Payer negotiations have been a challenge for some spine surgeons, especially with evolving reimbursements and financial headwinds.
Spine surgeons discuss the things that need to be in more payer conversations.
Note: Responses were lightly edited for clarity.
Question: What's missing in spine surgeon conversations with payers?
Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): Spine surgeons play a crucial role in improving the lives of patients and need to be recognized for their value. Enhanced communication and transparency in relationships with payers can hopefully lead to better understanding and improve surgeon reimbursement rates. It is essential to align goals and priorities to ensure that surgeons are adequately compensated for their important work.
Oren Gottfried, MD. Professor of Neurosurgery at Duke University School of Medicine (Durham, N.C.): We are very involved in collecting data, reviewing trends, and quality improvement for our health systems spine care and surgery outcomes, and we benchmark this data compared to top national, regional and state centers. We work very hard to improve patient satisfaction, our quality of care, while keeping costs down. The payers are also very good at collecting data on cost and outcomes on each surgeon, surgery type, hospital, and wider. The problem is the data between these two groups rarely look similar and this is likely due to patient selection and a focus on a specific target group instead of a bigger population, how and the extent risk adjustment or stratification is performed, or even how an outcome or metric is measured.
It would be ideal for both groups to review the same data real time and work toward mutual goals of improved patient outcomes and reduced costs. We are working with payers on shared data that is beneficial to both groups, but it is a work in progress.
Michael Gallizzi, MD. The Steadman Clinic (Vail, Colo.): Conversations between spine surgeons and payers often lack essential elements, including ongoing education and updates on new technologies, techniques, and research in spine surgery, which would help payers understand the value and effectiveness of innovative procedures. Fair reimbursement rates that reflect the complexity, risk, and value of robotic and endoscopic spine surgery procedures are also missing.
Additionally, quality metrics that differentiate surgeons based on their outcomes and revision rates, rather than just their location, are needed. The medical field is unique in that even the best surgeons are reimbursed at the same rate as less experienced ones, regardless of their outcomes. To address this, outcome-based payments could be considered. By addressing these gaps in conversation, spine surgeons and payers can work towards a more collaborative and value-based approach to reimbursement, ultimately improving patient care and outcomes.
Alok Sharan, MD. Spine and Performance Institute (Edison, N.J.): The goal of delivering better outcomes is missing in the conversations with payers. Currently a lot of the conversations that spine surgeons are having right now with insurance companies revolve around pre-authorization for surgery. Medical directors of the insurance companies are tasked with sticking to their internal guidelines and approving a surgery based off meeting that criteria. Unfortunately this leads to a “checklist” type of approach to medical care. As well know the practice of medicine is not so clear cut. There are times when a patient needs surgery but doesn’t meet the exact criteria.
It would be interesting if the medical directors called the providers 3 months after the surgery was completed to determine what type of outcome was achieved, and how the outcome was measured. In that discussion a spine surgeon can justify (with data) why they performed the surgery, and more importantly back it up with meaningful outcomes data. Perhaps this can help the medical director have more discretion in which surgeries they approve and which ones they disapprove.
Lali Sekhon, MD, PhD. Spine Surgeon at Reno (Nev.) Orthopedic Center: 1. Respect for national spine guidelines. A lot of payers have arbitrary internal rules that are not the community or national standard. eg MRI within 6 months or surgery not approved
2. CPT code 22853 approval. Looking at you, Aetna. Most of us use cages. To say there is no proof of their benefit over allograft or autograft is simple confirmation bias to support their denial agenda.
3. Peer reviews by practicing spine surgeons instead of retired pediatricians, internal med docs etc who just read from a script.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Prior authorizations are becoming more and more burdensome by the day. There is no doubt the denials, peer to peer requirements, and multiple appeals have increased dramatically over the past several years and in particular in the post-COVID time. Unfortunately, there is no evidence that these burdens have reduced unnecessary surgery. There is also no evidence that these processes have made care more efficient or streamlined. In fact, the evidence points towards delayed care, even for those who need urgent spine surgery, such as patients with myelopathy or foot drop due to nerve compression. I see it in my practice every day. The biggest thing missing in this conversation is how do we work together to ensure that every patient gets the right care that they need? It is undoubtedly important to ensure that patient's don't undergo unnecessary surgery. It is just as important to ensure that patients who need spine care get the right care in an efficient and timely manner. How do we move past the cat and mouse game of who is willing to jump through the hoops to a legitimate conversation about standardization, appropriateness, and efficient care?