Vertebral Columns International Society for the Advancement of Spine Surgery
Winter 2015
In This Issue
Editor in Chief Kern Singh, MD
EDITOR’S PERSPECTIVE
Healthcare Reform Through the Affordable Care Act — the Patient Suffers................................................1 POLICY
Developing New Physician Payment Models: Comprehensive Care for Joint Replacement Model — A Preview of What’s to Come in Spine ........................3 CODING
2015’s Latest in Coding ............................................5 DIVERSITY
#ILookLikeASurgeon ...............................................6
Editorial Board Matthew Colman, MD Jeffrey Goldstein, MD Jonathan Grauer, MD Hamid Hassanzadeh, MD Safdar Khan, MD Choll Kim MD, PhD Mark Kurd, MD Yu-Po Lee, MD Vikas Mehta, MD Isaac Moss, MD John O’Toole, MD Alpesh Patel, MD Sheeraz Qureshi, MD Kris Siemionow, MD Seth Williams, MD Publisher Jonny Dover
CROSS-LINK
Novel Radiographic Measures in the IJSS ................7 NEURO
The National Neurosurgery Quality and Outcomes Database (N2QOD) in the Era of “Big Data” ......... 8 REIMBURSEMENTS
Getting Approval for Lumbar Disc Degeneration ...10 CODING
CPT® Editorial Summary of Panel Actions ............12 REIMBURSEMENTS
Physician Fees and Final Rules ............................... 13 ORTHO
Medical Management of Osteoporosis in Spine Surgery Candidates................................................. 14
Vertebral Columns is published quarterly by the International Society for the Advancement of Spine Surgery. © 2015 ISASS. Opinions of authors and editors do not necessarily reflect positions taken by the Society. This publication is available digitally at https://vertebralcolumns.com.
EDITOR’S PERSPECTIVE
Healthcare Reform Through the Affordable Care Act — the Patient Suffers by Kern Singh, MD Department of Orthopaedic Surgery, Rush University Medical Center
On Thursday, December 3rd, the Senate approved a bill that would repeal the mainstay of healthcare reform for the Obama Administration, the Patient Protection and Affordable Care Act (ACA). Established in 2010, the ACA, sometimes referred to as “Obamacare,” aimed to provide quality healthcare coverage to the uninsured while reducing costs and limiting the gross domestic product expended on healthcare.1-3 By expanding Medicaid eligibility to a more inclusive income bracket, the ACA has estimated approximately 20 million additional Americans with limited prior access to healthcare would be insured. In addition to Medicaid expansion, the ACA has enacted measures estimating a 10-15% increase, or approximately 32 million Americans gaining access to healthcare by 2019.4 This drastic increase in patient volume puts a strain on the medical community, increasing the demand for primary care physicians and subspecialists; however, in the climate of an aging American population the requirement for orthopedic surgeons has been underestimated. Theoretically, an increase in the number of insured individuals would directly correlate to an increase in healthcare access; however, in regards to orthopedic spine surgery, several factors are inhibiting the ACA’s progress. Primarily, a shift in the volume and location of care obtained by low-income patients has been observed. Prior to the ACA, approximately 15-20% of the US population was uninsured. In order to access healthcare, low-income individuals would resort to public hospitals and emergent care facilities to receive treatment for any acute or chronic EDITOR’S PERSPECTIVE
condition. Through general insurance requirements, the ACA has mandated that individuals, who do not meet Medicare or Medicaid coverage, or those whose employers do not offer coverage, must purchase private insurance through the Health Insurance Marketplace. The resultant shift in coverage has altered the volume of patients, as well as the demographic and pathology of the patient population observed at many institutions. Prior to the ACA, private institutions accepting only patients with private insurance would have examined those who were assumed to belong to a healthier subset of the general population. However, following the ACA individuals with no or minimal prior access to healthcare, frequently with greater comorbidities and more