Young spine surgeons today are exiting their fellowships and entering into a vastly different healthcare environment than even five years ago.
Pressures and uncertainty from healthcare reform, coupled with generational differences and minimally invasive training, are making a big impact on how young spine surgeons are practicing and innovating today. Here are five key trends:
1. Minimally invasive surgical techniques are the rule. In some cases, surgeons are making 100 percent of their practice minimally invasive and marketing as such.
"The philosophies behind minimally invasive surgery are taking hold with the younger surgeons," says Hyun Bae, MD, medical director and director of spine education at Cedars-Sinai Spine Center in Los Angeles. "They are fellowship-trained and when they finish their training they see MIS as the future. The younger surgeons are adopting this as what they do and building their careers on being an MIS surgeon."
New technology innovations make it easier to employ less invasive techniques, even with more complex procedures. Patients today are also aware of less invasive approaches — whether they have smaller incisions or muscle-sparing techniques — and asking for surgeons who can perform them.
"Young surgeons today are more conscientious about patient anatomy and their ideas of soft tissue preservation are first and foremost," says Dr. Bae.
2. Fewer opportunities for spine device innovation. An innovation boom over the past decade has allowed surgeons to advance the field toward less invasive procedures, but for several reasons innovation will likely slow in the future. Payers and government regulators are demanding more evidence that new products or procedures are clinically- and cost-effective before adopting coverage policies.
The medical device excise tax implemented in 2013 to pay for a portion of the Affordable Care Act has also slowed research and development growth for spine device manufacturers. Conducting clinical studies and innovation is becoming more expensive, yet these companies have fewer resources to spread around. Coupled with cost pressure from hospitals, which previously paid a premium for surgeon preferences, device companies and representatives are feeling the pinch.
"You may not see as much innovation in spine anymore because companies are facing reimbursement challenges at the hospital," says Dr. Bae. "They aren't willing to pay the premium the way they were before."
There is also less venture capital money to go around. "The VC money and private equity money has left," says Kern Singh, MD, co-director of the Minimally Invasive Spine Institute at Rush in Chicago. "Younger surgeons have to figure out how to fund their ideas on their own with their own attorneys and complete the 510(k)s by themselves. As a result, more surgeons are turning away from innovation."
3. Heavier compliance concerns limit device company relationships. Compliance issues could stagnate collaboration between spine surgeons and the device industry. The Sunshine Act, which went into effect last year, requires surgeons to report anything they receive from industry amounting to more than $10 with few exceptions.
Even legitimate relationships have been scrutinized in recent years; the lay media has negatively reported on surgeons receiving royalties for spine devices they invented.
"This relationship of innovation is becoming more difficult," says Dr. Bae. "But you'll always have greatness. In the bleakest moments is when people really strive and show greatness. When times are tough, you'll get heroes. I always think there is room for innovation and you'll continue to have guys who do great things."
Dr. Singh has been able to work collaboratively with Rush University Medical Center to continue innovating. "They help foster my research and give me access to a research setting that I wouldn't have in private practice," he says. "People who want to innovate, research and publish are going into academics."
4. More surgeons choose large groups or hospital employment. The same pressures for cost-cutting measures in healthcare drive independent physicians into large group practices or hospital employment. Additional factors such as declining reimbursement, potentially significant Medicare reimbursement cuts, electronic medical record requirements and primary care physician employment make it incredibly difficult for specialists in most markets to survive on their own.
"The young spine surgeons would rather have an entity provide patients for their practice," says Dr. Singh. "Their main emphasis, as opposed to autonomy, is looking for geography. They want to practice in places like Chicago, Los Angeles and New York City, and private practice doesn't really exist there."
The employed model relieves surgeons of malpractice expenses and often they create their own hours in a flexible schedule. It's more difficult to build a private practice because renumeration is low and they still need to pay overhead and staffing expenses. In many cases, surgeons coming out of training are opting for employment right away.
"The young surgeon isn't starting out in private practice; they want to be employed by a huge hospital or care group like Kaiser," says Dr. Bae. "In that setting, I don't think innovation is rewarded or fostered in the same way as the private practice setting. I think young spine surgeons will make a name for themselves in MIS, but I don't think spine will continue to develop at the same pace because everyone is facing challenges."
5. Accountable care and hospital networks make private practice a risky business. Hospitals and health systems are growing larger today and many markets are dominated by a few major health networks. In some metropolitan areas, it's become nearly impossible to obtain patients outside of those networks.
"As a result, starting a private practice is high risk and low reward," says Dr. Singh. "The networks are driving down the payment to doctors as well. You might make a little bit more in private practice, but you have a huge amount of risk and stress."
The healthcare payment environment is changing as well. Accountable care organizations give one lump sum to the ACO leaders — often hospitals — and the leader divvies up payment. "If you are in private practice, you're at the mercy of the hospital," says Dr. Singh. "It's better to be in the network than being squeezed out."
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