Becker's Spine Review

21 Thought Leadership Q: You've done work to train spine surgeons around the globe in minimally invasive spine surgery. How has adop- tion of MIS evolved in the last few years? How widespread do you predict it will be in the next five years? ED: To be honest, I have been surprised by the seemingly glacial pace at which MIS improvements to patient care have been adopted. I did my first MIS screw-rod fusion through a tube in 1998, and my first MIS direct lateral trans-psoas interbody cage surgery in 2003. At the time, I thought these approaches would take our world by storm and be univer- sally applied within five years. Instead, I have experienced the real-world manifestation of the concept that it takes 17 years for evidence-based research to be adopted by the majority of clinical practices. ere are many reasons for this, but I do believe that at this time many forms of MIS have reached the 50 percent practice threshold, and will continue to evolve as we improve the use of navigation and robotics in spine sur- gery. At least we aren't as slow as the British Merchant Marine, who took 264 years to formally adopt Lancaster's scientific method of preventing scurvy! n How value-based care improve in orthopedics: 4 surgeon insights By Carly Behm F our orthopedic surgeons told Becker's how val- ue-based care can become more effective, from improving data analysis to using a stakeholder-focused approach. Question: How can value-based care become more effec- tive in orthopedics? Ammar Saymeh, DPM. Director of Foot and Ankle Medi- cine at NJ Spine and Wellness (East Brunswick, N.J.): Val- ue-based care holds each and every physician accountable for their diagnosis, plan of care and ultimate outcome for their patients on a case-by-case basis. The cost is more effec- tive than ever for both the patient and the healthcare system as a whole. To improve effectiveness of the value-based care model, it is important for each practice to undergo in-depth data collection and analysis. This level of analysis of data is essential to improving value-based care in orthopedics. Alan Valadie, MD. Coastal Orthopedics (Bradenton, Fla.): Value-based care will become more effective if the models are focused on benefiting all stakeholders, beginning with the patients. Patients must see increased efficiency and evi- dence-based care within a patient-focused system. Providers must be incentivized to provide such care. Within such a sys- tem, all stakeholders will benefit. Robert Peinert Jr., MD. Harlingen, Texas: From a human- ist perspective, value-based care must improve the function and existence of the patient to whom that care is applied. From an economic standpoint, value-based care is the least expensive care that can be given to a patient so that society pays the least possible money and resources, thereby maxi- mizing economic and not clinical outcomes. The difficulty here is finding a golden mean between treat- ing the patient and attempting to maximize clinical outcome while not breaking the piggy-bank! The solution is to have constant interplay between the patient side of the equation with the administrative/fiscal side in which the two balance each other. The system must not become one that is "profit driven." The key here is finding out statistically those medical and surgical interventions that help the greatest number of patients achieve improvements that are meaningful and ob- jectively improve quality of life. David Jacofsky, MD. The CORE Institute (Phoenix): Ini- tially, orthopedics was a leading specialty in value-based care models. Bundled payments, which are well-suited for the episodic nature of certain acute orthopedic diagnoses, provided a platform to engage musculoskeletal providers. However, due to pricing differences between facilities in the same market and the unsustainable nature of annually de- clining price targets with diminishing financial opportunities for providers, there have been a number of unintended con- sequences that have decreased enthusiasm for acute care bundles among providers and conveners. The best models to drive long-term performance and meaningfully bend the cost curve will be those models that accomplish three goals. First, models must align all stakeholders in the market for the long term. These models should align payers, providers and facilities. Second, models must recognize the current trend in spend and work to reduce the trend for the total cost of care, rather than drive a "race to the bottom" on simple epi- sode price. Finally, effective models must not only incentivize episode-based savings, but also must reward providers for appropriate indications for interventions, medical optimiza- tion efforts, and prevention and wellness activities. Bundles may effectively lower the "per unit" price for an episode, but this has no impact on managing the number of appropriate episodes in a market, decreasing unneces- sary bundles, nor does it engage providers in preventive care. Population health models that are diagnosis- or con- dition-based will be far more effective at both driving down care cost and eliminating waste while simultaneously im- proving provider engagement in activities that focus on well- ness instead of primarily managing sickness. This would be a win-win-win for all stakeholders involved.n

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