difficult pathology, are being seen at these private institutions. These patients frequently require a greater time investment by the physician to accurately diagnose, manage, and treat their conditions. Simultaneously, physicians are required to see a larger patient volume, leading to a relative reduction in time spent with each patient, introducing added pressure to efficiently elicit a thorough history, educate the patient properly, and make an informed decision on treatment options. While individuals desire a patient-centered treatment plan, the quality of care has evolved into a 15-minute scramble to explore the physical and psychosocial factors contributing to a patient’s diagnosis. Despite these constraints, physicians have adapted to provide the necessary care to treat their patient populations appropriately. Declining Medicare and Medicaid reimbursements, in conjunction with patient expectations and perceptions of physician compensation, have led to a spiraling disconnect among healthcare VERTEBRAL COLUMNS
employees and beneficiaries. In 2013, Badlani, et al.5 surveyed 200 patients in an outpatient office setting regarding their perceptions of physician reimbursement for common spine surgery procedures. The authors reported, on average, respondents believed physicians deserved $21,299, $29,457, and $25,226 for a lumbar discectomy, single-level lumbar decompression and instrumented fusion, and single-level anterior cervical discectomy and fusion (ACDF), respectively. The authors also reported that respondents believed the physicians were truly compensated $12,336, $17,308, and $15,791 for the same procedures; however, following Medicare analysis, physicians were compensated 10-20 times less than patients perceptions at $971, $2413, and $2158.5 In subsequent years, Medicare and Medicaid have continued to cut reimbursements to several areas of healthcare, with projections estimating the Centers for Medicare and Medicaid Services (CMS) would reduce hospital payments by $158 billion over 10 years in order to compensate for the newly insured patient population.4 As expectations of quality improvement rise, orthopedic spine surgeons are working towards eliminating inefficiencies in hospital protocols, reducing costs, and hospital resource utilization by transitioning aspects of their practices to outpatient surgicenters. In this environment, a spine surgeon may be more selective with the insurance payers they accept, and improve patient satisfaction through additional time spent on not only physical but psychosocial concerns, as well. In conclusion, several variables have contributed to the inefficiencies and shortcomings of the ACA in the current medical climate. While the newly passed senate bill will likely result in a presidential veto, unless alterations are made to reimbursement payouts, and improvements in patient expectations and 1
interactions are accomplished through proper transparency and acknowledgement of physician concerns, the struggle between patient-centered care and declining physician resources will result in a reduced quality of care and ultimately our patients will suffer.
References 1. Morton J. Affordable Care Act and bariatric surgery. Surg Obes Relat Dis 2014;10:571-2. 2. Butler PD, Chang B, Britt LD. The Affordable Care Act and academic surgery:
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expectations and possibilities. Journal of the American College of Surgeons 2014;218:1049-55. 3. Ugiliweneza B, Kong M, Nosova K, et al. Spinal surgery: variations in health care costs and implications for episode-based bundled payments. Spine 2014;39:1235-42. 4. Adkinson JM, Chung KC. The patient protection and Affordable Care Act: a primer for hand surgeons. Hand Clin 2014;30:345-52, vi-vii. 5. Badlani N, Foran JR, Phillips FM, et al. Patient perceptions of physician reimbursement for spine surgery. Spine 2013;38:1288-93.
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Correspondence Kern Singh, MD, Associate Professor, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612. kern.singh@rushortho.com.
Acknowledgement A special thanks to Dustin H. Massel, BS and Benjamin C. Mayo, BA of Rush University Medical Center who assisted with this commentary.
