A. Nick Shamie, MD, co-director of UCLA Comprehensive Spine Center, discusses new payment models on the horizon and how spine surgeons will fit into accountable care organizations.Q: What alternative payment models are spine surgeons considering today?
Dr. Nick Shamie: There have been talks about what may happen and the accountable care organization payor model is basically moving toward a single payee where typically the hospital or group that includes a hospital, physicians and clinicians, come together in a care network. This typically is run by hospitals, and the hospitals decide where the distribution of the funds will be.
Aligning with a medical group or a hospital ACO including a medical group would be extremely beneficial as the new structures are forming. This is especially true to busy, competitive markets, such as in big cities where doctors are purchasing physician practices.
Q: Should spine surgeons join an ACO?
NS: It comes down to what kind of provider you are — a single provider or group provider. Strength is in numbers — if you have a group that provides care in that community, they will have a much stronger voice than if you are a single practitioner. As importantly, if not more importantly, is the quality of care you provide. ACOs will be interested in getting good ratings from the patient.
This is part of the whole movement — to provide better care for less money. If you have a well-established, high quality and well-regarded practice, you will be in a much better position to negotiate.
Q: Will this trend lead to more consolidation and fewer independent physicians?
NS: I think it's uncertain what is going to happen exactly, but payors are aligning themselves with big centers and therefore being a part of these big centers will be a vital part of anyone's practice. We've seen that happen where a big orthopedic group was recently purchased by a hospital, which immediately injects cash flow into your practice, but long term the partnership will allow the hospitals to negotiate with payors and device proceeds between the facilities and faculties, and that medical practice they purchased.
I think upfront negotiations will be very important when this transition happens because both parties have to have an agreement and understanding. We don't know how this will play out.
Q: How can spine surgeons prepare for ACOs?
NS: It would be advantageous for both hospitals and spine surgeon groups to have hypothetical situations to basically predict future possibilities and watch each possibly on how the structure will work and what the agreement will be. That would help with future arrangements, however things pan out. Medicare may require hospitals to directly align themselves with the government payors or they may require some division between the medical groups and hospitals.
We have government payors, but also private payors, and what happens to private payors if the negotiation only considers ACOs with government payors? There has to be a clause discussing other payors that will remain as is. There could be opportunities for different arrangements for different payors.
Q: What kind of quality metrics are most important for spine surgeons to collect?
NS: Before we were collecting metrics like patient volume and complication rate; now we have to go beyond the basics of quality to care and focus more on patient satisfaction, wait time for visits and types of care provided. If you want an MRI done, having it in the same place for the patient is convenient and you'll get a higher rating. If you don't have enough providers and patients have to wait a month for a visit, that's going to be looked down upon and negatively impact the ACO's reputation.
I think it's going to be a given that spine surgeons will try to have the best care and fewest complications. It's going to be a challenge to reach these new metrics because this is a completely new paradigm that we have to work under and many of the terms will be determined as we learn more about how these systems work.
Q: How will reimbursement be impacted by new payor models?
NS: We are seeing gradual transitions where multiple codes traditionally have been used for spine surgery are getting less frequent. A recent example is posterior lateral fusion, which now includes the interbody. The interbody fusion includes extensive dissection and much more is involved than just the posterolateral fusion, but those codes are bundled now. That's in the works and been happening gradually. Anterior cervical discectomy and fusion reimbursements have seen the same bundling.
Q: What are the biggest challenges spine surgeons have with ACOs?
NS: As these organizations are forming, we have to take into account the expanded need for care. Any degeneration condition or disease of an older age patient will become a challenge if we maintain the same resources that we currently have. We have to expand our resources because if the hospitals are over flowing with patients, there will be more patients waiting in line.
On the bright side, we are seeing orthopedics and spine surgery needs expand because baby boomers are getting older and over the next 20 years, we will be busier than we ever have been. That is really going to be an important part of the successful transition to these newer payment models.
With these changes, we have to make sure we are getting more efficient because we have to provide more resources. We've seen it in other countries where specialty care is not adequately provided so people are leaving those countries and seeking care elsewhere and we want to make sure that isn't an issue in this country.
