The spine field 5 years from now: 3 surgeons on data collection, bundled payments & more

Laura Dyrda -   Print  |

During the Becker's Spine, Orthopedic & Pain Management-Driven ASC virtual event, four orthopedic and spine surgeons outline answered the question: Q: What will the spine field look like a year from now? Five years from now?

Click here to view the full interview on-demand as well as access several other fireside chats, panels and workshops during the event.

Cynthia Emory, MD. Wake Forest Baptist Health (Winston-Salem, N.C.): I anticipate our field will be a lot in flux. Many hospitals are facing months of limited capacity due to staffing and bed constraints, which will in turn limits the ability of the orthopedic surgeon to serve their patient populations. We've already been hearing stories from trainees who are finishing their fellowships in two months and have recently found out that their jobs no longer exist.

Imagine thinking six months ago, you've got this great job lined up and you're finally ready to start your practice. You're done with training. I want you to have all of that stripped from you in a matter of weeks. These trainees are desperate for jobs, many turning to locum work or choosing a position that's good enough for now.

I think the attrition rate will increase over the next few years, not only in our new hires, but also in our senior surgeons who aren't able to successfully adapt to a new environment. Our patients are timid about coming to the doctor and many are not enthusiastic yet about having an operation, whether it's concerned about COVID-19, financial constraints or just too much stress along with everything else. I think it's going to take some time, likely months, if not years, before patients feel comfortable seeking out elective orthopedic care with the same rigor as which they did before COVID.

We're also going to be making some difficult financial decisions over the next several months and years. Large health systems are suddenly losing millions of dollars a day. So capital expenditures for new things won't be happening and time away and expense coverage for presentations at meetings, those are going to be limited, and recruitment efforts will likely be tempered for the next few years. As we build back our volumes, I think five years from now, we'll be in a much more favorable financial picture, allowing more investment and growth into practices as well as new hires and advances in technology. But I think for the next year or two at least will be very limited.

Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): A year from now, practices will look the same and hospitals will look the same. In my practice, there will be more and more cases in the ASC; there were already some procedures going there and this has accelerated it. Across the board, in terms of practices, there will be consolidation. I think these small three, four, five person practices had tough go of it during the shut down and they are looking for groups to share some of the downside risk with them. For our practice, which is an established practice, a year from now it will look similar.

At one point, I thought [bundled payments] was the future. We were all in to measure and get our metrics prepared for this. In spine, it has been a lot fits and starts, it hasn't really panned out. Total joints are pretty uniform; every total hip replacement looks about the same. Spine is just a different animal. A bundle for a lumbar fusion up to five levels encompasses so many different pathologies and the economics of those are so different.

We have tried within our group to be part of Medicare bundles and accept different types of care, and that has been difficult to do in spine. It hasn't really taken off like it has in joints and other areas of orthopedics. I still think the principle of value based care will stay, there is no doubt, but it's a tough thing in spine to execute. Obviously payers want to move away from fee for service and we at the same time have to prove the value of what we do. But formal value based programs have been very elusive in spine. I think we should collect data and it's important that all practices do it; if you don't you'll be in trouble. But is it going to be the way of the future that people have talked about? I'm less certain of that than I might have been three or four years ago.

Alexander Vaccaro, MD. Rothman Orthopaedics (Philadelphia): So we go through stages. We were in bundled payments for the last 10 years, and we did great. We had shared savings with the insurance company and with the hospital. What happens is the growth change every year, the better you get the more difficult to get to save money, so we're now bottomed out. In the federal government and a lot of their value based systems, we're actually dropping out a lot of them because we can't get any more efficient.

We can get a hip fracture to the operating room within 24 hours and we can get them out of the hospital to a rehab or a home within one to two days; we've done everything. We looked at everything that we could sort of squeeze out any inefficiencies. The next step is population based medicine where you do per patient, a per member per month, per member, per year arrangements.

The low hanging fruit now is with the technology with, with telemedicine, as long as all the players are aligned and they say, listen, this telemedicine, you're delivering the same amount of care, the same value of care to the patient. We're going to now share the savings if they do that, that's a big one for value based healthcare…we have to be aligned with the insurance company for the right care at the right time for the right person. If they come back and they cut that value in half or 75 percent, then what's going to happen? Physicians aren't going to use telemedicine and we're going to lose our opportunity for value based care. As long as we're aligned and no one over-leverages there, we can continue to decrease the spend for healthcare.

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