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The devaluing of spine surgery — Dr. William Watters on 3 new trends Featured

By  Laura Dyrda | Thursday, 05 October 2017 11:47
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William Watters, MD, professor at the Clinical Orthopedic Surgery Institute of Academic Medicine at Houston Methodist Hospital and a clinical professor at the University of Texas Medical Branch, discusses the biggest challenges and opportunities for spine surgeons today.

Dr. Watters is a past president of the North American Spine Society and Texas Spine Society as well as the former chair of the NASS Research Council.

 

Q: What are your top two to three concerns for your spine practice today?

 

Dr. William Watters: My first concern is the decreasing reimbursements for spinal procedures that continue to mount. This is being accomplished in several different ways on several different fronts. One way is via the bundling of RVUs [relative value units] by the AMA in its CPT process. Surgical procedures, such as an ACDF [anterior cervical discectomy and fusion], can be reviewed every five years with respect to the "intensity" of the work product. Not only do these reviews usually result in procedure code bundling of the RVUs required for a procedure, thus reducing reimbursement, but within the spinal procedural mix, many review periods are being shortened to two to three years, essentially speeding up the financial devaluation of some spinal procedures.

 

Another way to decrease reimbursements is for third-party payers to withhold surgical approval at peer review for increasingly stringent criteria that are not necessarily evidence-based. Thus, we see the threshold for lumbar fusion approval shifting from previous criteria of grade 1 spondylolisthesis to the need for a grade 2 spondylolisthesis for approval. This latter process raises a second concern for me beyond reimbursement, and that is that surgical intervention for treatment of valid spinal disease is being withheld from patients.

 

Finally, a third concern I have for spine practice today is attempts by some third-party payers to direct the specific implants for patients who are approved for a surgery. This is seen in anterior cervical discectomy and fusions where some payers will not approve a fusion unless simple bone with plating is used, rather than the use of a self-retaining construct of a synthetic cage with screw fixation. My concern here is that this intervention by the payer runs the risk of compromising patient care in this particular case with a potentially higher incidence of postoperative dysphasia because of the high profile of a plate compared to self-retaining devices. A payer has no clear right to direct choice of procedure or implant, in my opinion.

 

Q: Where do you see the biggest opportunities for spine surgeons? How is the field evolving?

 

WW: The future of elective spinal surgery is likely, I feel, to be constricting. Spinal surgeons should familiarize themselves with clinical pathways that employ effective, evidence-based treatment. In the ideal situation, spine groups, to remain economically viable, need to be inclusive of other, nonoperative spinal specialists to provide the best care possible to their patients and also to capture the largest possible percentage of the revenue stream.

 

More articles on spine surgery:
How to save OR time and cost per case while performing successful spinal fusions
6 key trends in spine surgery malpractice litigation—average settlement is $1.9M
Dr. Alexander Vaccaro: 2 big concerns and the best opportunity for spine surgeons in the future

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