William Watters III, MD, a spine surgeon with Bone & Joint Clinic of Houston, became president of the North American Spine Society at its annual meeting in November 2013.
Dr. Watters discusses plans for his term as president and the key issues for spine surgeons today, including evidence-based medicine, healthcare reform and reimbursement in spine.
Q: What do you hope to accomplish during your term as President of the North American Spine Society?
Dr. William Watters: The primary goal of my presidency will be to lead NASS in its continuing efforts to utilize ethical and professional principles in advocating for quality spinal care in the current era of cost-containment and restriction of services. We will accomplish this through a higher integration of the strengths of our multispecialty organization in the areas of advocacy, education and research in spinal care.
An example of such integration is NASS' release this year of treatment coverage statements outlining best practices in spinal care. Both NASS and our membership can use these documents to advocate for payment for quality spinal care in this new healthcare environment.
During my presidency, I also intend to bring to fruition a number of large projects NASS has in motion to better serve its members, including a spinal registry, a distinction program for our member practitioners and consideration of development of a NASS Spine Foundation to foster improved spinal care.
Q: What key initiatives will the organization focus on over the next year?
WW: NASS will be piloting its spine registry this year. This registry will be diagnosis-based and will allow collection of data across a spectrum of spinal care. Increasingly, insurers are looking for practitioner participation in registries as one metric for value-based payment systems and this will be a potential benefit for our membership. It will also be a rich source of research and education for NASS in the areas of outcomes and comparative effectiveness.
Secondly, NASS is issuing evidence-based, expert derived coverage statements on nearly 30 different spinal treatments over the course of this year to better inform payers of the current state of spinal care and the appropriate use of these treatments. These coverage statements argue for reimbursement for spinal care, based on both evidence and the opinions of world experts in these treatments and can be used by both NASS and the NASS membership to fight against denial of appropriate care for our members and their patients.
In addition, NASS will continue to develop its Distinction in Spine Care Program, in which our membership will be able to participate. By being able to demonstrate best practices in spinal care, they will be able to prove themselves superior practitioners to their patients and to payers.
Finally, we are continuing preparations for the development of a foundation to promote improvement in the care and outcomes of back pain. Recent studies have shown back pain to be among the highest burdens of care to society and clearly there is a need for a focused and concerted effort to reduce this burden.
Q: NASS has been working on developing a spine registry. How will that impact spine providers?
WW: A spine registry will impact NASS spine providers in several ways. First of all, with the implementation of value-based payment systems, one of the metrics that payers are likely to utilize to determine appropriate reimbursement to providers will be participation in a registry. NASS' registry is going to be diagnosis-based and will allow input from all of our multispecialty members, not just surgeons. It will serve all equally.
Secondly, NASS members will be able to track their own outcomes. This ability has been shown to improve the level of care that members can provide for their patients. Finally, a NASS member will also be able to compare outcomes in a blinded fashion with the combined outcomes of other members to evaluate performance relative to peers.
Q: Where are the biggest opportunities for growth in evidence-based medicine in spine? Where do you think spine surgeon researchers should focus their efforts?
WW: First of all, it is important to understand that evidence-based medicine is a means of evaluating the strength and reliability of data in clinical research; that is in research on the diagnostics and treatment outcomes in human beings. EBM does not apply to laboratory research such as animal studies or to the materials R&D that goes into developing spinal implants. With that in mind, I feel the biggest opportunity for growth in EBM is in utilizing the technology of this discipline to prove the value of treatments we employ.
In addition by systematically combining the results of this research with the input of expert opinion where gaps in the research database exist we can use EBM to extend even further good spinal care. This is the process modified and utilized by NASS (developed by the RAND Corporation) in its Appropriate Use documents now being published that provide much more usable clinical information for our members in making treatment decisions than the traditional EBM guidelines.
Another growing area in which EBM should be used is by manufacturers. The use of the principles of EBM in designing high-level studies can help prove the value of their new technologies by comparing them to existing technologies in appropriate control groups. This approach would, I feel, greatly improve the rate of acceptance of these technologies by the regulatory panels.