EDITOR’S PERSPECTIVE
POLICY
Developing New Physician Payment Models: Comprehensive Care for Joint Replacement Model — A Preview of What’s to Come in Spine Morgan P. Lorio, MD, FACS Chair of ISASS Coding & Reimbursement Task Force
In November 2015, the Centers for Medicare and Medicaid Services (CMS) finalized a new payment model called Comprehensive Care for Joint Replacement (“Model”). The Model bundles Medicare payment for lower extremity joint replacements (hip and knee) and holds the hospital in which the joint replacement surgery takes place accountable for the costs and outcomes of the surgery throughout the episode of care. The Model defines the episode of care as the date of admission for surgery through the 90-day post-surgical period. The Model is set to take effect on April 1, 2016 for a 5-year period in 67 geographic areas throughout the United States; most hospitals, physicians and post-acute providers in these areas are required to participate. According to CMS, the Model encourages patient-centered care and greater coordination among hospitals, physicians, home health care agencies and nursing/rehabilitation facilities through incentives and/or penalties to hospitals based on the costs and outcomes during each episode of care. Under the Model, each entity involved in the episode of care continues to bill Medicare fee-for-service, just as it has always done. After the episode, the actual costs and outcomes are evaluated by CMS and compared to CMS’ target cost of the episode. If the episode comes in less than the target, CMS makes incentive payments to the hospital. If the episode comes in over the target, penalty payments must be made to CMS by the hospital. This Model may constitute an “alternate payment model” but it certainly does POLICY
nothing to transform healthcare delivery systems. It represents a mandatory edict from CMS that establishes a 5-year human experiment, billing stakeholders as usual with subsequent reconciliation and financial penalties, and will serve as template for more to come. Rather than patient-centered care, this Model encourages hospital-centered care and represents the beginning of hospital-based reimbursement. If CMS puts the hospital at the center of the episode (i.e. the entity designated and held accountable by CMS), the hospital naturally will attempt to control all aspects of the episode of care (the inpatient surgery and all follow-up care in the 90-day post-surgical period) in order to minimize its costs, maximize its outcomes and ultimately minimize its risks. How will the hospital do this? By acquiring/merging all parts of the care chain (e.g. MDs, nursing facilities, rehab facilities, home health agencies, physical therapy agencies)? By treating only the patients with the lowest risk of surgical and post-surgical complications? By restricting patient choice in surgical and post-surgical care? There is little to no infrastructure in place to coordinate care within this mandatory Model. As proposed, the Model gives hospitals more leverage than currently exists and physicians become easy targets. We have already started to see consolidation and mergers of hospitals and healthcare systems in order to manage broad geographic networks; this Model incentivizes hospitals to continue down the path of acquiring all parts of the care chain as part of a plan for a united health system. This begs the question of whether the physician, rather than the hospital, should be the accountable entity at the center of the episode of care and be responsible for assembling the “care team” necessary to treat the patient during the episode.
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Let’s consider the care chain: the patient presents to his/her primary care physician (PCP) with lower extremity joint pain; the PCP evaluates the patient, orders imaging and attempts to manage the pain with physical therapy and/or medication; if the pain cannot be managed, the PCP refers the patient to an orthopedic surgeon; the surgeon evaluates the patient and determines whether joint replacement surgery is necessary; if necessary, the orthopedic surgeon schedules the surgery and develops the surgical and post-surgical care plan; the patient is admitted into the hospital and the surgery is performed by the orthopedic surgeon with involvement from anesthesiologists/anesthetists, radiologists, nurses and other healthcare professionals (this triggers the beginning of the “episode” of care under CMS’ Model); post-surgery, the surgeon, PCP/ hospitalist, nurses and other healthcare professionals are involved in the patient’s post-acute care; the patient is discharged from the hospital and either goes home or to a nursing/rehab facility; home services and physical therapy services are utilized in the 90-day post-surgical period; the patient has follow-up appointments with the surgeon and/or PCP in the 90-day postsurgical period. Based on this care chain, the care team would consist of the PCP, a radiologist, potentially a pain management physician, a physical therapist, a surgeon, an anesthesiologist/anesthetist, nurses, a hospitalist, a nursing/rehab facility, and a home services agency. Which member of the care team and which part of the care chain has the largest impact on patient outcomes and cost of the episode? Cost containment and quality outcomes are dependent on a number of factors that are difficult for any one piece of the care chain and/or care team to control. Does the patient have chronic conditions that must be managed? Are there geographic 3
considerations for discharge planning (e.g. where the patient resides relative to his/ her PCP, surgeon, hospital, nursing facility, rehab facility, physical therapy agency, family/friends/support team)? Accountability requires that one individual/entity controls the care team and how and where services are provided to the patient during the episode. Who should pick the individual members/ entities and assemble the care team? The hospital? The surgeon? The patient? Should patients’ options be limited to a predetermined menu of care team members? What happens if the patient deviates from the menu—could a patient choose a nursing or rehab facility that is not a part of the standard care team due to geographic considerations (e.g. distance to home, family, support team, etc.)? We currently have a culture of choice in care for Medicare beneficiaries, but this mandatory Model could restrict the ability of the patient to choose individuals/ entities involved in his/her care team. A physician-led team should have an equivalent voice throughout the episode of care at a minimum and ideally, the episode should be overseen by a physician team leader because he/she bears a substantial amount of risk in containing costs and optimizing patient outcomes. The surgeon should clearly be the team leader during and after surgery. However, the acute total joint episode of care is directly controlled by the surgeon in the hospital for approximately 3.4 days of the 90-day episode; approximately 87 days are managed outside the hospital. This Model makes it difficult for the surgeon (or the hospital) to lead from afar. The PCP becomes very relevant and a constant in the chain of care from the upstream management phase, intra-surgery phase (inpatient phase), and post-surgical recovery phase. This Model does not make sense for patients or physicians. The accountable
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entity should only be held accountable for the pieces of the care chain it can control. The best scenario might be a specialtyowned-system, but the financial risks to the physician to implement the Model are substantial and not accounted for within the Model. At a minimum, a functional risk status assessment needs to be developed prior to implementation of the mandatory Model so the surgeon can stay upstream, ahead of the currents.
