Artificial disc replacement technology has evolved tremendously over the past decade to become a viable alternative to fusion for some cervical spine procedures. More young surgeons are learning the techniques and data will be coming forward over the next few years that will illustrate whether disc arthroplasty makes a significant impact on the cost and quality of spine surgery."Five years ago, disc replacements were a hot topic and there were fellowships just for those procedures, which is what I did," says Thomas Roush, MD, founder of Roush Spine in Lake Worth, Fla. "There has been an evolution in the approval process and application of cervical arthroplasty, and that has been payor driven. It remains quite difficult to obtain approval for lumbar disc replacement, but the approval process and implementation of arthroplasty of the cervical spine is much easier and the results, clinically speaking, for cervical disc replacements are outstanding."
Dr. Roush has built his practice on performing artificial disc replacements. He discusses the six steps for running a successful practice focused on disc replacements.
1. Train aggressively and stay abreast of new developments. Training in artificial disc replacement is extensive. Inadequate training could lead to suboptimal prosthesis placement and a slew of negative issues for the patient.
"My biggest concern about disc replacement is the repercussions of the prosthetic discs not being placed optimally," says Dr. Roush. "If the disc isn't placed optimally, there is a correlation with acceleration of facet degenerative disease and patients will be of a higher likelihood to experience deterioration of axial back and neck pain."
However, even after the surgeon is comfortable with the technique and ultimately optimal disc placement, they must stay abreast of new technology and techniques that could lead to even better outcomes for their patients. "We are trying to find a disc that replicates the compressibility and axial mobility of normal discs," says Dr. Roush. "The artificial discs that we currently place in this country don't exactly replicate the intact biomechanics of an intact motion segment, but they are more normal than fusion. We need to find a biomaterial that can replicate the compressibility and elasticity."
Current attempts at designing this implant have failed, but surgeon innovators and device companies will likely continue working toward reproducing the motion, compressibility and elasticity of the natural disc.
2. Negotiate payor contracts. Over the past six months, most of the major insurance companies have begun approving on-label artificial disc replacements for the cervical spine. Approval was once a road block for many surgeons, but now that has been largely removed.
"A year ago, my experience was that approval for arthroplasty was quite difficult, says Dr. Roush. "But a few payors have been advocating for appropriate patients to undergo disc replacements and others have followed suit. I haven't had a particular problem with approval as long as there has been on-label adherence to the indications — one level disc replacements for patients with radiculopathy."
Off-label approvals are still very challenging to achieve. However, even with approval there is approximately a 40 percent reduction in the in-network insurance reimbursement rate for disc replacements as opposed to fusions, which has a big impact on spine practices.
"Surgeons take a major pay cut from performing these procedures," says Dr. Roush. "Disc replacements must present a better opportunity to drive more volume to partially offset the lack of per-case reimbursement. However, with the largely excellent patient outcomes and the subsequent discussion between patients and their friends and relatives in the community, my experience has been that there will be a fairly precipitous volume increase."
The lower reimbursement is counterintuitive because disc replacements are more technically dependent and require additional expertise than fusions; the disc must be placed perfectly for optimal outcomes. However, the lower rate shouldn't deter surgeons from performing the artificial disc procedures.
"I've made up for it in volume, so there hasn't been a financial sacrifice to use this technology that is better for the appropriately selected patients who have good indications," says Dr. Roush. "It's very gratifying to achieve such outcomes — that has driven me to minimize any thought about reimbursement."
3. Transition business from ancillary revenue to patient volume. Disc replacements are associated with quicker recovery times, so there are fewer postoperative opportunities to capitalize on treatment or bracing; instead, shift your business to dedicate more resources to preoperative and perioperative issues.
"My business model depends less on ancillary revenue and more on trying to drive the patients to the practice who will actually require and benefit from the procedure," says Dr. Roush. "That's the biggest issue for me; marketing upfront and having an educational focus for patients about the virtues of disc replacement. Once they have the procedure, it is rare for the patient to be seen in the office after the first follow-up visit or two."
Spine surgeons focusing on disc replacements can channel their efforts on targeting new patients instead of moving patients through the postoperative process.
4. Market the technology. Surgeons must be a major advocate for the disc replacement technology to build their practice around it. With the appropriately indicated patients, give them the option of receiving a disc replacement or a spinal fusion and thoroughly explain the procedural and postoperative expectations to them.
"I've never had a patient with the option of artificial disc replacement and fusion who chose the fusion," says Dr. Roush. "Arthroplasty is a very popular technology and leads to a quicker recovery because patients don't have the prolonged convalescence which produces postoperative deconditioning. It also takes time for the fusion to take place, but the artificial disc with precise placement allows patients to return to significant activities within a day or two."
Dr. Roush performs multiple disc replacements per week and finds that patients ask about the artificial disc technology by a three-to-one margin at his office.
"Surgeons have to have a significant commitment and adherence to the belief that this is a better treatment," says Dr. Roush. "Overall pain relief for the disc replacement may be better, depending on the further results of the ongoing IDE studies. There could also be a lower re-operation rate with disc replacements and higher patient satisfaction. It's going to take another 5-10 years before the midterm data supports that, but early data is very promising."
5. Target the right patient demographics. Not every patient falls within the appropriate indications for disc replacements, and not every patient will be comfortable with the technology or understand it. Dr. Roush has most success targeting educated and younger patients who are dependent on the internet to obtain information on the practice and procedure.
"The internet is the most important technology for empowering and educating patients of the procedure," says Dr. Roush. "Those patients are committed to performing their own research. There are entire websites directed to online forums for discussing disc replacements. The patient based dialogue is more complex than my experience with average patient population. I've focused on that subset of patients and they are more likely to understand the mechanics of the spine and benefits of motion preservation."
These younger patients often don't have arthritic change to the facet joint complexes — which would preclude them from having a disc replacement — and they understand the difference between the prosthesis with motion preservation and fusion arthrodesis. These patients will also be more likely to live in urban and suburban areas, and can be targeted through websites, blogs and other informational discussions about the procedure catered to that geography.
6. Network with referral sources. Beyond direct-to-patient marketing on the internet, surgeons can network with referral sources within the community. Primary care physicians are always a great referral source, but when your practice focuses on disc replacement you can also target specialists such as chiropractors, pain management and other orthopedic surgeons who work with chronic pain patients on a regular basis.
"There might be some orthopedic spine surgeons in the community who are confident with their skills as a fusion surgeon and don't want to adopt the disc replacement procedure because they have good results with fusion," says Dr. Roush. "They can refer the appropriate patients who want and are good candidates for disc replacements to you. Essentially any physicians or surgeons who are not doing disc replacements though are seeing a number of spine patients are outstanding foci to cultivate referral networks specific to disc replacement. I have found that this also drives the volume for other spine procedures, as well."
Focus your networking efforts on these specialists by speaking to large groups, hosting luncheons or networking at professional conferences. Selective “door-to-door” meetings are also quite effective to demonstrate your passion and commitment to artificial disc technology in a more personal fashion.
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