Eeric Truumees, MD, is the administrative and development council director for the North American Spine Society. He is a fellowship-trained orthopedic spine surgeon and practices at Seton Spine and Scoliosis Center in Austin, Texas.
Dr. Truumees serves as the medical editor for NASS's SpineLine publication and has published extensive spine research of his own, including more than 100 abstracts, scientific papers and book chapters. Dr. Truumees completed his fellowship at William Beaumont Hospital in Royal Oak, Mich. Here Dr. Truumees discusses how drastically the spine industry has changed since he first graduated from medical school 20 years ago, and he highlights the need for interdisciplinary cooperation to fight for proper patient care.
Question: Why did you choose to specialize in spine?
Dr. Eeric Truumees: In medical school at the University of Virginia, I was lucky enough to work with both outstanding orthopedic and neurological surgeons. In the early '90s, many spine cases performed at UVa were collaborative efforts between both departments. The technical challenge provided by those combined cases was attractive as was the art of selecting the right patient and the right procedure. Unlike some of my other medical school and residency rotations, spine as an anatomic area of specialization exposes the physician to patients of both sexes and all ages. Treating diseases ranging from spondylosis to acute trauma seemed to be a surefire way to limit burn out. Ultimately, in residency, I liked the idea that spine care is far from a "solved problem." Spine continues to present a wide array of diagnostic, treatment and research challenges from natural history and diagnostics to prevention and improved surgical techniques.
Q: Have you worked with any other spine surgeons or mentors who have shaped your practice?
ET: It would be easy for me to lose count of all of the ways I've been lucky. But, the people I’ve gotten to work with have had an incredible impact on my career and current practice.
In residency, I worked with a group of spine surgeons that really spanned the spectrum of philosophies of spine care. These included Gordon Bell, MD, Izzy Lieberman, MD, Rob McLain, MD, and Robert Biscup, MD. Each brought a very different approach and skill set. My fellowship was with Harry Herkowitz, MD. Both he and Jeff Fischgrund, MD, expected a great deal, but gave me great latitude to develop my skills and confidence. Both have remained true mentors and been very supportive of my career.
Q: How has the practice of spine surgery changed since you first graduated from medical school?
ET: I just had my 20th medical school anniversary. As I look back, spine care has changed markedly. In surgery, some of the most obvious changes have come in decreased incision size, faster mobilization and shorter hospital stays. Our attention to and ability to improve spinal balance has changed the way I look at a spine patient. Our tool chest for anterior and lateral access and the various interbody and fixation options has allowed us to increasingly customize our approaches to a given patient's pathology. That approach, however, requires a more complete, level-by-level understanding of spine biomechanics and the natural history of degenerative processes. I think we still have a great deal of work to do in these areas. Disc replacement and motion preservation technologies still hold a great deal of promise, but they are far from mature at this point.
Q: How has SpineLine evolved since you first started working with the editorial board? What role do you think the publication plays in the overall industry?
ET: I joined the SpineLine Editorial board in 2003. In 2007, I took over as medical editor from the founding editor, Stuart Weinstein, MD. In January, Tom Mroz, MD, became the new medical editor. SpineLine was an amazing, educational experience. When I came in, I had a pretty solid footing in the research and education areas of organized spine. But, my knowledge base in advocacy, industry and the business of spine care was sorely lacking. SpineLine provides an excellent bridge between the critically important economic side of spine care, as covered by Becker’s Spine Review and the formal, scientific approach offered by the peer-reviewed journals.
My work as editor was a baptism in fire as I struggled to learn what was really going on in healthcare. I'll never forget an early column in which I tried to break down the various government entities that regulate healthcare. My own practice had seen legal bills for HIPAA and other consulting services skyrocket. In trying to figure out why it was all so expensive, I discovered that there are different rules and investigative guidelines within the Departments of Justice and of Health and Human Services. Even within a department, like HHS, there are FDA, CMS and Office of the Inspector General to worry about. Of course, state law is important and occasionally commerce gets involved. Just reading the bulletins and translating them from bureaucratese into English could be a full time job. SpineLine continues to interpret these new rules, safe harbors and advisory bulletins for its readers. Just as the "Clean Water Act" may have little to do with water pollution, the latest "Pay For Quality" initiative may have nothing to do with actual, quality medical care.
SpineLine also offers diagnostic and therapeutic pearls, practical advice on coding, primers on the language of medical economics, a language we are all increasingly expected to speak fluently. Unlike the formal spine literature, SpineLine’s content is very much of-the-moment as each issue goes to press. Papers do not spend months or years in review and awaiting publication. Authors are free to comment on how various advances or technologies fit in to their practice lives. Moving forward, SpineLine is now available online and a smartphone app was recently released.
Q: Are you currently working on any research you could talk about?
ET: My main research interest lies in fixation in the compromised spine. Typically, my work includes biomechanical studies of various facets of cervical and thoracolumbar reconstruction. Currently, we are examining the merits of routine extension of long cervical fusions into the thoracic spine. With the aging of the population and the increased survival of cancer patients, I think work will be increasingly relevant.
