Payers are expanding site-neutral payments, and for spine surgeons that will bring new challenges and potential wins.
Four surgeons across the nation discuss what it means for them.
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. Becker’s invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, Oct. 21.
Editor’s note: Responses were lightly edited for clarity.
Question: As payers expand site-neutral payment policies, what impact will this have on your practice? Where do you see opportunities or risks?
Adam Bruggeman, MD. Texas Spine Care Center (San Antonio): Enacting site-neutral payments have the potential to completely upend orthopedic practices. Without substantial clinical net profit, many hospitals could terminate contracts with employed/contracted physicians or not renew their contract. Even in orthopedics, where we have a lower employed population than other specialties, this will create significant strain on physician practices to be able to manage the complex regulatory and administrative part of practice. In specialties like cardiology where there are very few independent practices, it will be difficult for transitions to occur.
In addition, many employed physicians may see a dramatic decline in revenue during the transition. Other associated issues that will need to be addressed include non-compete provisions for those leaving contracts, certificate of need laws to allow for new ASCs, and the removal of Section 6001 of the Affordable Care Act to allow physicians to open and start their own hospitals in their communities.
Pierce Nunley, MD. Spine Institute of Louisiana (Shreveport): Site-neutral payment expansion will create both challenges and opportunities for my practice. As a physician-owner of both a hospital and an ASC, I expect downward pressure on hospital-based reimbursement since payers will no longer differentiate payments based on site of service. This will likely reduce margins for hospital operations and negatively affect shareholder distributions.
However, the shift could favor my ASC. With reimbursements becoming more aligned, procedures that are safe and efficient to perform in an ambulatory setting will migrate out of the hospital, enhancing ASC volume, efficiency and profitability. The key opportunity lies in strategically transitioning appropriate cases to the ASC while preserving hospital capabilities for complex, high-acuity cases.
Overall, success will depend on optimizing site selection, negotiating payer contracts effectively, and balancing capital investments between the two entities to maintain financial stability as payment policies evolve.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: These policies, expanding under Medicare and some commercial payers, aim to eliminate the payment differential between hospital outpatient departments and ASCs for the same procedures. The Medicare Payment Advisory Commission has estimated potential savings of $500 million annually. For spine procedures, this could accelerate the migration to ASCs, as the economic incentive to perform procedures in higher-reimbursed hospital settings diminishes.
However, this raises questions about case selection criteria, emergency response capabilities, and whether cost reduction compromises care quality. The policy assumes equivalent outcomes across settings, but comparative effectiveness research specifically for spine procedures across different care settings remains limited.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The expansion of site neutral payment policies by pairs is actually now extended to large medical systems that have developed outpatient surgical services. These payment policies have definitely been an equalizer to better compete with for profit surgery centers, which locally have a notorious reputation of balance-billing, which are costs in addition to insurance coverages. This has now evened the playing field on a competition basis with these institutions, since larger healthcare systems are much better equipped and staffed to manage the higher equity patients.
