The biggest challenges in spine from 9 surgeons: Drs. Alexander Vaccaro, Michael Musacchio & more

Alan Condon -   Print  |

From prior authorization requirements to value-based care initiatives and payer battles, nine spine leaders discuss the biggest challenges affecting their practice today.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: How do you see value-based care developing in spine in the next 2-3 years?

Please send responses to Alan Condon at by 5 p.m. CST Wednesday, April 21.

Note: The following responses were lightly edited for style and clarity.

Question: What is the biggest challenge facing your practice now?

Alexander Vaccaro, MD, PhD. Rothman Orthopaedics (Philadelphia): The biggest challenge facing our practice is promoting value-based care with appropriate incentives for all stakeholders. Value-based care has been shown to provide savings to the payer and provider when utilizing appropriate incentives. This can be achieved through alignment of the payer, health system and provider through demand matching point-of-care strategies and strategic partnerships. These strategies can result in a reduction of cost by almost 20 percent per episode, which not only translates to savings for the provider, but also better outcomes for patients.

In these models, we have been able to discharge a much higher percentage of patients to home (97 percent discharged) as well as reduced infection rates (99 percent reduction) and reduce complications by more than half (56 percent reduction). Still, promoting value-based care remains challenging because of the payment structure and difficulties aligning all stakeholders. Because the baseline target in CMS bundles are adjusted from the previous year's total cost of care, providers experience diminishing return and are not incentivized to improve dramatically — as doing so could significantly alter target prices and potentially reduce share savings significantly. Therefore, under the current bundle payment scheme, the dramatic diminished marginal benefit to the provider must be rethought to maintain alignment in order to further flatten the cost curve of medicine today.

Michael Musacchio, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): The biggest challenge continues to be insurance coverage of diagnostic tests, procedures and surgeries. Coverage denials are too frequent and disruptive. Guidelines are confusing, conflicting and rigid. It is often the case that the denial is received within a day or two of surgery, which is very disruptive to patients' and surgeons' schedules. It is rare that the surgery is ever fully denied, but the appeals process and peer-to-peer process is extremely time- and resource-consuming. 

Furthermore, insurance coverage matters many times have stifled the introduction to new technologies. There are innumerable excellent and useful products for spine surgery that are simply inaccessible in the U.S. due to insurance coverage questions, even when they are FDA approved. The insurance coverage process needs to change for patient care to experience ongoing meaningful improvements. 

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): The immediate challenge we face is maintaining quality nurses with a great deal of the healthcare personnel taxed by the COVID-19 pandemic, and in different times before vaccination, subject to repeated isolations from contact or close contact. Maintaining adequate numbers of nursing care to deal with our center has been a challenge. While it seems to be improving now that the vaccinations are rolling out and the numbers are going back down, we remain fearful of another spike. During the period of the pandemic, we also saw significant growth in cases, as patients did not wish to be cared for at hospitals during this time. A combination of increasing patients seeking the outpatient environment and decreased available healthcare providers has made 2020-2021 a very challenging time.

Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Insurance companies have always posed a great impediment to providing excellent patient care, but it appears their efforts to delay, discourage and deter high-quality medical care are getting worse every year. From the simple, but absurd processes of trying to get a hold of companies (which can absorb hours of your office staff’s time) to the outright denial of medical care to patients (which defies medical reason), the spectrum of disruption of care touches almost every aspect of practice. The net effect is certainly diminution of care for patients but also greater burnout and turnover in office staff and financial stress to physicians. With no unifying voice or effort to push back against this tidal wave of disruption, I fear this bad situation will only get worse.

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): Currently, we are spending a lot of time and resources on the preauthorization process. The guidelines for each insurance company are a moving target. Certain insurance companies are requiring specific words to be used in imaging reports while other insurance companies have no specific requirements. Often our patients are in pain and their surgery is delayed as a result of this preauthorization process.

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: As Medicare and private payers attempt to add more steps to taking care of patients, we are not seeing any let-up in the other difficulty in getting paid for services rendered. There are certain surgeons that for some reason think fee-for-service is the root of all evil. I would counter that it can be a viable model for delivering services. Paying a surgeon as you would anyone else providing a service is not irrational, nor bad. It escapes me why every other vocation can get paid once the work is done, but for some reason, when a surgeon asks to be paid — it is seen as heretical.  

I propose we keep fee-for-service and make payers accountable. Set a benchmark for surgical performance. As we do better and better surgically, the fees go up commensurately. Link authorization to payment. Fine insurance companies when they state the patient was not covered at the time of service, limit premium increases and create an ombudsman office in the insurance companies by Congressional mandates. You will see most of the challenges disappear and physicians can concentrate on their patient outcomes.  

William Taylor, MD. University of California San Diego: Our biggest issue continues to be the give-and-take between the hospital for new instrumentation, new procedures and new equipment that may improve outcomes but not necessarily save costs or time. The decision-making occurs outside of the operating room for the vast majority of procedures and continues to stymie innovation, new technology and access.

Richard Kube, MD. Prairie Spine (Peoria, Ill.): I'm not certain if it is the largest challenge, but certainly a significant problem we see for patients is the increase in deductibles for surgery. Besides the typical surgery denials from insurance carriers, we are seeing patients struggle to be able to obtain the care they need due to cost. It is common to have patients postpone surgery because they cannot pay deductibles, or they are worried about costs. Frankly, we often have the ability to offer a cash bundled rate for people that makes it cheaper to pay cash for services than it is to use their insurance plan. The use of narrow provider networks drives this equation as often the only in-network options are hospitals, which are typically much more expensive options than a surgical facility.

Andrew Hecht, MD. Mount Sinai Health System (New York City): The biggest challenge facing spine practice is dealing with the COVID pandemic and its gradual unwinding. Patients are slowly increasing again, but concerns remain regarding getting care in both ambulatory and inpatient settings. Patients still remain concerned, however, this is easing with the increasing amount of vaccinated patients. 

More articles on spine:
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2 spine surgeon leaders exit Johns Hopkins
5 high-profile device company court battles: Medtronic, Smith+Nephew & more 

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