Q: How can spine surgeons best embrace evidence-based medicine in their practices? What potential benefits does it have for the field of spinal care?
WW: I think it is fair to say that all of us practicing medicine wish to do the very best things for our patients' care and welfare. This is only common sense and also is the core of the Hippocratic Oath. Practicing evidence-based medicine is not "cookbook" medicine, as claimed by some. It is defined as the melding together of the surgeon's knowledge and experience, the patient's needs and wants and the very best evidence in a given clinical situation.
The techniques of EBM provide the "very best evidence" for the surgeon and this is one of its greatest benefits. None of us can remember all we learned in our training. We cannot read all of the (54) currently available spine journals, nor should we. We should only spend our time on the highest level of evidence, the best stuff in our field and EBM points the way.
There is another great benefit of EBM in its ability to provide a correcting mechanism in clinical decision-making. By always utilizing the best research evidence in the context of one's own experience in clinical decision-making, one is most likely to serve the patient's interests and not one’s own.
Q: Healthcare reform will continue implementation this year. What are the biggest challenges for spine surgeons related to healthcare reform changes?
WW: To be frank, the way it has been rolling out, it is hard to be specific. Surprises keep popping up and implementation dates prolonged making the entire situation fluid as we discuss this. But some very significant trends are clear and they almost all spell decreasing reimbursement for the spinal surgeon and for the implant industry.
Bundled payments will have to affect payments further, decreasing surgeon reimbursement and device reimbursement. The surgeons understand this as this has been going on now within various payment systems for a while. The effect on industry is likely to be a reduction in return on investment on the margin and squelch innovation. If innovation does indeed influence patient care, then improvement in patient care could also be slowed.
The acquisition of medical practices (the AMA states that 50 percent of surgeons in the U.S. are now employed) and the consolidation of large hospital systems and insurance companies are going to move control of reimbursement further and further from the surgeon, no matter what the fine details of the Affordable Health Care Act turn out to be. Understanding and managing multiple performance reporting programs and their resulting administrative burden continue to be challenging as well.
Q: What coverage and reimbursement issues are most pressing for spine surgeons today?
WW: At the Centers of Medicare and Medicaid Services level, the major issues are the re-valuing of CPT codes and the bundling of CPT codes, which have the same effect. When CMS re-surveys a particular CPT-coded procedure, previously done on a five-year basis but now even more frequently because of changes in the coding system or introduction of new technology, the result seems to inevitably be a decrease in the relative value of existing procedures.
An example of this is the recent bundling of the code for a cervical discectomy with that of the cervical fusion following that discectomy into a single code, of lesser value than the two previous codes combined. At the private payer level, the issue is non-coverage decisions based on non-transparent, internal guidelines of questionable validity and source.
This used to be a particular problem with new technology, but we now see an almost relentless attack on previously accepted procedures (i.e. lumbar fusion for disc disease) denying these procedure as being "experimental" or "investigational," which of course is a perversion of these terms.
Q: Where do you see the biggest opportunities for spine surgeons to be successful in the future and to make significant contributions to the field?
WW: At this year's at NASS Annual Meeting in New Orleans, I had the opportunity to have an interactive session with several hundred NASS surgeon members recently out of their residency and fellowship training. This was an “Ask the President” session and was great fun, bringing back many happy memories of my own development. But there was tension in the room also concerning the future, happiness in their choice of profession and the whole question of reimbursements and their decline.
My answer on this front was clear: If you have entered spine surgery because you truly love doing it, you like innovation and you value helping people, you will still make a comfortable living and have a satisfying career. However, if you entered spine surgery for the simple reason that it has carried some of the highest reimbursements in recent years and you expect to carry on such a practice, you are likely to be very disappointed and unhappy with your career.
So the biggest opportunity for spine surgeons to be successful pretty much depends upon how you define "success." It is that simple. With respect to making significant contributions in the field beyond excellent patient care, I feel an academic career still holds the best promise for making significant contributions in both clinical and laboratory research.
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