10 Biggest Concerns Facing Spine Surgeons From Healthcare Reform

Written by Laura Dyrda | December 17, 2010 | Print  |
Much speculation surrounds the changes healthcare reform will bring, and physicians from every specialty, including spine, are concerned about how to meet the challenges it will present. Here, spine surgeons and industry leaders discuss the ten aspects of healthcare reform that are most concerning to them and how spine specialists will have to adapt their practices as a result.

1. The influx of spine patients.
Over the next few years, the introduction of more Medicaid patients under healthcare reform law and an increase in the aging population means there will be an influx of patients seeking orthopedic and spine surgery. At the same time, the number of spine surgeons coming out of spine fellowships hasn't increased to fulfill the needs of these patients, which means spine surgeons around the country will experience an increase in patient volume. "With the aging population, there will be more people than ever clamoring to have operative and non-operative treatment for spine conditions," says Andrew Hecht, MD, co-chief of orthopedic spine surgery at Mount Sinai Medical Center in New York City. "That's going  to be first and foremost on everybody's mind in terms of what that's going to do to the [shortage] of physicians in the U.S."

One of the potential solutions for meeting the complications that will arise from this influx of patients is to utilize more non-surgical specialists, such as nurse practitioners or physician's assistants, and direct patients to a primary care physician or pain management physicians instead of going directly to the spine surgeon when a problem arises, says Steven Wertheim, MD, co-president of Resurgens Orthopaedics in Georgia. While these professionals may be able to see patients more efficiently, patients may not appreciate the redirection away from spine surgeons. "A lot of ancillary providers are good, but many patients want to see spine surgeons, which won't always be possible," says Dr. Wertheim. "There will be a lot more screening of the patients before they go to the spine surgeons by the ancillary providers."

2. Spine surgeon employment. Across the board, many orthopedic and spine surgeons and industry leaders are seeing the days of solo practitioners come to an end as pressure from healthcare reform make it expensive and difficult to manage a solo practice. The trend for spine surgeons coming out of training is hospital employment, says Brian Gill, MD, a spine surgeon with the Nebraska Spine Center in Omaha, because employment limits the stresses of running a practice and ensures a certain amount of compensation. "At the hospital, you tend to get a salary and your overhead staff is taken care of," he says. "You don't have to manage hiring and firing staff members, the billing is taken care of, the radiology and ancillary services are all done at the hospital. Some physicians don't like being employed by the hospital because they don't want to be told by a hospital executive about how to run their practice. Other physicians are okay with that."

Spine surgeons who don't want hospital employment but can't survive as a solo practitioner are joining larger specialty and multispecialty groups. "Being part of a larger group is better for the surgeon because the groups can offer security," says Dr. Gill. "Larger groups have scale economies to support personnel to manage the business functions of the practice," says David Shrier, CEO of HCPlexus, the company that produces the Little Blue Book database of physicians. Additionally, he points out that a large single or multispecialty practice may be in a better position to negotiate contracts with payors and suppliers.

3. Declining compensation. Medicare reimbursements are low and many other payors take cues from Medicare, which means the future of spine surgeon compensation could turn grim. While spine surgeons are one of the highest paid subspecialties, surgeons often need the extra compensation for liability and technology funds. An additional decrease in spine surgeon compensation may occur in an attempt to increase the compensation for primary care physicians, who are among the lowest paid and least available physicians. "Everyone values the role of every different type of specialty, and everyone has a role to play," says Dr. Hecht. "However, improving the primary care compensation shouldn't come at the expense of specialists."

The trend toward spine surgeon employment may also affect compensation for spine surgery, as hospitals are trending toward offering surgeons a salary and performance based incentives. More surgeons are opting for hospital employment now than they have in the past for the guaranteed income, even if the income may be lower than what they could have made at a private practice.

4. Treatment for Medicare patients.
Physicians of all specialties are struggling to treat Medicare patients under decreasing reimbursement rates that show little promise of improving in the future. "The constant struggles with Medicare and the constant lack of sustainable fix to the SGR formula is very concerning to everyone," says Dr. Hecht. "Taking care of Medicare patients is a labor of love for most doctors, especially for the level of complexity of the needs of these patients." Because older patients who are on Medicare often have spinal conditions or deformities, spine surgeons are particularly concerned about where Medicare reimbursement is headed. An increasing number of surgeons are deciding to withdraw from Medicare because continuing to treat Medicare patients isn't sustainable. Dr. Gill sees Medicare patients needing to wait for several days or months to see spine surgeons and having to pay out of pocket for their care in the future, if reimbursement rates don't improve.

5. Involvement in ACOs. Accountable care organizations are being pioneered by many physician groups and hospitals around the country and only time will tell whether the different models for them will stick. Surgeons who join ACOs must follow the protocols set by the ACO when treating their patients. Dr. Gill says spine surgeons are wary of ACOs because many surgeons would rather conduct their practice as they see fit, rather than consulting with a hospital or organization about cost-effectiveness.

However, Mr. Shrier says that ACOs may benefit orthopedic surgeons because it could promote better care for patients. "There are incentives that will be put in place for a well-care relationship," says Mr. Shrier. "This is going to reconfigure the way surgeons interact with their patients."