or not work? (2) how should spine surgeons prepare for the day that CMS announces its “Comprehensive Care for Spine Model”? It is my intention to engage ISASS membership to start a dialogue on alternate payment models and develop ways that we spine surgeons can advocate for functional payment and delivery models.
At this point you may be wondering how this joint replacement model relates to you as a spine surgeon. Keep in mind that CMS developed this Model because joint replacements are the most commonly performed Medicare inpatient surgery with long, resource-intensive recovery periods. Additionally, CMS predicts high utilization going forward. Fee-for-service will soon be a thing of the past as CMS continues to consistently identify high-expenditure, high-utilization procedures and develop bundles and/or alternate payment models. Spine is next. Implications for ACDF and TLIF are obvious.
1. AAOS Comment Letter to CMS. “[CMS-5516-P] Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services; Proposed Rule”. 09/08/15. 2. Alternative Payment Model Discussion. “Implications of CMS Bundled Payment Proposals for Joint Surgery and Other Procedures and Conditions”. Hosted by Sandy Marks & Harold Miller, Center for Healthcare Quality & Payment Reform 10/01/15. www.CHQPR.org 3. AMA Comment Letter to CMS. “Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services; Proposed Rule [CMS-5516-P]”. 09/01/15. 4. CMS Final Rule. “Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services”. Federal Register. 11/24/15. https://www.federalregister.gov/articles/ 2015/11/24/2015-29438/medicareprogram-comprehensive-care-for-jointreplacement-payment-model-for-acutecare-hospitals 5. Rubenfire, Adam. “It takes a village to merge Wellmont and Mountain States Health Alliance.” Modern Healthcare. 06/ 12/15. http://www.modernhealthcare.com/article/20150612/NEWS/150619968.
As spine surgeons, we cannot be caught flat-footed and must be ready to respond with our solutions for an alternate payment model that works and makes sense for spine surgeons and patients. In terms of a risk assessment tool, we might think about using something similar to the Society of Thoracic Surgeons’ risk calculator (http://riskcalc.sts.org/stswebriskcalc/#/calculate). In fact, it is now a SCIP (Surgical Care Improvement Project) requirement to document the risk calculation as well as an attestation to its discussion with the patient as part of the pre-op evaluation. Or we might adopt something like The Euroscore (http://www.euroscore.org/calc.html). I encourage you to read the rule in addition to the AMA comment letter and the AAOS comment letter to CMS on this Model and think about (1) how does this model work
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References
POLICY
CODING
2015’s Latest in Coding Matt Colman, MD Department of Orthopaedic Surgery, Rush University Medical Center
This year has brought a complex and rapidly changing CPT coding environment, with the principle issues being coding structure for minimally invasive (MIS) procedures, technology-specific codes, and delivery of spine care via ambulatory surgery centers (ASCs). Recently, we observed the categorical rollercoaster of MIS sacroiliac joint fusion. As many are aware, the coding for this procedure moved from a Category I open CPT code (27280), to a Category III code (0344T), and back to a Category I MISspecific code (27279). Since the investigational quality of a Category III code is often (perhaps unfairly) equated by payors as not reimbursable, there is no question that the re-assignment of the procedure to a Category I code was a win for surgeons and practices performing using this procedure. However, we should view the events surrounding this progression in the larger context. At their best, minimally invasive procedures are designed to push the technical limits of surgery, with the end goal of faster recovery and fewer complications for patients. While the incisions may be smaller, many feel that the work involved and the learning curve for the procedure are just the opposite. Why then, do minimally invasive procedures tend to carry a significantly lower reimbursement rate? For example, the physician work
CODING
relative value unit value for the MIS sacroiliac joint fusion is undervalued at roughly 62% of the open variant. As we move forward and ask for more specifications in CPT coding to reflect the increasingly sophisticated and varied procedures we perform, whether they be MIS or not, we should use caution. Reevaluation of codes requires careful advocacy on our part to ensure that the rereview process does not artificially lessen reimbursement, especially in the MIS realm.
