the decision to no longer take Medicare patients. 

Managing practice costs and revenues

With CMS pay declining and operating costs rising, spine and orthopedic surgeons are exploring opportunities to cut overhead costs and increase revenue. 

Solutions some spine surgeons have leveraged include moving cases to the ASC when possible and performing minimally invasive surgeries. These can reduce complication risk, patient length of stay and pain medication needs postoperatively. Other strategies include implementing enhanced recovery after surgery protocols and working with health systems to negotiate prices and purchasing agreements for implants.

To boost revenues some spine surgeons are looking for ways to scale their reach by opening additional locations and offering telemedicine services. 

"Heavy use of telemedicine services can optimize clinic throughput and be used in the expansion of services geographically," said Scott Raffa, MD, surgeon with Cantor Spine Center at the Paley Orthopedic & Spine Institute in West Palm Beach, Fla. "Ongoing expansion of services such as second opinion services, specialized programs, and/or wellness and preventative programs may also contribute to an expanded products and service lines for additional top-line revenue."

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