Payer power, surgical denials & more: Healthcare policies that most concern spine surgeons

Alan Condon -   Print  |

Four spine specialists discuss what healthcare policies concern them the most.

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 advances do you hope to see in 3D printing in the next five to 10 years?

Please send responses to Alan Condon at acondon@beckershealthcare.com by Wednesday, March 4, 5 p.m. CST.

Note: The following responses were edited for length and clarity.

Question: What healthcare policies concern you the most?

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: As a member of two different political action committees, we are very concerned about surprise billing laws and the refinements that will be made to the ACA. The proliferation of Medicare Advantage plans is also concerning. Giving insurance control over a portion of our healthcare system is like giving the fox the all-access pass to the henhouse. Once again, we have to deal with the misinformation and misleading statements that supposed 'healthcare policy' experts are whispering in Congress' ear. Every stakeholder in this space must get involved. Contribute to your medical PACs and help drive change. 

We already see what happens when payers replete with opaque medical guidance and capricious and ill-informed denial processes leads to. Why would we let them get a step further? Here's how I think the current system can be fixed:

1. Connect authorization to payment: If you get the insurance company to authorize a surgery, they cannot deny payment or put in place stumbling blocks to paying the doctor or hospital.

2. Payers must justify to the state insurance commission of increases in premiums more than inflation rate.

3. To maintain a license to operate, payers must maintain generally agreed upon guidelines set by the appropriate professional bodies, e.g., coverage recommendations put out by the American Academy of Orthopaedic Surgeons, the North American Spine Society and the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

4. Payers must contract with an independent ombudsman that is an internal, independent arbiter of disagreements between payer and patient, and payer and physician.  

Issada Thongtrangan, MD. Microspine (Phoenix): I have seen increasing denials of surgical coverage based on payers' outdated guidelines, despite the clinical evidence showing medical necessity for the surgery requested. In addition, some payers dictate what types of biologics, cages and spacers that surgeons can use, which in my opinion, is solely based on the cost and not the effectiveness or outcomes.

James Chappuis, MD. Spine Center Atlanta: My biggest concern today in healthcare politics is that there are no checks and balances with the insurance industry. The Employee Retirement Income Security Act allows payers to be exempt from civil litigation and the federal government becoming involved with them through Obamacare plans has resulted in no government oversight. It is very troubling to me.

Brian Adams, MD. Spine Center Atlanta: Policies regarding the utilization of opioids are becoming an ever-increasing concern. I agree wholeheartedly that opioids need to be limited and that continued pharmaceutical research needs to be done to find safe alternatives. However, there is concern that policy changes are happening rapidly, and it may be difficult for providers to stay up to date with the ever-changing information. 

I also think that the medical community as a whole needs to continue to advance the practice of regenerative medicine to allow relaxation of some of the restrictions in place regarding stem cell and orthobiologic utilization.

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SASpine partners with Dr. Stanley Jones, establishes new location

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