codes will take effect January 1, 2016.
ISASS believes that physicians working in the trenches, performing these procedures, and understanding the complexity of same, are best qualified to assess intraservice time, technical skill, and total resource utilization reflected in the work RVUs assigned to 27279. The ISASS December 2014 request for a CMS refinement panel to re-assess the physician work value for CPT 27279 has been accepted and the outcome of that review will become public in the Physician Fee Schedule Final Rule published at the beginning of November. This outcome is yet to be quantified but CMS’ consideration of our request is promising.
Just released for 2016, CMS has approved another procedure for the ASC setting. Interspinous spacer procedures, both one and two level, will be recognized. As we continue to demonstrate the ambulatory safety of these procedures through excellent patient selection and continue to realize the significant cost-savings of ambulatory surgical care, we expect the 10 payable codes to expand significantly. Future targets include cervical disc arthroplasty, endoscopic decompression, and posterior interbody fusion.
Beyond MIS, we should begin to see an expansion of new technology-related CPT codes. The May 2015 CPT Editorial Panel approved two (2) Category 1 CPT codes for insertion of interlaminar/ interspinous stabilization/ distraction devices WITH open decompression and maintained (for now) code set 0171T/ 0172T to report spacer procedures (without open decompression). The new Category 1
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A final category of current focus is ASC delivery of spinal procedures. As of January 1, 2015, the Centers for Medicare and Medicaid Services recognizes 9 category I CPT codes for use in ASC’s encompassing decompression-only procedures in the cervical and lumbar spine. Also included are limited fusion procedures such as anterior cervical decompression and fusion and lumbar posterolateral fusion.
Overall, spine surgeons along with their partners and advocates must lead the way in continuing to provide safe, efficacious, and low-cost care. Re-review of existing codes and increased coding specificity has the potential downside of leading to undervaluation. The ultimate reimbursement for the care we provide has to be rooted in the value equation of patient-reported outcomes and cost, and we should use a data-driven approach to value in our advocacy efforts.
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DIVERSITY
#ILookLikeASurgeon #ILookLikeASurgeon is a campaign created by the Association of Women Surgeons to highlight diverse contributors to surgery, provide role models to aspiring surgeons, and align the public image of surgeons with reality. Vertebral Columns profiles Dr. Karin Büttner-Janz in this issue. Prof. Dr. Karin Büttner-Janz is a living legend in the field of spine surgery. Prior to beginning her medical education, Dr. Büttner-Janz was a competitive gymnast
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and won two gold medals in the Olympics. She was inducted into two Halls of Fame for her athletic achievements. Turning her attention to orthopedic sports medicine and then to spine, Dr. Büttner-Janz defended her Professorial Dissertation in her native Germany and completed a fellowship in the United States after developing the first artificial disc, named the Charité for the teaching hospital at which she obtained her State Doctorate for the disc’s development. She went on to act
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as director of multiple clinics and has most recently established the Büttner-Janz Spinefoundation. Its online database supports doctoral candidates in the creation of systematic reviews and metaanalyses. She is presently undertaking to earn an MBA from the HTW in Berlin. She has served on the Board of Directors for ISASS and was President of the Society from 2008 to 2009.
