Looming healthcare reform changes coupled with tightening reimbursements for spine procedures have left many surgeons wondering what the future of spine surgeon employment will look like.
Gunnar B. J. Andersson, MD, PhD, is the vice president and treasurer of the International Society for the Advancement of Spine Surgery. He serves as The Ronald L. DeWald, MD, Professor and chairman emeritus of the Department of Orthopedic Surgery at Rush University Medical Center in Chicago and practices with Midwest Orthopaedics at Rush. In May 2014, Dr. Andersson will succeed Luiz Pimenta, MD, as president of ISASS.Here Dr. Andersson discusses various spine surgeon employment models and gives his take on how the majority of surgeons will practice in the coming years.
Question: Will independent spine practices become a thing of the past?
Gunnar Andersson: Over time, as more and more physicians enter the healthcare market as it is now evolving, there will be fewer independent practices. There will certainly be less of us older doctors around to remind the younger ones of how it used to be, "back in the day." However, unless something significant happens beyond implementation of the Affordable Care Act, there will always be physicians and surgeons practicing independently, albeit aligned with hospitals, accountable care organizations and state health exchanges.
Q: Do you foresee hospital employment of spine surgeons becoming a new norm? What about surgery center employment?
GA: It seems that in some states, like California, hospital employment of spine surgeons is advancing rapidly. In Illinois, however, surgical practices, while becoming more aligned with specific hospitals and ASCs, are being acquired at a slower rate than those in other states. Clearly this is a trend that may become the "new normal," but we saw this back in the 1990s with hospitals and HMOs buying up practices in order to control their costs in a capitated environment and then a quick reversal of that trend once everyone determined it wasn't a successful business model. Hospital employment offers a degree of security but at the cost of losing independence and control.
Q: What are the biggest drivers of spine surgeon employment trends?
GA: As government and private payers pilot new methods of bundling payments for entire episodes of care — including site-of-care reimbursement, as well as device acquisition and fees for physicians and other healthcare providers — it will be more likely that surgeons will become more closely aligned with hospitals and ambulatory surgical centers. Some will choose to be employed, while others may simply wish to contract with those entities while maintaining more autonomy. I suspect most surgeons would choose to maintain some level of independence until or unless it seriously impacts their ability to make a living.
Q: How does spine differ from other specialties, as far as employment trends go?
GA: I think the bottom line is, how much risk do we want to take on? It's my impression that spine surgeons are less likely to rush toward being employed by hospitals. But there are many forces now at work driving us toward being employed — flat or declining reimbursement rates, more time spent appealing denials of coverage, more regulatory hurdles and an environment hyper-focused on evidence-based medicine and the need to continually demonstrate improved outcomes.
I've always found spine surgeons to be more likely than other specialties to be more receptive to the risk/reward aspects of independent practice, but perhaps the external influences will push spine surgeons into employment arrangements at rates similar to that of other specialists.
Q: What does the future model of spine surgeon employment look like?
GA: I think a lot of that will be determined by current and future regulatory changes. Will CMS and commercial payers allow more spine surgeries to take place in ambulatory surgical centers? How will payers reimburse for ASC-based surgeries versus hospital inpatient surgeries? Will lower payment rates for procedures at ASCs offset the loss of control an employed surgeon might experience working solely in one hospital? How will regulatory changes impact a surgeon's ownership of, or referral of patients to ASCs?
If spine surgeons are able to develop and grow a practice within their own ASCs, and are successfully able to gain access to patients through accountable care organizations and state health exchanges, then I don't think they will be rushing to become employed by hospitals any time soon.
Q: For surgeons who remain independent of health systems, how must they alter their approach and practice to survive in a tighter economic market?
GA: I think as ACOs continue to evolve and state health exchanges get up and running next year (in some states, anyway), many surgeons will be taking a "wait and see" approach. Certainly remaining independent is going to take more work and require a continual acquisition of health information technology to remain relevant with and acceptable to payers. Again, if bundled payments for an entire episode of care become the norm in terms of reimbursement, then independent surgeons are not going to have a lot of leverage with hospitals and ASCs in order to gain their share of that shrinking pie.
The other challenge independent surgeons face is a growing trend of payers requiring data collection as part of an approval of a given surgery; independent surgeons are going to have to build the proper infrastructure to accommodate those requirements, and that requires resources and efficiencies that may not be possible in smaller, independent settings. Independent physicians can work with hospitals without being employed through physician hospital organizations, provider contracts and similar arrangements. I foresee alternative approaches being developed over the next several years.
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