Here are six predictions and trends spine surgeons can anticipate throughout the coming year, according to several industry experts.
1. Coverage denials will continue among many payers. This year more than ever, spine surgeons are reporting coverage denials from insurance companies for surgery as well as other procedures and tests.
"The last two years have been extremely challenging," said Neel Anand, MD, director of spine trauma, minimally invasive spine surgery at Cedars-Sinai Spine Center in Los Angeles. "Seemingly, everything is being denied, including MRIs and CT scans. We spend at least 50 percent of our time, compared to two years ago, getting approval for patients and talking to non-medical personnel. Sometimes even then, we aren't able to get clearance for the surgery."
The inability to treat patients quickly and efficiently could lead to health problems in the future, especially for patients with degenerative conditions.
"It really has become a vicious and ineffective cycle that I think will adversely affect patient care," Dr. Anand said. "It is delaying patient care and it's really sending them backwards. There is a very finite window for treatment, and that's become apparent now. If we are able to tackle the problem right away, patients can go back to work and their regular life. On the flip side, if the back pain digresses and they are unable to work for a year or more, patients don't tend to do as well."
2. Advocacy efforts are challenging payment regulations. Professional societies are responding to payers and advocating in Washington, D.C., so patients can receive the care they need without bankrupting the healthcare system.
"I know the North American Spine Society [has started] a registry to gather evidence," said Jeffrey C. Wang, MD, vice chair of clinical operations in the UCLA department of orthopedic surgery and chief of the orthopedic spine service at the UCLA Comprehensive Spine Center. "Whenever there is a new code or issue, NASS is there to respond and have an evidence-based approach. When payers announce an inappropriate coverage decision, NASS responds."
3. Patients are searching for low-cost spine care. Historically, physicians have had little involvement with reimbursements at their facilities, said Hallett Mathews, MD, executive vice president and chief medical officer of Paradigm Spine. Costs were not in the purview of a practicing physician, but now surgeons must be very aware of reimbursements and payers requirements.
"The economy has challenged many elective and non emergent procedures. Payers have exercised more control of pre-certs and denials of surgeries. Facilities are seeking favorable pricing for implants because of declining reimbursements from payers. More physicians are employed by institutions every year aligning the surgeon with the facility challenging the payers," he said. "This vertical restructuring of stakeholders brings the physician into the discussion and creates opportunity to perform appropriately invasive and cost saving procedures in the appropriate care setting."
For physicians employed by ASCs, cost containment has become a greater priority. Physicians are looking for the "purist and safest, data driven, most financially-correct way to perform surgery," Dr. Mathews said.
If they have not yet begun, surgeons need to shop around for lower implant costs, cut operational waste and work with payers ahead of time to ensure a patient's procedure is appropriately covered. Smaller settings have the advantage when it comes to lowering procedure costs and increasing efficiencies.
4. Lateral approach is gaining steam. More procedures are looking for a lateral approach to the spine, and device companies are developing new lateral systems to meet these needs. Initial minimally invasive procedures approached the spine anteriorally or posteriorally, but there have been some proven benefits to the lateral approach when possible.
"The biggest trend in minimally invasive surgery right now is the lateral approach," said Jennifer Sohal, MD, a spine surgeon with St. Vincent Spine Institute in Los Angeles. "It has been very effective in decreasing postoperative pain and allowing surgeons to perform more complex procedures with less morbidity."
Even high acuity procedures such as scoliosis repair are now accessible through a lateral approach. However, the technique has not become a standard of care yet.
"It's still in the early stages, but I think more people are increasing their skill level in these techniques," Dr. Sohal said. "We'll see more training opportunities available and surgeons will become more comfortable selecting the right patients for the procedure. Minimally invasive techniques are not replacing all open techniques; it's just another tool in the toolbox."
5. New innovation can make performing outpatient spine surgery easier. The pedicle screw for minimally invasive spine surgery, particularly fusions, has been routinely accepted for many years as the best method of fixation. However, Dr. Mathews said, pedicle screws are not necessarily a mainstay of decompression for spinal stenosis in outpatient spine surgery.
"Pedicle screw fixation techniques are less invasive than older traditional methods, but there is a gap of evidence to prove they are always needed," he said. "Some of these devices can be placed in an outpatient setting, but surgeons are challenging whether pedicle screws are the best device to do that."
Surgeons are discovering the concept of stabilization without fusion and are not necessarily performing fusion as their first choice for restabilization.
6. Computer navigation could have a place going forward. Computer assistance and robotic guidance for orthopedics and spine have been a contentious issue for the past few years; the equipment is expensive and surgeons question whether it actually improves the procedure enough to warrant that cost. However, there is a market for this technology and future iterations could make an impact on spine care.
"Surgeons are able to use navigation to assist in surgery, decreasing operative time and need for revision surgery," Dr. Sohal said. "It involves obtaining an intraoperative CT scan to create a model of the spine on which we can project our operative plan."
Mazor Robotics, a robotic spine technology company, has published results from individual surgeons on their accuracy placing pedicle screws.
"I think we have navigational systems working now, but there will be a continued improvement there," said Paul Nottingham, MD, a spine surgeon in Walnut Creek, Calif. "The technology continues to reduce our element of error and the amount of radiation used to produce images."
