Becker's Spine Review

Spine Advocacy & Policy 10 6 Top Advocacy Issues for North American Spine Society Dr. John Finkenberg By Heather Linder J ohn Finkenberg, MD, is on the North American Spine Society's board of directors as the chair of the advocacy committee. He has practiced orthopedic surgery for 20 years while also staying active in laboratory and clinical research. Dr. Finkenberg advocates for NASS and the spinal field through frequent trips to Washington, D.C., to meet with Congressmen and discuss healthcare policy. Here Dr. Finkenberg discusses NASS' top six advocacy priorities and how the organization is pursuing these issues. 1. Medicare sustainable growth rate formula. The Medicare SGR caps payments when utilization increases above expected levels relative to the gross domestic product. NASS members, as well as many other physicians, feel it doesn't accurately keep pace with the cost of running a medical practice. "We think the Medicare economic index has a greater likelihood to show how the costs of running a medical practice change," Dr. Finkenberg says. "It measures inflation and the increasing cost of physician-specific goods and services — the new Medicare payment system needs to utilize the MEI. The Medicare payment advisory commission has consistently agreed payments should be based on the Medicare economic index instead of the GDP. There are a few new Congressional plans coming out, and we are in the process of reviewing those to understand exactly how they work. The authors of these proposals have asked for our opinion and we plan to respond." 2. Medical liability reform. Medical liability is a huge issue across the country. If the government could do something about medical liability reform, it would save $62 billion over the next 10 years. Some experts believe that the costs associated with medical liability issues total as much as $850 billion dollars per year. "When I go to Washington, I talk to our Representatives about the successes California and Texas have had since they limited non-economic damages," Dr. Finkenberg says. "That, in addition to implementing an arbitration system, keeps the courts less busy and keeps malpractice insurance significantly lower. My liability insurance is $30,000 per year but my colleagues on the East Coast pay four or five times that for medical malpractice insurance. What happens in those states is that the doctors start practicing defensive medicine. Costs for Medicare in these areas are spiraling out of control." One way to control escalating healthcare costs is to eliminate the practice of defensive medicine and encourage physicians to order directed diagnostic studies that will alter their treatment choices according to the study findings. "We are also asking that the government consider protecting physicians that volunteer in disaster areas or volunteer to cover emergency rooms to assist hospitals in fulfilling EMTALA mandated services," Dr. Finkenberg says. "Physicians want to provide needed emergency services but Medical Liability concerns and escalating malpractice insurance is a deterrent." 3. Independent Payment Advisory Board repeal. NASS is concerned about the unilateral power given to the IPAB Committee. IPAB is comprised of 15 members. None of the members are practicing physicians and only a few will have a medical degree. "We understand the Board has been established, but we feel practicing physicians need to be involved and the Committee should only operate in an advisory role to Congress regardless of our legislators' ability to curtail healthcare costs," Dr. Finkenberg says. "Interestingly, the repeal of the IPAB Board has bipartisan support. Patient concerns are voiced by their Representatives in Washington D.C. and empowering this Board to make unilateral decisions eliminates majority public opinion." Legislators often focus on physician payments as the primary reason for increasing healthcare costs. Only 9 to 11 percent is spent on physician payments, which is only a small portion of the Medicare healthcare dollar. Other areas should be explored, as they could bring greater cost savings. "I would love to see the option for privatization," Dr. Finkenberg says. "Many seniors want to use their Medicare benefits as they have been paying for the privilege their entire career. Patients are willing to pay the balance of their medical bill in exchange for the opportunity to pick the specialist of their choice. Many physicians who opted out of the Medicare system would consider re-enrolling if this option were enacted. We support patients being allowed to establish Defined Contribution Plans or Medicare Savings Accounts. We are hopeful that this is part of what's implemented." 4. Utilization review process. "The utilization review process has increased in the last several years. Insurers have created treatment guidelines established by their own medical panels in an effort to curb spiraling healthcare costs. The medical panels support their recommendations by claiming the medical algorithms are supported by evidence based medicine. Unfortunately, each of the guidelines (Milliman, Interqual, etc.) differ and physicians are not being told the details of the utilization review criteria by the insurers who state proprietary reasons," Dr. Finkenberg says. "Physicians need to be given the guidelines and have an opportunity to appeal treatment algorithms if other Level I, peer-reviewed studies support alternative treatments." If the doctor neglects to put in the patient's physical exam or history that the reviewers are looking for, it's denied. Doctors can appeal this decision, but it requires a discussion with another doctor who is often not a specialist in the field of the physician appealing the denial. Many providers are frustrated because the utilization review process puts another step in the care process and it has not been established to result in better value or higher quality care. "The delay in care is aggravating to the patient and physician, and is not warranted," Dr. Finkenberg says. "I've started participating as a utilization reviewer in an effort to improve the process. I believe that it is the responsibility of the reviewer to explain why the treatment is being denied and how the information found in the accompanying physical exam may be sufficient to allow approval if they had supported their request with that data. If the process is made more transparent, doctors will be less frustrated. I'm also pushing hard for same-specialty utilization reviewers." 5. Electronic medical records. Most surgeons understand how electronic medical records can assist physicians with sharing diagnostic evaluations and tests. However, the implementation of this technology has not been smooth. Examination templates have been established for primary care physicians and the

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