What is the most important issue facing spine surgeons in 2015?

Responses are edited for clarity and length. If you would like to respond to this article or contribute to future spine-related articles, contact Laura Dyrda at ldyrda@beckershealthcare.com.

Jeffrey R. Carlson, MD, President, Orthopaedic and Spine Center, Newport News, Va.: Spine surgeons are coming under greater scrutiny for the expense of the surgeries that they perform. The complex procedures that are needed to improve a patient's function are some of the most expensive surgeries performed. These procedures will continue to be questioned through hospitals, insurers and governmental agencies which will force surgeons to limit their practices and withdraw from these highly specialized skills. As these outside forces pressure surgeons, innovation and creativity will be hindered.

Andrew M. Cordover, MD, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Ala.: Numerous issues and challenges face spine surgeons today. These encompass multiple arenas (political, insurance, quality of care, technology, etc;). One area of major concern is that of the aging spine. Surgery can be more complex, with lesser outcomes, increased complications and longer duration of hospitalization. These all contribute to higher-level utilization of resources. This places new levels of demand on our system.

Philip Schneider, MD, Montgomery Orthopedics, a division of The Centers for Advanced Orthopaedics, Director of the Spine Center, Holy Cross Hospital: There are several major issues confronting spine surgery at the moment. The first major issue is the government's insistence that spine surgeons participate in PQRS, Meaningful Use, and Value Based Modifiers by using metrics that have been developed for primary care physicians. The whole process is counter intuitive to good care and wastes valuable resources and money. However, without playing this game, we could stand to lose 10 percent of our Medicare dollars.
 
The second issue is the obstacle that insurance companies have created to impede patient care. Unnecessary time-consuming phone calls in the guise of "peer-to-peer" conversations are now dominating my day. Rejections of appropriate medically-indicated imaging studies and treatments have become the norm. Recently, I did a very successful right S-I joint fusion. One month later, the patient wanted the left side done. During that one month timeframe, the insurance company created a new obstacle that prevented the left side from being done. The patient is devastated.

Ian Armstrong, MD, Medical Director, Southern California Spine Institute, Los Angeles: One of the most important issues facing spine care and spinal surgery is moving spine care and spinal surgery into an evidence-based decision making process; one with broader more standardized algorithms and protocols for treatment decision making. This must be done in a manner that does not interfere with the individual doctor-patient relationship, but shapes spine care in to a more uniform care model. This will allow for improved outcomes, while maintaining economically-sound patient care principles. Some form of evidence based, "standardized treatment" with spine surgeon and spine care professional society self moderating and monitoring is important if we are to maintain the highest quality patient care model that is doctor, patient and outcome driven. This is also important if we as physicians want to maintain our important role in the spinal surgery decision making process.

This has become more important as rapidly improving and advancing spinal surgery technologies are being introduced almost daily. This presents a confusing constellation of care options for the insurance companies, patients and provider. It is the medical professionals, and our professional societies that must drive the development of these spine care protocols. If we do not take the lead we will follow primarily corporate based, economically driven models.

Hooman Melamed, MD, Spine Surgeon, Marina Del Rey & Newport Beach, Calif: Insurance companies meddling with and denying surgeon's diagnosis. It's more and more common for insurance companies to make the final decision when it comes to a patient receiving surgery or treatment. Oftentimes the doctors evaluating the request for imaging or surgery at the insurance companies are not spine surgeons or even doctors specializing in spine/back procedures. The most common response as the guidelines become more and more strict is "not medically necessary," but patients don't always fit into guidelines — spine surgery isn't always black & white.

[Additionally] procedure codes are being lumped together and surgeons who are performing very difficult cases are receiving the same reimbursements as they would if they preformed a more common procedure.

Scott Lederhaus, MD, President of the Association for Medical Ethics: From my perspective the most interesting and most tragic issues surround the corruption in medicine, but in particular with the spine industry. The corruption surrounding consulting arrangements, physician-owned distributors and the idea that every patient with any level of low back pain is a surgical candidate is nothing short of unbelievable. Spine surgeons, and physicians in general, have lost the ability to police our own industry. The State Medical Boards have become impotent. The peer review at our hospitals is equally impotent. Physicians are afraid to say anything against another physician for fear of retaliation and slander/liable suits. What about the patients?  Have we forgotten our role in treating patients? It would seem to me that the spine world needs to refocus on what is important and get back to doing what is best for the patient and not what is best for our bank accounts.

