Ensuring Access to Quality Care

Christopher Kauffman, M.D., is an orthopedic surgeon and member of the HealthTrust Physician Advisors Program. He spoke to HealthTrust about how applying evidence-based medicine to surgical decisions and negotiations with payers can help ensure greater access to quality spinal care.

What are your past and current responsibilities with the North American Spine Society (NASS), and why has this volunteer involvement been important to you?

I’m currently on the NASS Coding Committee. In the past I chaired that committee, as well as the Professional Economic and Regulatory Committee (now the Payor Policy Review Committee, PPRC), and for many years ran the society’s coding course. The PPRC evaluates the policies of insurance companies and responds, in writing, to advocate for coverage of medically necessary spinal procedures. Our recommendations are based on whether or not clinical evidence supports the use of particular treatments. We want to ensure that payers are not denying coverage or care for patients inappropriately.

Ensuring patient access to quality spine care is also my personal reason for being involved with NASS. People make generalizations about spine surgery that aren’t true. Nerve pain is truly miserable. Surgery is sometimes the best course of treatment, and it can makes a big difference in a patient’s life. Unless clinicians get involved by educating their peers and working with insurers, I’m concerned that good quality spine care will be neither available nor affordable.

Payers tend to focus on the failures in spine surgery, which has led to many more restrictions on its use. These include new technologies, techniques and procedures that can make a real difference for patients with spinal conditions.

What are some of the top challenges you experience in your field?

Payers still see spine surgery as the Wild West, so they tend to ignore the good outcomes that are possible. No one calls their insurance company to say, “My legs were killing me, but the doctor fused my spine to stop the instability, and now I don’t have to go to the pain clinic, and I’ve returned to work, and, wow, this is fantastic.” All the insurance company focuses on are the problem cases, such as a patient with complications who is readmitted and runs up a high bill. They really come down hard on providers and patients with blanket policies such as, “We do not cover spinal fusion for degenerative disc disease.” It’s inappropriate to offer these types of generalized statements because there are clinical scenarios where spinal fusion is indicated for degenerative disc disease.

Physicians are often frustrated because they spend a lot more time these days with administrative paperwork, peer-to-peer conferences and EMR technology rather than directly taking care of patients. While we are spending more time working, it’s not necessarily on tasks that patients will see. Plus, we’re getting reimbursed a lot less. Peer-to-peer reviews (e.g., of MRIs, injections and surgeries) for insurance companies is a non-reimbursable activity that is often difficult to schedule and, given the increasing number of denials, takes a significant amount of time away from patient care. Physicians working for payers often have their hands tied by written policies they have no authority to override. This makes the time spent on appeals seem useless at times.

How has evidence-based medicine helped in negotiations?

We’re no longer living in a time where a physician can say, “I’m the doctor. I have the patient relationships; therefore, I will choose what’s best.” Now we’re saying, “Let’s make some logical choices. Let’s guide the patient to a reasonable course of action that is backed by evidence.” NASS has worked very hard to grade the available evidence and help determine whether it’s the fantastic, Level I variety, or whether it’s mediocre or absent entirely. But even in cases without hard Level I evidence, we must often rely on expert opinions about what is and isn’t wise. For some diagnoses, it is not appropriate nor possible to randomize, and we need to turn to our collective clinical experience.

Why did you join HealthTrust’s Physician Advisors Program, and how would you like to contribute?

The problems I’m talking about aren’t just problems for physicians; they’re also issues for hospitals and patients—and the Physician Advisors Program gets doctors involved in solving them. It’s HealthTrust’s way of demonstrating its commitment to improving the quality of care. Physicians in the program are available to help hospitals make appropriate care available to patients and ensure surgical outcomes are as good as possible.  As standardization becomes more common with care algorithms, patients will generally know what to expect when they come to our hospitals. Conversely, in places where physicians don’t get involved, there are going to be big disparities in care access and quality. HealthTrust’s Physician Advisors Program will also be hugely valuable in facilitating collaboration between physicians and hospitals around how to understand patient problems, potential obstacles and best possible solutions when patients don’t fit any of the established care algorithms.

What’s your take on new technology in spine surgery, and how can physicians aid in the medical device decision-making process?

I find the sales pitch aspect of new medical technology frustrating. Company A comes out with a new widget, which it claims is so much different from and superior to everything else that came before. Company B comes out with a different widget and makes similar claims. In reality, they’re pretty much the same.

When physicians hear about a great new device, they often get excited. But supply chain leaders are immediately wary, wondering: Isn’t this equal to what we’ve already got?

Physicians could instead work as intermediaries between suppliers and supply chain managers to lead the conversation about these new devices. We need to ask the right questions, such as: What operation are we performing, and which disease are we going to treat with this device? What current technology do we have for the same problem? Is there a significant difference or clinical advantage in switching to the newer device? Will it save money or cost more? If it costs more, does it offer a large, demonstrable difference in patient outcomes? If the new product represents only an incremental improvement over existing technology, we’ll want the supplier to be honest about that. We need to be asking for sufficient evidence that new technology is worth the cost. I think these are appropriate and reasonable questions for everyone involved in healthcare to ask.

The U.S. healthcare system is inherently different than what can be found anywhere else in the world. That includes the unique opportunity for physicians to work collaboratively with implant manufacturers, supply chains, hospital systems and insurers. It’s why I choose to be active in societies such as NASS and be part of the industry-differentiating work being done by the HealthTrust Physician Advisors Program.

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