Becker's Spine Review

15 SPINE SURGEONS The Devaluing of Spine Surgery — Dr. William Watters on 3 New Trends By Laura Dyrda W illiam Watters, MD, professor at the Clinical Orthopedic Surgery Institute of Academic Medicine at Houston Methodist Hospital and a clinical professor at the University of Texas Medical Branch, discusses the biggest challenges and opportunities for spine surgeons today. Dr. Watters is a past president of the North American Spine Society and Texas Spine So- ciety as well as the former chair of the NASS Research Council. Q: What are your top two to three concerns for your spine practice to- day? Dr. William Watters: My first concern is the decreasing reimbursements for spinal proce- dures that continue to mount. is is being accomplished in several different ways on sev- eral different fronts. One way is via the bun- dling of [relative value units] by the AMA in its CPT process. Surgical procedures, such as an [anterior cervical discectomy and fusion], can be reviewed every five years with respect to the "intensity" of the work product. Not only do these reviews usually result in proce- dure code bundling of the RVUs required for a procedure, thus reducing reimbursement, but within the spinal procedural mix, many review periods are being shortened to two to three years, essentially speeding up the finan- cial devaluation of some spinal procedures. Another way to decrease reimbursements is for third-party payers to withhold surgi- cal approval at peer review for increasingly stringent criteria that are not necessarily evi- dence-based. us, we see the threshold for lumbar fusion approval shiing from previous criteria of grade 1 spondylolisthesis to the need for a grade 2 spondylolisthesis for approval. is latter process raises a second concern for me beyond reimbursement, and that is that surgical intervention for treatment of valid spinal disease is being withheld from patients. Finally, a third concern I have for spine prac- tice today is attempts by some third-party payers to direct the specific implants for pa- tients who are approved for a surgery. is is seen in anterior cervical discectomy and fusions where some payers will not approve a fusion unless simple bone with plating is used, rather than the use of a self-retaining construct of a synthetic cage with screw fix- ation. My concern here is that this interven- tion by the payer runs the risk of compromis- ing patient care in this particular case with a potentially higher incidence of postoperative dysphasia because of the high profile of a plate compared to self-retaining devices. A payer has no clear right to direct choice of procedure or implant, in my opinion. Q: Where do you see the biggest op- portunities for spine surgeons? How is the field evolving? WW: e future of elective spinal surgery is likely, I feel, to be constricting. Spinal sur- geons should familiarize themselves with clinical pathways that employ effective, evi- dence-based treatment. In the ideal situation, spine groups, to remain economically viable, need to be inclusive of other, nonoperative spinal specialists to provide the best care possible to their patients and also to capture the largest possible percentage of the revenue stream. n Spinal Biologics, Regeneration and Minimally Invasive Surgery: Dr. Mick Perez-Cruet on how Spine Treatment is Evolving By Laura Dyrda M ick Perez-Cruet, MD, is the chief of minimally invasive spine surgery at Beaumont Hospitals in Royal Oak, Mich., and a neurosurgeon at Mich- igan Head & Spine Institute in Southfield. He also serves as chairman, director and professor of minimally invasive spine surgery at Oakland University William Beaumont School of Medicine and leads the Minimally Invasive Neu- rological Society. Here, Dr. Perez-Cruet discusses where the spine field is headed. Q: Where do you see the biggest opportunities for spine surgeons? How is the field evolving? Dr. Mick Perez-Cruet: The biggest opportunities for spine surgeons are that we will continue to be extremely busy due to the growing aging population. Because patients ex- pect to recover quickly and fully, minimally invasive spine surgery is growing in leaps and bounds with new MIS inno- vations and options continuing to expand. I am particularly excited about the future of biologic treatment of spinal disorders. This remains a challenge but new and exciting research may, in the future, allow us to regenerate the intervertebral disc and restore natural function and motion to the degenerated vertebral seg- ment. Our group is currently very active in this research using disc distractive device mechanisms in conjunc- tion with cultured nucleus pulposus human stem cells to achieve this goal. n

• Cover