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"The last two years have been extremely challenging," said Neel Anand, MD, director of spine trauma, minimally invasive spine surgery at Cedars-Sinai Spine Center in Los Angeles. "Seemingly, everything is being denied, including MRIs and CT scans. We spend at least 50 percent of our time, compared to two years ago, getting approval for patients and talking to non-medical personnel. Sometimes even then, we aren't able to get clearance for the surgery."
The inability to treat patients quickly and efficiently could lead to health problems in the future, especially for patients with degenerative conditions.
"It really has become a vicious and ineffective cycle that I think will adversely affect patient care," Dr. Anand said. "It is delaying patient care and it's really sending them backwards. There is a very finite window for treatment, and that's become apparent now. If we are able to tackle the problem right away, patients can go back to work and their regular life. On the flip side, if the back pain digresses and they are unable to work for a year or more, patients don't tend to do as well."
2. Advocacy efforts are challenging payment regulations. Professional societies are responding to payers and advocating in Washington, D.C., so patients can receive the care they need without bankrupting the healthcare system.
"I know the North American Spine Society [has started] a registry to gather evidence," said Jeffrey C. Wang, MD, vice chair of clinical operations in the UCLA department of orthopedic surgery and chief of the orthopedic spine service at the UCLA Comprehensive Spine Center. "Whenever there is a new code or issue, NASS is there to respond and have an evidence-based approach. When payers announce an inappropriate coverage decision, NASS responds."
3. Patients are searching for low-cost spine care. Historically, physicians have had little involvement with reimbursements at their facilities, said Hallett Mathews, MD, executive vice president and chief medical officer of Paradigm Spine. Costs were not in the purview of a practicing physician, but now surgeons must be very aware of reimbursements and payers requirements.
"The economy has challenged many elective and non emergent procedures. Payers have exercised more control of pre-certs and denials of surgeries. Facilities are seeking favorable pricing for implants because of declining reimbursements from payers. More physicians are employed by institutions every year aligning the surgeon with the facility challenging the payers," he said. "This vertical restructuring of stakeholders brings the physician into the discussion and creates opportunity to perform appropriately invasive and cost saving procedures in the appropriate care setting."
For physicians employed by ASCs, cost containment has become a greater priority. Physicians are looking for the "purist and safest, data driven, most financially-correct way to perform surgery," Dr. Mathews said.
If they have not yet begun, surgeons need to shop around for lower implant costs, cut operational waste and work with payers ahead of time to ensure a patient's procedure is appropriately covered. Smaller settings have the advantage when it comes to lowering procedure costs and increasing efficiencies.
4. Lateral approach is gaining steam. More procedures are looking for a lateral approach to the spine, and device companies are developing new lateral systems to meet these needs. Initial minimally invasive procedures approached the spine anteriorally or posteriorally, but there have been some proven benefits to the lateral approach when possible.
"The biggest trend in minimally invasive surgery right now is the lateral approach," said Jennifer Sohal, MD, a spine surgeon with St. Vincent Spine Institute in Los Angeles. "It has been very effective in decreasing postoperative pain and allowing surgeons to perform more complex procedures with less morbidity."
Even high acuity procedures such as scoliosis repair are now accessible through a lateral approach. However, the technique has not become a standard of care yet.
"It's still in the early stages, but I think more people are increasing their skill level in these techniques," Dr. Sohal said. "We'll see more training opportunities available and surgeons will become more comfortable selecting the right patients for the procedure. Minimally invasive techniques are not replacing all open techniques; it's just another tool in the toolbox."
5. New innovation can make performing outpatient spine surgery easier. The pedicle screw for minimally invasive spine surgery, particularly fusions, has been routinely accepted for many years as the best method of fixation. However, Dr. Mathews said, pedicle screws are not necessarily a mainstay of decompression for spinal stenosis in outpatient spine surgery.
"Pedicle screw fixation techniques are less invasive than older traditional methods, but there is a gap of evidence to prove they are always needed," he said. "Some of these devices can be placed in an outpatient setting, but surgeons are challenging whether pedicle screws are the best device to do that."
Surgeons are discovering the concept of stabilization without fusion and are not necessarily performing fusion as their first choice for restabilization.
6. Computer navigation could have a place going forward. Computer assistance and robotic guidance for orthopedics and spine have been a contentious issue for the past few years; the equipment is expensive and surgeons question whether it actually improves the procedure enough to warrant that cost. However, there is a market for this technology and future iterations could make an impact on spine care.
"Surgeons are able to use navigation to assist in surgery, decreasing operative time and need for revision surgery," Dr. Sohal said. "It involves obtaining an intraoperative CT scan to create a model of the spine on which we can project our operative plan."
Mazor Robotics, a robotic spine technology company, has published results from individual surgeons on their accuracy placing pedicle screws.
"I think we have navigational systems working now, but there will be a continued improvement there," said Paul Nottingham, MD, a spine surgeon in Walnut Creek, Calif. "The technology continues to reduce our element of error and the amount of radiation used to produce images."
More Articles on Spine:
70% of Physicians Say Insurers Require a Generic Drug Substitution
5 Methods for Spine Surgeons to Avoid Burn-Out From Dr. Amir Vokshoor
SpineMark, California Healthcom Partner on Medical Tourism