DIVERSITY
CROSS-LINK
Novel Radiographic Measures in the IJSS Ashish Diwan, MD Section Editor, IJSS
I am one of the Section Editors of our Society’s journal, the International Journal of Spine Surgery. In this column, CrossLink, I select a recent publication and have a tête-à-tête with the lead author to link our Society’s publications. For this issue I asked Dr. John Hipp, Chief Scientist at Medical Metrics and lead author of “Development of a novel radiographic measure of lumbar instability and validation using the facet fluid sign,” to explain his team’s work. AD: What was the clinical problem you wished to solve? JH: Since instability is considered a primary indication for several treatment options, most notably spine fusion, it is important to have a measurement (or metric) that quantifies lumbar instability. Despite a large body of research, no validated, quantitative, standardized test is in routine clinical use. AD: What did you find? JH: The MRI fluid sign is currently one of the most accepted indicators of lumbar instability, supported by at least a dozen peer-reviewed publications. The fluid sign was therefore used as the “Gold Standard”. The main finding of our research was that a simple measurement tool based on the ratio of intervertebral translation to intervertebral rotation is significantly elevated in the presence of the MRI fluid sign (fluid in the lumbar facet joints). The metric we investigated is calculated from standard clinical flexionextension radiographs. We reported the metric in the form of a Z score. This normalization makes the metric easy to CROSS-LINK
interpret. For example, a Z score of two would mean that the translation per degree of rotation (TPDR) is two standard deviations greater than the average translation per degree of rotation or TPDR for an asymptomatic population. Using the facet fluid sign as the “Gold Standard” for defining lumbar instability, we found that the amount of sagittal plane translation that occurs per degree of rotation between flexion and extension is elevated when the fluid sign is present. AD: How did you investigate the problem to arrive at your findings? JH: We used preoperative flexionextension radiographs and MRI exams from a large FDA IDE study that had enrolled patients with symptomatic lumbar stenosis. An experienced radiologist assessed the MRI exams for the presence of a fluid sign, while blinded to the results of the flexion-extension analysis. Intervertebral translation and rotation had already been measured from the flexionextension radiographs using quantitative motion analysis (QMA) software for the purpose of the IDE work. The normalized TPDR was calculated from the QMA measurements, and the average TPDR in the presence of a definite fluid sign was compared to the average TPDR in the absence of a fluid sign. AD: What is the “weakest link” of your work? JH: The weakest link in the work is the use of facet fluid sign as a “Gold Standard.” Although the fluid sign is currently one of the most accepted of clinical indicators of instability, the fluid sign requires that a facet joint fill with fluid when a patient is supine. Gas can sometimes be seen in CT exams of facet joints. Gas in the facet joint is also an indicator of instability, but the fluid sign would not be seen in a MRI of a gas-filled facet joint. Presumably, in the presence of instability, the facet joints gap VERTEBRAL COLUMNS
open when a patient is supine, in both MRI and CT exams. It is unclear why, in the presence of instability, some joints fill with fluid and others fill with gas. It may be that gas-filled joints would eventually fill with fluid if the patient remains in the supine position long-enough. However, this is just a hypothesis. The net result is that there may have been some levels that were unstable, and where the TPDR was high, but the fluid sign was not present. That is a weakness in the study. An additional weak link is that typical flexion-extension radiographs depend on patient effort. Some patients may not flex and extend sufficiently to stress the spine to the point that instability is detectable. Similar to other orthopedic stress tests, the spine must be stressed to the point that the disc, ligaments, and facet capsule would restrain motion if they were intact. Without sufficient stress, a flexion-extension test may yield a false-negative result. AD: How do you think surgeons in clinical practice will benefit with your work? JH: Objective tests will be valuable for clinicians to help reduce the subjectivity, variability and uncertainty in diagnosing spinal disorders. Payers appreciate objective tests, and several payers have spinal fusion coverage policies that require objective evidence of spinal instability prior to authorizing fusion. An objective metric that can document the presence (or absence) of instability may help clinicians choose the optimum treatment for each patient, and may help to avoid coverage denials when instability is truly present. Our study supports that instability may be detectable using a normalized metric calculated from flexion-extension radiographs. The ultimate goal of the research is to help improve clinical outcomes by identifying the correct patients who will benefit from treatment for spinal instability.
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