Becker's ASC Review

20 ORTHOPEDICS Spine surgeons' next payer battle By Carly Behm S pine surgeons saw a major victory in a yearslong payer battle when Aetna revised its lumbar disc replacement policy in February. Now, some surgeons are looking ahead to the next hurdle they could face from insurers. Endoscopic spine surgery, a minimally invasive technique, has grown its reach in the U.S. in recent years. But it's seeing some resistance, Michael Gallizzi, MD, said. "Payers currently pose a significant barrier," Dr. Gallizzi, of the Steadman Clinic in Vail, Colo., told Becker's. "Some states strongly oppose the adoption of this technology on the payer side, even though it's an approved Medicare procedure." However, Dr. Gallizzi didn't think conflicts with payers and endoscopic spine would mirror those of disc replacement. "I believe that part of the issue with disc replacement in the neck and lumbar spine arises from the fact that it involves an implant rather than a technique or technology," he said. "Because it's an implant, payers are oen reluctant to cover something that's expensive. Conversely, adopting these tools and performing procedures in this manner usually falls under the category of equipment, typically the responsibility of hospitals." Saqib Hasan, MD, of Walnut Creek, Calif.-based Golden State Orthopedics and Spine, said he's encountered challenges with the current coding for the technique. "e coding of spinal endoscopy is premature and inconsistent," Dr. Hasan said. "e early use of endoscopic procedure codes were conflated with percutaneous procedures performed by non- spine surgeons. e lumping of apples and oranges resulted in an inaccurate reflection of the true value of the work inherent to full- endoscopic spine surgery. e key distinction between percutaneous spine procedures is that endoscopy utilizes direct-light based visualization of anatomy, akin to using a microscope and a tube — just on a miniature scale. Hence, coding should reflect that. Payers still sometimes deny these procedures as 'experimental,' despite some of the best randomized controlled studies in spine surgery affirming their benefits and at minimum, equivalence in outcomes." Robert Rothrock, MD, director of spinal oncology at Miami Neuroscience Institute said the word "experimental" was a frustrating description of endoscopic spine. "When you say 'experimental,' to a surgeon, we have a very guttural response to that. Because [this technology] is not experimental," Dr. Rothrock said. "We're not experimenting on our patients. e [insurance] industry has termed it experimental because they don't feel they have sufficient long term outcomes data." Dr. Gallizzi, Dr. Hasan and Dr. Rothrock all emphasized the importance of research and gathering data for endoscopic spine surgery to help improve payer interest and reimbursements. "e onus is on us as a community to perform research that is credible and ethical, such that we perform evidence-based surgery," Dr. Rothrock said. "My attitude is that there's enough of a foothold in the community of spine surgeons that I think [reimbursements] will get there, and that's why I'm more positive about it." n Where spine practices are making, losing money By Carly Behm There are several factors behind what's profitable for a spine practice and what could be putting one in the red. Four spine surgeons told Becker's what's making spine practices money and what's holding back revenues. Note: Responses were lightly edited for clarity. Question: Where are spine practices making money? Where are they losing money? Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): Clearly the main avenue of making money is the outpatient surgery center and facility fees. Practices are likely losing money on patient visits and medicare surgery professional fees. Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Some spine practices are making money by doing more volume. Many practices hire midlevel practitioners to 'amplify' their reach and increase their work productivity. Whether or not this is a winning strategy is debatable, as continued reimbursement cuts administration after administration coupled with inflation, it seems doctors are running harder and faster for the same or less money. Money is being lost in practices on unnecessary employees and expenses. Practices have to look hard at how many full-time employees they employ and decide if you need two FTEs for each physician? Or would one FTE and one part-time employee cover them? Sometimes, physicians need to not be afraid to send their own faxes and answer their own emails. The more costly layers of expenses physicians ladle upon themselves and their business, the more bloat and cost it creates. Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): Spine practices make money when they have adequate insurance contracts with fair reimbursement or if they charge their patients fair price for their services that covers the costs of running the practice and allows for profit. Spine practices lose money when their insurance contracts do not adequately reimburse them. This especially applies to Medicare as they continue to lower physician reimbursements every year. Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Clearly the provider owned surgical clinics and hospitals are continuing their methodologies of money making, based on case mix and insurance base indices. While the non- patient discerning hospital systems have experienced another round of Medicare Physician Fee Schedule and Medicare Sequestration cuts (5% combined) for 2023. A recent internal polling of surgeon-physician patient payor mix revealed a greater than fifty percent Medicare and Medicaid shift among employed providers. The employed neurosurgical pool was even higher in these two underinsured populations. n

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