Becker's Spine Review

Spine Surgeon Leadership 8 How Will the Healthcare Changes Shape the Practice of Spine Surgery? Q&A With Dr. Ziya Gokaslan of Johns Hopkins (continued from page 1) Dr. Ziya Gokaslan The other major change has to do with how the insurance companies are trying to be gatekeepers with a variety of spine procedures with the screening and approval processes. Regulatory challenges are increasing for the spine surgeons and will continue to do so going forward. All of those elements are becoming a daily part of our practice, making the system much less efficient, less user-friendly, and the patient-physician relationship is being affected negatively as result of that. Q: Do you think the current minimally invasive spine techniques match the hype? ZG: I would say there are a number of spinal procedures that are being advertised for a minimally invasive application which are done quite well with traditional techniques, such as a microscopic lumbar discectomy done with a small incision and openly with a microscope. This procedure is already by definition minimally tissue destructive, and the results are outstanding with the traditional open technique. In this particular situation, it's hard to demonstrate that a MIS operation does improve patient outcomes. One procedure where we see the difference, however, is with lumbar fusion procedures, where the open approach tends to be tissue destructive. You can do that less invasively with percutaneous screws and rods. This makes the operation less destructive, which patient outcomes tend to support, and helps the patient return to work more quickly, though the long-term outcomes don't differ much between the two approaches. Under the right circumstances and for the right patient and indication, minimally invasive makes a difference. I think we will see more minimally invasive technologies going forward. 12th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Business of Spine June 12-14, 2014 • Chicago 132 Sessions • 168 Speakers 63 Physician Leaders • 28 CEOs Keynote Speakers: NBA Hall of Famer Kareem Abdul-Jabbar Former Six-Term Governor of Vermont Howard Dean To learn more or register, visit www.beckersasc.com/beckers or call (800) 417-2035 "The surgeon ought to be a better advocate for maintaining autonomy with decision making and choosing the right option for the patient." — Dr. Ziya Gokaslan Q: How will increased regulations change the way spine surgeons practice? ZG: If payers are not paying for the procedures, then physicians will be less enthusiastic about performing the procedure. One such procedure is the artificial disc replacement for cervical spine. There is room for that procedure in young patients with one- or two-level disc disease or a herniated disc, yet many physicians would not offer that to the patient because it's practically impossible to get approval. It is such a painful process to the physician and the patient to spend hours on the phone to convince a third party provider to cover the procedure. I suspect similar types of situations in the future to disincentivize surgeons to offer an option to the patient. The government is using some of that strategy for strategically reducing reimbursements for common procedures with the hopes that it will reduce healthcare expenditures in the long-run, but it seems to be backfiring. Q: Can anything be done to combat restricted access to spine surgery? ZG: The surgeon ought to be a better advocate for maintaining autonomy with decision making and choosing the right option for the patient. Patients need to be better advocates for these matters, as well, through writing their Congressmen. Many people are not affected by these processes until they are afflicted by a disease. We need to educate people, and the burden is on us to produce evidence that what we are offering does make a difference. Q: How viable is outpatient spine surgery, and will it become more or less prevalent? ZG: I anticipate it will become more prevalent, but I don't think it will be a very significant portion of spine surgeries. In academic situations, we do more complicated procedures. However, in large private practice groups, outpatient is becoming more important. A lot of procedures we used to do inpatient, such as a disc laminectomy or simple fusion, have turned to outpatient. This is a trend that will continue in private practice but not so much in an academic environment. Q: What does the future of spine surgery look like? Will physicians be more financially-focused than in the past? ZG: Under ideal circumstances I would rather not know about insurance or what we are getting for a procedure. I try to differentiate that from the decision-making process and blind myself to it, but it's a reality you are held accountable for your collections. It's also a reality for any physician, particularly those running practices, that you have to produce in order to keep staff and stay in business. As much as we would like to be divorced from reimbursements, when it comes to caring for your patient, it is a reality of life. Under ideal circumstances it should not be an issue in making decisions, period. The moment you start thinking about how much you will get paid for a procedure and that influences your decision-making process, then it's time to retire. I firmly believe spinal surgery is an exciting subspecialty to be in. We are learning an incredible amount every day. Technology is evolving rapidly, and the options for our patients are exponentially increasing. I think the future is very bright for our subspecialty. The population is aging, patients are here to stay and research with advances in technology will have many more options in treating patients. n

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