6. EMR implementation.
Healthcare reform law promotes the use of electronic medical records for healthcare providers to keep track of patient records more effectively and efficiently. EMRs will also help the providers gather statistics on their patients and share the records among their staff and other providers. That is, if the other providers use compatible programs. "It's a great thing to organize and electronic record, but it doesn't help when we aren't all on the same system," says Dr. Hecht. "The government thinks we all have the same EMR, but we don't. It's a great concept, but the practical realities haven't been addressed." Some providers are having trouble implementing EMRs because once they begin using them, the patient volume diminishes, says Dr. Hecht. "There is a lot of wording about being involved with EMRs," he says. "We're all in favor of it. The problem is I don't think the technology and practicality has caught up with the theoretical efficiencies."

Mr. Shrier echoed these sentiments about EMR implementation. "What we're hearing is a lot of confusion about what healthcare reform means in terms of how to adopt EMR, which EMR system providers should get and what it's going to mean for patient care in general," he says. "The orthopedic surgeons need to see more patients to keep up with the declining reimbursements and invest in EMR technologies at the same time." He says one of the solutions many spine surgeons are finding to combat these higher costs is to join a specialty practice or merge their practice with another to form a larger multispecialty practice. "The healthcare reform act requires a lot of technology and that is difficult for small practices to grapple with," he says.

7. The make-up of the Independent Advisory Board.
The Independent Advisory Board is an aspect of healthcare reform law that essentially creates protocols for healthcare professionals to follow when diagnosing and treating patients. There are many concerns with the board, including the number of participants who aren't medical professionals. "The Independent Advisory Board does not have significant representation from actively practicing physicians, [but has] a lot of power and very little accountability," says Dr. Wertheim. "There are protocols that doctors need to follow that are good medicine, but not all patients fall into that category. The ability to dictate patient care the patient without seeing the patient (while knowing the factors of the case) is very scary."

The Independent Advisory Board is concerning for spine surgeons because the board is taking some of the treatment choice away from the patient and surgeon and giving it to a group that hasn't met the patient. "The only way to make healthcare work cost wise with the plan in place is to ration care," says Dr. Wertheim. "That is more of a social question. There are procedures that might be good for one patient but not the other. Members of the board don't have the knowledge of the specialty for deciding treatments for the patient."

8. The lack of tort reform.
Medical liability is a big concern for spine surgeons because they work on such a sensitive area of the body, which could easily lead to complications in some patients. "One of the issues with all physicians, especially something as high risk as spine surgery, is the cost of defensive medicine," says Dr. Wertheim. "There are a lot of expensive tests and procedures which spine surgeons do on regular bases purely for defensive medicine." Spine surgeons are often required to order an MRI for patients with back pain, even if they don't think the patient needs surgery, to avoid malpractice suits. "The lack of tort reform has been a huge factor in not decreasing the cost of medical care," he says.

When healthcare reform law was signed in last March, many physicians were hoping the bill would address medical liability and protect physicians while decreasing the cost of healthcare. However, that was not the case, which reflects the fact that much of the legislation was drafted by law professionals instead of medical professionals, says Dr. Hecht. "Spine surgeons are very concerned that there's no lack of meaningful medical liability in healthcare reform," he says. "We need meaningful tort reform. In states that have enacted tort reform measures, there has been great changes. In states that don't, malpractice is big." This is also a concern for medical students coming out of training programs because they increasingly need to protect themselves, he says.

9. Evidence-based medicine and technological developments. Spine surgery has had an immense amount of development over the past several years, producing laser spine surgery, robotic-guided procedures and stem cell technology, and all trends are heading toward minimally invasive procedures. However, healthcare reform's focus on cost-effective and evidence based medicine could derail these developments for the future. The government wants evidence showing that a procedure is necessary and helpful for a patient. This means surgeons need to have clinical studies showing new technologies and procedures are successful, which takes an extensive amount of time and resources. "One of the issues with spine surgery and orthopedics in general is that the ultimate results of the procedures we do are not know until ten years down the road or longer," says Dr. Wertheim. "That makes these research studies and outcome studies very expensive and difficult to do."

An additional problem with evidence based medicine is that the studies must be highly controlled to meet approval, says Dr. Gill. The standard is double-blind randomized studies, which can be difficult to complete for spine surgery. The surgeon must also take practical use of the developments into consideration before implementing them into practice. "Things that look good on paper and in biomechanical testing sometimes don't always turn out so well when inserting them into people," he says. "You have to weigh the cost of new technology and if it produces the same function of old technology, it isn't worth it. If the technology is able to make the outcome better, it may be worth the extra cost."

10. Political involvement.
Today's political environment is wrought with discussions of healthcare reform and legislative changes that directly impact every physician's practice, which means many more physicians are becoming politically active than ever before. "Being actively involved with legislators and being involved in politics is something that spine surgeons haven't traditionally done," says Dr. Wertheim. "Physicians have to get to know their legislators, participate in fundraisers and really spend time with people who are making these decisions if they really want to have a voice." Spine surgeons should become more active in their specialty and state medical societies to work towards an educated legislative change because at the moment, many of the decisions about healthcare are being made by politicians, not physicians, says Dr. Wertheim.

Read other coverage on healthcare reform for spine surgeons:

- Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery

- 7 Healthcare Reform Changes Affecting Orthopedic Surgeons

© Copyright ASC COMMUNICATIONS 2018. Interested in LINKING to or REPRINTING this content? View our policies here.

Top 40 Articles from the Past 6 Months