Becker's ASC Review

16 ORTHOPEDICS How the payer market is evolving in 4 spine surgeons' markets By Carly Behm T he relationship between spine surgeons and major payers has been complicated over the years. Four spine surgeons shared their perspective on the payer market where they live. Editor's note: Responses were lightly edited for clarity and length. Question: How is the payer market evolving in your region? Brian Gantwerker, MD. e Craniospinal Center of Los Angeles: In our market, managed care continues to try to call the shots. Whether it's some big box plan or Medicare Advantage, it never ceases to amaze me the bill of goods they sell our patients. Our staff are extremely adept at explaining patients' insurance to them, which to me seems perverse. Many patients don't realize what they've signed up for until they try to get care and realize the only thing they are saving is the plan's own money and making their shareholders and C-suite gobs of money. Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): Self-funded, self-insured employers are starting to wake up to the idea of direct contracting for service. In our market, small, self-funded businesses regularly pay 600 percent of Medicare for in-network spine surgery. Based upon the EOBs we have been able to acquire, we have saved businesses on average $80,000 per surgery when they direct contract with us rather than going through their existing BUCA TPA- driven plan. is is money that falls directly to their bottom line. Rojeh Melikian, MD. DISC Sports and Spine Center (Newport Beach, Calif.): Historically, too much of the healthcare spend in spine has been focused unnecessarily on fixing surgeries with poor outcomes. ankfully, this is changing due to two major trends. First, more surgeons are adopting leading-edge, minimally invasive techniques that give their patients better outcomes both more safely and quickly. Second, some of us are also taking leadership roles in working closely with payers to optimize site of service for elective spine care. We're prioritizing quality, minimally invasive surgeries over bigger, traditional procedures and bringing them into the ASC setting. As a result, the cost savings is spread between payers, providers and patients. is is also helpful in encouraging payers to increase patient access to quality specialists. Who a patient chooses as their health insurance carrier should not be a limiting factor in receiving quality care from leading experts. Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): is healthcare payer market is locally driven; however, the largest payer in our state is United Healthcare, leaving one perplexed as to control and pricing. e indisputable drubbing that healthcare suffered under the pandemic is seemingly slow in its return to pre-pandemic or near normal-numbers from fluctuating payer mixes. labor constraints, salaries and expenses and the learned process of navigating surges and volumes. Medicare/Medicaid volumes have certainly expanded, but the majority of these patients are currently under new legislation to provide new work programs all the while being directed towards larger healthcare systems. Overall, spinal surgery reimbursements are lower than five years ago duly affecting capital purchase, hospital employment contracts and certainly morale. n The 10 highest-reimbursing orthopedic procedures performed at ASCs By Claire Wallace A s orthopedic procedures migrate to ASCs at higher rates every year, revenue cycle management platform Nimble Solutions has identified the 10 orthopedic procedures with the highest reimbursement rates. The highest-reimbursing orthopedic procedures at ASCs, according to an Aug. 24 webinar from Nimble: 27279 — SI joint arthrodesis 27428 — Open reconstruction intra-articular 24666 — Open treatment of radial head or neck fracture 24545 — Open treatment of humeral supracondylar fracture 20692 — Application external fixation, multiplane 24366 — Arthroplasty radial head 29889 — Arthroscopic PCL repair 27415 — Osteochondral allograft knee, open 27429 — Open reconstruction intra- and extra-articular ligament 23615 — Open treatment proximal humeral fracture n

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