My exposure to advocacy and patient access issues at NASS has prompted other research as well. Recently, we completed a look at surgeon reimbursement in the private practice versus hospital employment scenarios. As you can imagine, the bargaining power of a hospital can have a marked impact on reimbursement. On the other hand, incentivized physician's private offices are probably much better at collecting surgical fees. Given the vulnerability of in-office ancillary services, I am interested in looking at the economics of spine surgeon's in-office X-ray. Losing an in-office X-ray will have a major, adverse impact on not only convenience of care for spine patients, but also quality and timeliness of that care. Yet, we cannot make a good case to our lawmakers without data. It doesn't help that our radiology colleagues are fighting us here. I hope, someday soon, doctors' groups will realize that the divide and conquer approach will only hurt the economic viability of our practices and our patients' access to care.
Q: How has spine research evolved as federal regulations for clinical trials have increased?
ET: While we do have a company-sponsored FDA trial underway at my center, I am not currently as involved with these trials and industry efforts to introduce new technologies as I was a few years ago. That said, I have seen an increasingly challenging environment. Increased regulation, an overburdened 510(k) process and astronomical expense seem to have slashed venture capital funding available for spine. Having been burned by low reimbursements for new technologies, the implant companies appear to be taking a very cautious approach to developing any technologies that might need an investigational device exemption. Some of this work seems to be moving off shore and some just seems to be on hold as the FDA modernizes and regulations to flesh out the Affordable Care Act are written.
At the May National Orthopedic Leadership Conference, Jeffrey Shuren, MD, JD, the Director of the Center for Devices and Radiological Health (CDRH) at FDA, addressed some of these concerns. He talked about ways to expedite review and then improve post-market surveillance. I hope these changes come to pass; because, as far as spine has come, we clearly have much further to go. I hope this is an area in which individual physicians, organized medicine, the implant industry and patient groups combine efforts to tackle these problems. Specifically, we need funding mechanisms that better connect basic research with patient care. That is, most venture capital monies are available on a limited time horizon that deters potentially revolutionary ideas from inching their way to the market. We cannot count on the National Institutes of Health and government funding to get this done.
Q: How can spine surgeons work with surgeons of other disciplines or specialties to better themselves and their practice?
ET: Whether mandated by accountable care organizations or demanded by the economic challenge of keeping one's practice afloat, spine surgeons will need to increasingly integrate their practices with those of other disciplines. Today, there is simply too much duplication of effort. We are often working at cross purposes with other spine care givers. This is ultimately self-defeating. Spine surgery is not competing with PMR or pain management. We are competing with breast cancer and heart disease for increasingly scarce financial resources. Clinically, in that many spinal afflictions are, or become, chronic, we should take a disease management view. We should work with internists to ensure that bone mineralization is optimized. We should work with pain management to curb over-prescription of opioids. We should work closely with our physical therapists to optimize rehabilitation strategies. If ACOs become a dominant care model, where possible, physician groups should seek to run them. Our patients and our professions gain little and lose much when we cede power to the hospitals.
Rather than short-sighted protectionism, long-term patient access to care is best preserved by publishing and adhering to appropriate use criteria for common conditions. In these AUCs, we should speak with a single voice with other specialties and stakeholders. Together, we should continue to collect outcomes data supporting the cost effectiveness of the care we deliver.
Q: What are the biggest challenges currently facing the industry?
ET: Spine surgery is expensive. Back pain and sciatica rarely kill people. Those facts put us in the crosshairs of payors. Similarly, the implant industry will face increasing pressure to offer the same implants for less money. A major aspect of this challenge arises from the fact that most commercial payors look at the value equation over a relatively short time horizon. The benefits of optimal spine care, for example sagittal rebalancing, make take years to be revealed.
Additionally, spine care has a huge impact on non-medical/social costs. These costs are far too infrequently taken into account when determining the true value of a spine intervention. The benefits to the employer, the family and society at large of getting a spine patient back to function must be included in cost per quality adjusted life year calculus. Often, the spine intervention will have negative cost or net savings to society.
Here too, the best way to address these challenges lies in how we tell the story. Bickering with primary care or the radiologists about pieces of the pie and infighting with non-surgical spine care specialists will only detract from our ability to make our case to payors and lawmakers. Instead, we need to learn the language of medical economics. We need to speak a common language in terms of patient reported outcomes. We have to fight CMS's and payors' efforts to use proxy measures like satisfaction and process measures like readmissions as their main measures of quality of care. Most importantly, we need the data to support the quality and, over the mid- and long-term, cost-effectiveness, of the care we deliver.
Q: What is most fulfilling part of practicing as a spine surgeon?
ET: I have a great job that's different every day. I can contribute in a host of ways from the office to the OR to the lab. I work with outstanding, motivated and intelligent people. But, the best part of the job comes when a patient and their family put their trust in me to take them to the operating room, address their pathology and guide their road to recovery. Pinched nerves are miserable. "Fixing" the patient's problem and alleviating the pain is an incredible rush. In the future, I hope we can ask our patients to help preserve access and improve care for those coming after them. This request could come in the form of donations for research or a letter to their legislator. I think we need a mechanism to make this easy for all parties involved.
My work with NASS and other groups is also fulfilling. In particular, I am co-chairman of the program committee for the 2013 NASS Annual Meeting in New Orleans. I am very proud of the outstanding program NASS President Charles Mick, MD, my committee, my co-chairs and I have put together. Any reader of Becker’s Spine Review will find a wealth of interesting material including the always popular and up-to-the-minute "hot topics" sessions. I'd like to invite you to attend what promises to be a great meeting.
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