Amer Samdani, MD, Chief of Surgery, Shriners Hospital for Children:

1.      Spine education — neurosurgery and orthopedics now with separate residencies, but should there be a combined training program?

2.      Innovation — working through the FDA

3.      Outcomes — proving we are doing better

Patrick Cahill, MD, Spine Surgeon, Shriners Hospitals for Children—Philadelphia:

1.       Justifying our work; proving the benefits scoliosis intervention on our patients' health and the cost to society.

2.       Learning how to learn. Understanding the process of how surgeons master their craft and continue to improve throughout their careers.

3.       Unlocking the molecular level processes that are involved in scoliosis.

Ara Deukmedjian, MD, Founder, Deuk Spine Institute, Melbourne, Fla.: In my opinion, the most important and interesting issues facing spine surgeons center around patient access to effective spine care. The most common spinal conditions that cause patient complaints are degenerative conditions of the spine like spinal stenosis, herniated discs, bulging discs, degenerative disc disease and radiculopathy. The spine is full of joints that commonly cause pain and pinch nerves as the joints develop arthritis from old injuries to the spine. As we age, the arthritis progresses and may cause symptoms such as neck or back pain, numbness or tingling or weakness in the arms or down the legs. These symptoms usually require surgical intervention to cure. Surgery is expensive and insurance companies are using any means possible to deny these treatments.

At Deuk Spine Institute, our surgery success rate is above 90 percent and we offer the only spine surgery warranty to cover the cost of any additional treatment that may become necessary after surgery. Surgery performed with excellent, advanced techniques on the right condition will result in outstanding relief of pain from the back or neck. We are confident in the results of our spinal surgery and offer the warranty for any patient undergoing spinal surgery at our outpatient surgery center, Surgery Center of Viera. The warranty comes standard with payment of the full facility and professional charges. The warranty covers post operative therapy, office visits at Deuk Spine Institute, advanced diagnostic imaging including MRIs and CT scans (if needed), home nurse, pain medication, post-operative pain management procedures if needed such as facet rhizotomy or spinal cord stimulator (not expected), Sacroiliac joint treatments or even additional surgery on the part of the spine being treated. The warranty covers the cost of any additional post operative treatment in our Deuk Spine Institute network of providers under the direction of the medical director.
 
Access to high quality, individualized care is in jeopardy right now. We are seeing healthcare insurers constantly looking for new treatments or services to strip away from patients. Insurers are refusing to cover even the most obvious tests and treatments that are known to work and replace them with much less expensive treatments that don't work. Health insurers understand that people switch their health insurance often and the insurer just needs to fend off paying for expensive treatments that work (but costs the insurer substantially more) for a few months until the person changes their insurance or gets dropped or loses their job (and their health insurance benefits).

Stefan Prada, MD, Laser Spine Institute, Tampa, Fla.: It can be difficult to get new devices passed through the FDA, so the challenge in passing new innovation should be considered. Because of the costs, many companies who are developing products that might be tremendously helpful for patients are growing cautious about innovation. Europe has had a lot of new technology that has shown to be successful, but it may take several years for some products to get past the FDA. Because of this, the amount of new innovation may be limited in the U.S., which can have an effect on patient care.

Navin Subramanian, MD, Aviva Spine Centers, Houston: There are numerous challenges to the practice of spine surgery, however, from a patient care standpoint, one of the biggest issues is insurance carriers denying and delaying patient care. Due to the complex nature of spine procedures, and the numerous techniques used to obtain the necessary surgical goal, I have seen an increase in insurance carrier denials of procedures. Many of these denials may be due to documentation requirements, choice of surgical technique, choice of surgical implants, or failure to meet that carrier's guidelines for the procedure. This adds additional administrative work for the surgeon, decreasing the amount of time he or she can concentrate on patient care. With the cost of healthcare continuing to rise, I imagine that this will only worsen.

Gowriharan "Ty" Thaiyananthan, MD, Founder of BASIC Spine, Newport Beach, Calif.: Balancing the challenges of delivering cost-conscious care access to promising but sometimes expensive and novel technologies that offer our patients the best options.

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