Seven spine and neurosurgeons share their insight on consolidation in healthcare and anticipate how the trend will impact spine 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.
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Please send responses to Alan Condon at acondon@beckershealthcare.com by Wednesday, Jan. 15, 5 p.m. CST.
Note: The following responses were edited for length and clarity.
Question: How do you feel about consolidation in healthcare? How will it affect spine surgeons over the next five years?
Oren Gottfried, MD. Duke University School of Medicine (Durham, N.C.): As the total episode of care will be grouped together, we will need to provide the most effective, efficient and inexpensive interventions or surgeries to get patients back to better functioning and health. Using risk-adjusted personal, hospital and nationwide data from national registries like the American Spine Registry to judge our outcomes and costs will be essential to maintaining our relevance. In this system, outliers for quality and safety, costs or outcomes will have a harder time functioning and there will be significant pressure to reduce variability in practices.
The best tactics to stay ahead of this curve are to embrace evidence-based decision-making, predictive analytics and risk stratification calculators; follow strict indications and contraindications to surgery based on literature and peer review; optimize health of sick patients before surgeries; identify when surgery is futile and no longer of benefit or too high risk; and collect and assess outcomes and costs on all cases as well as designing initiatives to improve these results. There will be very firm competition to get the most highly sought after contracts to serve large and specific populations for their spine health, and I can imagine groups, centers, hospitals or health systems staying busy would have embraced all of these elements. Finally, in addition to more spine surgeries being done outside of the hospital, there will be a specific emphasis on population health and optimizing the care and costs of the non-operative spine patient.
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The entire premise of an operative consolidation in healthcare/industry is obligatory for long term viability and imposing efficiencies while simultaneously eliminating the redundancy in organizations. Albeit expensive from its initiation, cost savings and market share consolidation are potential net results.In this community, payers have 'consolidated' their surgical approvals based on more quality based scrutiny and value equity measures.
This has placed both the complex and quotidian case management in larger institutions who demonstrated more adept and safer outcomes. Cost is still king, which also brings to the discussion the compromising issues surrounding referral patterns and antitrust. Prospectively speaking, consolidation and reduction will continue as surgical interventions remain labeled 'last ditch' efforts and the use of conservative measures remain intact. The reality of portability and access are healthcare policy issues for the present and future.
James Chappuis, MD. Spine Center Atlanta: Over the next five years, there will be significant mergers and acquisitions in orthopedics and in healthcare in general. As much as I don't necessarily like this because now there will be corporate-run healthcare systems who may not always have the best interests of the patient, I believe it's a necessary reality for us all to survive in this current environment. Also over the following five years, I think the day of the smaller spine practice is slowly going to be eliminated, larger groups are going to coalesce and we are all going to be working in larger settings as opposed to smaller groups that exist today.
Fred Naraghi, MD. Comprehensive Spine Center (San Francisco): Consolidation is inevitable. As the cost of providing services increases and reimbursements dwindle, systems have to consolidate. It would be more difficult for spine surgeons to remain independent. Personally, after many years of private practice, I'm now joining a larger group, and although I'm very happy and excited about it, it was inevitable.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: By its very nature, consolidation will increase prices as competition decreases. It will be the undoing of the insurance companies. As more physicians join large organizations, those organizations will leverage their contracting power against these companies. No amount of price transparency will be able to undo these market forces. As spine surgeons get more pressure to 'join or die,' patients' choices will decease and overall satisfaction will likely decrease.
My hope is that spine surgeons can partner with some of these organizations to maintain independence, and perform high quality surgeries and patient care while being able to be nimble so patients can have timely access to care. My concern is that as the landscape flattens, the 'care deserts' will expand as patients have to wait longer and longer to get in to see their surgeons.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Just like any other industry in a market economy, greater consolidation will lead to less competition, which leads to higher costs and lower quality. Consolidation among payers will lead to higher prices for consumers (large employers and individual buyers alike), lower quality and more denials of service. Consolidation among hospital systems will lead to higher prices for services, lower quality of care, and less access to care. The higher cost of providing care (due to lower reimbursement, increasing unfunded but mandatory government and private regulatory burdens, and persistently high cost of medical liability insurances and litigation) is currently driving independent physician practices to either conglomerate into large entities, be sold to venture capital firms or become employed parts of hospital systems. This will leave patients with less choices for care and inevitably to lower quality care and less access to care.
While all this consolidation has been going on for years under the pretense of making the healthcare services cheaper, more accessible, and higher quality the actual results have been quite opposite. For spine surgeons, this consolidation will make it harder to stay independent and the cost of running a practice will continue to increase while reimbursement for services will continue to decrease. To stay profitable and competitive, spine surgeons will need to seek alternative payment models and ancillary services while providing higher quality of care and patient satisfaction.
Harel Deutsch, MD. Rush University (Chicago): Systems will continue to want to employ physicians and spine surgeons to drive volume to their institutions since each surgeon generates a significant amount of dollars based on their practices.