CMS has proposed cutting payment for some of the most common spine procedures performed in ASCs. Four spine surgeons discuss how the cuts, if finalized, would reshape their site-of-service decisions.
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Editor’s note: Responses were lightly edited for clarity and length.
Question: CMS has proposed cutting payment for some of the most common spine procedures in ASCs. If it holds, how does it reshape your site-of-service decisions?
Jeffrey Carlson, MD. Orthopedic Spine Surgeon at Orthopaedic & Spine Center (Newport News, Va.): Unfortunately, we have seen this movie before. CMS is again moving to decrease payments as part of an “efficiency adjustment,” which will cover many high-volume pain procedures, including epidural steroid injections and facet and radiofrequency ablations. The reason these are high-volume procedures is because they actually work.
Physicians who are able to hone their craft, better improve patient care, make a scary procedure less daunting and provide care more efficiently and effectively will be penalized for being good at their job. We have seen this in surgery, as surgeons have gotten more experienced and efficient at delivering high-quality surgical procedures. Insurers reduce what they reimburse as thanks for that experience and improved expertise.
A dramatic example is knee replacement surgery, which was reimbursed well but has since declined significantly, forcing surgeons to create a highly efficient “assembly line” to keep their practices afloat. Interventionalists, like any business, will evaluate the profitability of these procedures across different facilities, improve efficiencies where they can and may look for a new, more expensive procedure to replace them.
Brian Gantwerker, MD. Neurosurgeon and President of The Craniospinal Center of Los Angeles: With the new cuts from CMS and the commensurate raise for hospital systems and insurers, it’s more “meet the old boss, same as the old boss.” I can’t say I’m surprised, given the bill of goods the administration has sold to many true-believer physicians who held out hope that things would be different with a physician in charge of CMS.
It hasn’t changed any of my site-of-service decisions, since I had already assumed it would be more of the same from CMS, and I’m frankly surprised many of my colleagues thought otherwise. It’s important to remember two things: One, no one is going to help us fix healthcare but us. Two, that means collective action, however that looks.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): If CMS pushes these cuts through, it’s going to force us to change our game plan for where we treat patients. Taking a hit on common procedures like lumbar radiofrequency ablations and epidural injections means the numbers just won’t work for an ASC anymore; the facility overhead will eat up whatever reimbursement is left.
To protect the practice financially, we’ll likely have to shift those standard, lower-acuity interventional blocks out of the ASC and bring them back into in-office procedure suites, where we can control costs. That frees up our ASC time to be reserved strictly for what it does best: complex, device-intensive decompression and fusion surgeries. It’s frustrating to juggle these federal pricing swings, but it means we have to be intentional, using the office suite for pain management and keeping the ASC focused purely on higher-end surgical cases.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Using linear historical reasoning, the most likely scenario for the proposed CMS payments will follow the past decades of bundling codes and resulting reimbursements.
All things considered, the minor upticks will correspondingly balance the downturns, making this another stalemate. For most uncomplicated spinal procedures, 23-hour admissions or less are a renewed and expected methodology, reinforcing the use of integrated or freestanding ASCs. The comorbidly challenged or underinsured population will remain system-bound, including Medicare and older patients. Site-of-service decisions are multivariate, and efficiencies in pre- and postoperative anesthesia and nursing management are excellent and reproducible daily.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.