More Articles on Spine Surgery:
Inpatient vs. Outpatient Lumbar Fusions: 5 Points of Comparison
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Dr. Nick Shamie: There have been talks about what may happen and the accountable care organization payor model is basically moving toward a single payee where typically the hospital or group that includes a hospital, physicians and clinicians, come together in a care network. This typically is run by hospitals, and the hospitals decide where the distribution of the funds will be.
Aligning with a medical group or a hospital ACO including a medical group would be extremely beneficial as the new structures are forming. This is especially true to busy, competitive markets, such as in big cities where doctors are purchasing physician practices.
Q: Should spine surgeons join an ACO?
NS: It comes down to what kind of provider you are — a single provider or group provider. Strength is in numbers — if you have a group that provides care in that community, they will have a much stronger voice than if you are a single practitioner. As importantly, if not more importantly, is the quality of care you provide. ACOs will be interested in getting good ratings from the patient.
This is part of the whole movement — to provide better care for less money. If you have a well-established, high quality and well-regarded practice, you will be in a much better position to negotiate.
Q: Will this trend lead to more consolidation and fewer independent physicians?
NS: I think it's uncertain what is going to happen exactly, but payors are aligning themselves with big centers and therefore being a part of these big centers will be a vital part of anyone's practice. We've seen that happen where a big orthopedic group was recently purchased by a hospital, which immediately injects cash flow into your practice, but long term the partnership will allow the hospitals to negotiate with payors and device proceeds between the facilities and faculties, and that medical practice they purchased.
I think upfront negotiations will be very important when this transition happens because both parties have to have an agreement and understanding. We don't know how this will play out.
Q: How can spine surgeons prepare for ACOs?
NS: It would be advantageous for both hospitals and spine surgeon groups to have hypothetical situations to basically predict future possibilities and watch each possibly on how the structure will work and what the agreement will be. That would help with future arrangements, however things pan out. Medicare may require hospitals to directly align themselves with the government payors or they may require some division between the medical groups and hospitals.
We have government payors, but also private payors, and what happens to private payors if the negotiation only considers ACOs with government payors? There has to be a clause discussing other payors that will remain as is. There could be opportunities for different arrangements for different payors.
Q: What kind of quality metrics are most important for spine surgeons to collect?
NS: Before we were collecting metrics like patient volume and complication rate; now we have to go beyond the basics of quality to care and focus more on patient satisfaction, wait time for visits and types of care provided. If you want an MRI done, having it in the same place for the patient is convenient and you'll get a higher rating. If you don't have enough providers and patients have to wait a month for a visit, that's going to be looked down upon and negatively impact the ACO's reputation.
I think it's going to be a given that spine surgeons will try to have the best care and fewest complications. It's going to be a challenge to reach these new metrics because this is a completely new paradigm that we have to work under and many of the terms will be determined as we learn more about how these systems work.
Q: How will reimbursement be impacted by new payor models?
NS: We are seeing gradual transitions where multiple codes traditionally have been used for spine surgery are getting less frequent. A recent example is posterior lateral fusion, which now includes the interbody. The interbody fusion includes extensive dissection and much more is involved than just the posterolateral fusion, but those codes are bundled now. That's in the works and been happening gradually. Anterior cervical discectomy and fusion reimbursements have seen the same bundling.
Q: What are the biggest challenges spine surgeons have with ACOs?
NS: As these organizations are forming, we have to take into account the expanded need for care. Any degeneration condition or disease of an older age patient will become a challenge if we maintain the same resources that we currently have. We have to expand our resources because if the hospitals are over flowing with patients, there will be more patients waiting in line.
On the bright side, we are seeing orthopedics and spine surgery needs expand because baby boomers are getting older and over the next 20 years, we will be busier than we ever have been. That is really going to be an important part of the successful transition to these newer payment models.
With these changes, we have to make sure we are getting more efficient because we have to provide more resources. We've seen it in other countries where specialty care is not adequately provided so people are leaving those countries and seeking care elsewhere and we want to make sure that isn't an issue in this country.
More Articles on Spine Surgery:
Inpatient vs. Outpatient Lumbar Fusions: 5 Points of Comparison
10 Hospitals Growing Spine Surgery Services
10 New Spine Device Launches