5 Qualities of Spine Center Leaders for Today & Tomorrow

"Prizm developed the network because they had just completed a very creative spine care contract with United Healthcare and the medical director asked 'Where else do you have these kinds of spine centers," says James Lynch, MD, FRCSI, FAANS, founder and CEO of SpineNevada, and chairman and director of spine at the Surgical Center of Reno, a member of the Spine Center Network. "Consequently, Prizm developed credentialing criteria for those spine centers that emphasized non-surgical treatment options and invited them to become Spine Center Network."

The credentialing criteria requires: integration of spine surgeons with PMR and spine therapy; production of a Clinical Outcome Report Card; and use of a Home Remedy Book that educates patients to non-surgical treatment options.

"Prizm began developing its non-surgically oriented spine center model more than 18 years ago," says Bob Reznik, President of Prizm Development. "We had done more than 500 one-on-one meetings with health insurance medical directors and large employers. We learned that they really wanted patients to be educated to their non-surgical treatment options. They wanted patients to avoid 'surgical mills' where they too often received surgery without any non-surgical treatment options. They also were frustrated that patients never received any home exercises that strengthen the back, make it more flexible and resistant to future strain. The centers in Spine Center Network emphasize non-surgical options before spine surgery. But when symptoms indicate surgery is needed, they are decisive and try to use a minimally invasive approach."

Mr. Reznik believes that healthcare reform will cause emerging accountable care organizations to seek out these types of spine centers. Consequently Spine Center Network is already developing bundled case rates for spine surgery and non-surgical episodes of care.

"Spine Center Network helps push us along to be sensitive to the needs of employers and payors for predictability and case rates," says Dr. Lynch. "That is the future of spine."

Here are five qualities of spine centers that will be in the best position to lead in the future, and become part of the Spine Center Network.

1. Integrated surgical specialists with non-surgical care. According to Mr. Reznik, around 90 percent of spine issues can be treated non-surgically. Patients and payors are looking for providers who can triage care, fast-tracking patients to the right specialist for their individual needs.

"With healthcare reform, there will be 30 million more potential patients and some of them will have back and neck issues," says Mr. Reznik. "How can we triage these patients so spine surgeons aren't having to assess simple acute back pain cases? Several health insurance plans in Michigan, Minnesota and Nevada have already mandated that physical medicine and rehabilitation physicians act as the gatekeeper. Some states have implemented a surgeon blockade, requiring the patient to see a PM&R physician before seeing a surgeon."

These trends could push spine in a similar direction as cardiac care. Currently, patients with beginning stage heart disease see a cardiologist before the cardiothoracic surgeon.

"In spine, you should have triage protocols so the person with a neurological deficit sees the right specialist," says Mr. Reznik. "I think payors are becoming educated about the high volume of surgery being performed, and healthcare providers need to do a better job of directing the patient to the right provider."

2. Ability to perform minimally invasive procedures. Technology and technique for minimally invasive spine surgery has evolved over the past several years into highly sophisticated instrumentation allowing surgeons to perform traditional procedures with a less disruptive approach. "These benefits are why we are opening a new dedicated office facility, SpineNevada Minimally Invasive Spine Institute, in July to address patient and insurance carrier needs," says Dr. Lynch.

Proven minimally invasive procedures can have several benefits, including less pain, blood loss, recovery time and cost than open surgery.

"When patients do need surgery, they should be directed to someone who performs a high volume of spine procedures with a minimally invasive approach so patients get the benefit from proficiency as well as a smaller incision," says Mr. Reznik. "These procedures can also reduce the length of stay, and some surgeons can perform them in same-day surgery centers."

The procedure costs less for the insurance company and patients are able to return to work more quickly, which softens the overall economic impact of spine surgery. Surgeons who perform a high volume of cases will have a more predictable outcome.

"I think payors are attracted to predictable patient outcomes and rates for surgery," says Mr. Reznik. "I think payors have been burned by unpredictable rates for facilities in the past, and that's one reason why payors are more intrigued by centers with non-surgical treatment options."

However, minimally invasive surgery isn't right for every patient and spine surgeons must understand appropriate patient selection before moving forward with surgical cases.

3. Achieve predictable outcomes. Spine care is expensive and stakeholders want to make sure they have a positive experience. Whether its spine surgery or non-operative treatment, payors may be willing to compensate more for quality in the future.

"Case rates can be a win-win for the payor and spine care provider. In return for a predictable total bundled rate, payors can provide reimbursement to the spine surgeon that may actually be better than their current unbundled and heavily discounted CPT code rate," says Mr. Reznik. "From a lot of discussions we've had with payors and medical directors, they aren't trying to abuse spine surgeons with their pricing, but they are frustrated with the unpredictability."

A spine center should be transparent with its protocols and philosophy for spine care by publishing online a Clinical Outcome Report Card that is generated not by themselves, which has little credibility, but rather by an outside entity. The report card should reveal not only patient satisfaction, but also what percent of patients receiving therapy, injections or surgery in the course of their treatment. Also, the report card should reveal what percent received a home exercise program and Home Remedy Book to demonstrate efforts toward prevention of future spine problems.

"Spine Center Network is the only network of truly credentialed spine centers where outcomes are reported online," says Dr. Lynch. "It's truly unique. As such, it is by invitation only, and a very elite group of spine centers."

4. Participation in new payment models. Insurance companies are interested in accountable care organizations and bundled payments, which lean toward a pay-for-performance instead of a fee-for-service reimbursement model. Providers participating in these payment models accept more risk for patient outcomes by negotiating a global fee for service. Additional costs for care, such as re-operations within a specified period of time, or complications are not covered within that fee.

"In 2013 we will be contacting medical directors of regional health insurance plans and ACOs in different locations and presenting them with bundled rates for simple back and neck surgery and ACDF," says Mr. Reznik. "The benefit for member centers is that they would ultimately get access to contracts of ACOs and we would provide a template on which they could bundle pricing for the local ASC and hospital. With that said, every center controls its own rates."

Each location would negotiate individual pricing, at a reasonable rate for the provider. Centers controlling more of the care can better guarantee quality outcomes.

"With healthcare reform, all accountable care organizations will be looking for spine centers that emphasize non-surgical treatment options and minimally invasive spine surgery to reduce costs," says Dr. Lynch. "National payors always have to search to find the best spine centers in the region [and they will be] attracted to the Prizm model that includes PM&R, spine surgeons, spine therapists, clinical outcome report cards, emphasis on home exercise and non-surgical treatment all under one roof."

5. Include patient education beyond medical care. Innovative spine care providers are beginning to focus attention on non-medical treatments for spine care and maintenance, such as fitness and personal health specialists. Spine centers that will be leaders in the future are open to any pathway that would benefit their patients.

"If you look at how heart centers have evolved, you have fitness specialists, cardiac rehab and disease process specialists," says Mr. Reznik. "You are going to see the same thing with spine. Right now spine is more fragmented and patients could see several different specialists and still not receive the right care. The mature spine center of the future will have orthospine surgeons, neurospine surgeons, physical medicine, therapists and exercise physiologists that move patients through to recovery as soon as possible."

More Articles on Spine Surgeons:
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