Independence is Possible: 3 Spine Surgeons on Opportunities in the Future

Laura Dyrda -  
Amir Vokshoor, MD, of DISC Sports & Spine in Marina del Rey, Calif., Terrence Crowder, MD, of Sonoran Spine Center in Mesa, Ariz., and Joseph Zavatsky, MD, section chief of orthopedic spine surgery at Ochsner Medical Center in New Orleans, discuss today's challenges for spine surgeons and where the opportunities are for success in the future.
Q: Considering the consolidation in the industry today, is it still possible for spine surgeons to remain independent?

Dr. Amir Vokshoor discusses independent spine groupsDr. Amir Vokshoor: They can remain independent, but I think the best option spine surgeons have is joining together into large or small groups to have negotiating power, not joining hospital systems. Spine surgeons are unique subspecialists who are able to control quality and cost to such an important sector in orthopedic and neurological spine treatment. We can avoid direct employment at the hospital by providing high quality care. Many other options also exist for partnering with the hospital on projects like creating a joint venture surgery center or center of excellence.

Right now, less than 40 percent of doctors are independent practitioners and that's a trend that will continue to put pressure on the small business model of one doctor with his practice. Medicine has been traditionally a very industrialized science and art; with the advent of standardization and technological innovation, we can create care pathways and medicine has become 75 to 95 percent formulaic.

As this trend continues, doctors will have to form larger groups and/or join health management organizations on accountable care organizations and not be the smallest voice in the room during these negotiations. They need to reap the benefits of the good things about standardization, which does help overall quality of care and possibly an improved lifestyle by sharing the responsibilities and duties of the practice.

Q: What are some of the alternatives spine surgeons have to hospital employment?

Dr. Terrence Crowder discusses independent spine groupsDr. Terrence Crowder: One of the best ways to avoid hospital employment is to instead partner with the hospital to make their spine service better, more productive, more profitable and more efficient. Hospitals want to be very efficient and they are looking for surgeons and practices to partner with them for effective business. Partnering on comanagement arrangements or co-marketing agreements are very productive; they help the hospital and the surgeon because the surgeon is able to use the hospital's resources to improve his practice and the hospital will see more cases.

The other way spine surgeons can avoid hospital employment is by joining a larger group. Instead of being a small practice, joining a multispecialty group or large orthopedic group decreases the financial stress surgeons have in one-surgeon groups and the practice becomes easier to operate.

Q: What do surgeons need to know about entering into a larger practice after being in private practice for a period of time? Are there any challenges associated with this transition?

The biggest thing to keep in mind is that when you join a group, you are partnering with people so you give up some autonomy. Things you do now directly impact the group, not just you. You are giving up independence, but gaining partners. In that group, you may be forced to do general orthopedic call — which is something most spine surgeons don't do because they would rather do just spine call.

Another challenge is that you may not be the only surgeon doing spine care, so you'll have to share the patients coming in. When you join an orthopedics group and you are the only spine surgeon, you can get all of those cases, but if you join a spine focused group, you have to give up a certain amount of patients coming through the door.

There is also the potential that you will make less money overall, but ultimately you will have a lot more control over how you make that money.

Q: How will these changes to larger surgeon practices or surgery centers impact reimbursement for spinal procedures?

Surgeons are the number one customers as well as leaders of healthcare innovation, so when they partner up they have more negotiation power with their numbers. Multiple surgeons banning together in a practice can help lower the cost of implant usage for the hospital or surgery center they work at. They could also use their collective knowledge to help payors understand what a particular care pathway should cost and deliver better quality to payors that way.

By sheer numbers they can have better bargaining power, although reimbursement is becoming alarmingly low for some surgical procedures, and the near future is alarming!

Q: Overall, what is the biggest challenge for spine surgery reimbursement today?

Dr. Joseph Zavatsky discusses independent spine groupsDr. Joseph Zavatsky:
I feel the biggest challenges facing spine surgeons and reimbursements going forward are bundled charges. There is variability in the way many spine surgeons perform the same spine procedure. Previously, you billed for the different procedures that were performed. For example, a transforaminal lumbar interbody fusion or TLIF is now a bundled procedure. Even though the same amount of technical work is performed and takes the same amount of time, the bundled charge results in lower reimbursement to the surgeon.

But minimally invasive spine surgery could be a way to offset these changes. The data on minimally invasive spine surgery is showing that the complications associated with this technique are lower. These include less blood loss, decreased infection rates, decreased post-operative pain, and more importantly shorter hospital stays. The overall cost of care to the system could decrease because patients are leaving the hospital more quickly and there are less re-operations due to infection.

Surgeons do not need to become hospital employees, but they can align themselves with their respective hospitals in an attempt to improve patient care and ultimately drive down costs. If properly negotiated, these affiliations could prove to be financially beneficial to both the surgeons and the hospitals.   

Q: How can spine surgeons approach hospital executives for these types of partnerships?

Surgeons can initiate these conversations with hospital administrators and inquire about patient safety and or quality outcome committees. Providing data to the hospital about how to improve the quality of patient care, decreasing complications, and shortening patients' length of stay are ways to develop these relationships.  

Everyone is feeling the effects of healthcare reform and the cuts being made. But if we work together with a common goal, we all benefit — the surgeon, the hospital and most importantly the patient.

Q: When surgeons are partnering with hospitals, how can they make sure the partnership is beneficial for them?

The key factor here is for physicians and leaders of the healthcare team to work together. Surgeons are the quarterback of the entire healthcare delivery team. The most important thing is to focus on the patient and demonstrate to payors, government members and our hospital and insurance colleagues that we need to take healthcare back by leading the charge for quality. In any partnership where you put the patient and care pathway as the central goal, and have surgeon leadership in putting the team together of other physicians and allied healthcare professionals, there is chance of success!

That team should include administrators, experts in healthcare finance, physicians and surgeons who must be the leaders because they can demonstrate they are critical to the strategic partnership and lead the healthcare team, which is our calling. We need to demonstrate that we remain a critical part of the team there.

More Articles on Spine Surgery:

7 Spine Surgeons on Biggest Opportunities for Growth in Spinal Surgery

7 Spine Surgeons on Cash-Pay Options

5 Spine Surgeons on Negotiating Out-of-Network Payor Contracts

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