Dr. Frank Cammisa: 8 Top Challenges for Spine Surgeons This Year

Becker's Orthopedic and Spine—January 31, 2012

Frank Cammisa, MD, Chief of the Spine Service at Hospital for Special Surgery in New York City, discusses the biggest challenges for spine surgery heading into 2012.

1. Influence of insurance companies on access to spine care.
Over the past few years, insurance companies have tightened their guidelines on spine coverage, making it difficult for surgeons to perform surgery in once-routine cases. More frequently than in the past, surgeons are being asked to speak with medical representatives in peer-to-peer reviews which often still result in coverage denial.

"I think the biggest concern is the influence of insurance companies on our ability to see patients," says Dr. Cammisa. "For example, there is a push not to authorize fusion-type surgeries for patients. In these cases, we must do a peer review. We spend a lot of time talking on the phone to insurance companies substantiating why we think a certain type of procedure should be done. It's onerous for the surgeon and the patient because it takes the physician/patient relationship and inserts a middle man who decides whether the patient will have surgery."

There is a perception among some circles of healthcare that too much spine surgery is being done and payors must control rates of surgery, says Dr. Cammisa. "Will we be able to independently recommend surgery for our patients or will there be an arbiter?" he says. "This is a concern for every medical specialty."

2. Dealing with regional differences in spine care. The perception of too much spine surgery has been propagated by several sources, including statistics showing rates of spine surgery are higher in some parts of the country than others. Dr. Cammisa says there are several factors contributing to this difference, including:

• How quickly new procedures are
• When spine surgeons are willing to adopt new procedures
• Demographics — percentage of the population who are likely candidates for spine surgery

"It may be that one area is treating spinal conditions more aggressively, but another area might not have the resources available to perform the same procedures on their patients," says Dr. Cammisa. "There may be just as many patients needing surgery in both areas in terms of population percentage, but the care isn't as advanced. From the statistics, it's hard to tell whether surgery is being overused or underused in different regions of the country."

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4. Proving the effectiveness of spine surgery in the literature. Approval for spine procedures depends on published outcomes data now more than ever. Strong evidence-based medicine is essential for specialists to show procedures they recommend will have a positive impact on the patient's life. Spine surgeons are more focused today on participating in strong studies and publishing their results.

"What I find particularly exciting is the fact that at one point spine surgery was considered a black box — we weren't sure whether something really worked for the better — but now we are coming out with good research to prove the effectiveness of our procedures," says Dr. Cammisa. "I participated in the SPORT study where we were able to show good outcomes for appropriately indicated surgeries. As we go on, we'll be able to recommend surgery when the patient will likely have a positive outcome and have the data to back that decision up."