The key issues standing in the way of value-based spine care

Written by Anuja Vaidya | March 21, 2019 | Print  |

Three spine surgeons weigh in on the challenges of shifting to value-based care.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What devices currently on the market do you think have the most potential to improve spine care?

Please send responses to Anuja Vaidya at by Wednesday, March 27, at 5 p.m. CST.

Question: What do you see as the biggest roadblock to value-based care in spine?

Leo Spector, MD. Chief Quality Officer of OrthoCarolina (Charlotte, N.C.): I believe the biggest roadblock to value-based care in spine, and orthopedics in general, is a fundamental resistance to change. As Mark Twain said, 'I'm in favor of progress, it's change I don't like.' In general, the people that deliver the care (providers and hospital systems), pay for the care (federal and private insurers) and receive the care (patients) are creatures of habit. Proper incentives are needed to create an environment where individuals and organizations are willing to transform their behavior.

The patient experience is central to this transformation. We need to recognize and begin treating patients like consumers, similar to any other business that is selling goods and services. Informed and invested consumers will begin to make decisions in their best interest — as defined by them. Only then will they begin to demand the change that needs to occur. Ultimately, until all stakeholders within the healthcare ecosystem are rewarded for value-based care, change will be slow and sporadic.

Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: There is a fundamental problem with value-based care. The erroneous assumption is that you can get the best care for 'cheap.' First, it depends on what you mean by 'cheap.' In this case, it is a relative term. Now, if one place charges $15,000 for a microdiscectomy versus a place that charges $10,000 — to most people that is still a whole heap of money. We still don't have any idea what a 'reasonable' cost is. We have never established this, and the error promulgates from there. It turns out, those prices are actually fairly low, if they are an 'all-in' price. So right there, we have to adjust our expectations.

We then started asking questions about what it means to have 'quality.' Lots of people have tried to sell their idea of what quality means. We still don't have consensus. The answer is 'depends on who you ask.' What hospitals and insurance companies define as quality is very likely not what the layperson, and more importantly, patients, would define as quality. Again, there is dissonance. We have to adjust our thought processes and get to what a patient would define as quality and stop there.

Finally, and most importantly, [value-based care] assumes that 'the cheapest is the best.' And that is the most dangerous and fallacious assumption in this process. Much like the EMR debacle when it started 10 years ago, doctors are the canaries in the coal mine and twittering: 'this does not make things better!' Fact: you cannot get a Maserati at a Yugo price. If you want quality, you must pay for it.

Issada Thongtrangan, MD. Orthopedic Spine and Neurosurgeon at Minimally Invasive Spine (Phoenix): Value-based care is the balance between outcomes and cost. The advanced technology in spine will come with cost, and it will need validation to prove that it can impact patient outcomes.

Currently, there is no consensus on what measurements or data are 'the benchmarks' either among the surgeons or the payers.

It also will be difficult to implement in a solo or an independent practice because it will need more resources and infrastructure to gather the data, and this adds on expenses for the practice.

More articles on spine:
How well is Walmart's spine center of excellence program working? 5 takeaways
Dr. Todd Albert to complete surgeon-in-chief term in June, maintain spine practice at Hospital for Special Surgery
Penn Medicine opens $10M spine center with Dr. William Welch as medical director – 4 things to know


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