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A Spinal Shift

Elyas Bakhtiari, for HealthLeaders Magazine, January 13, 2009
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As minimally invasive procedures consume a larger portion of spinal care, provider organizations have many opportunities—and challenges—in an increasingly outpatient service line.

Before he was CEO of the Texas Back Institute, Michael Franz was a patient. He was nearly paralyzed in 1990 when the back wall of a racquetball court fell on him in a freak accident, and surgeons from the institute performed a complex, 11-hour spinal operation that eventually led to a full recovery.

He was working in the telecommunications industry at the time, but his accident sparked an interest in spine care and inspired him to join various boards, including the Texas Back Institute's, and offer feedback from a patient's perspective. Now that he's an executive at the Plano-based full-service spine clinic with 25 physicians at eight locations, however, he says complex surgeries like the one that potentially saved him from paralysis are not his primary focus.

About 90% of patients at the Texas Back Institute are treated through methods other than surgery, and the industry in general is shifting toward high-volume, outpatient treatment alternatives, he says. "The minimally invasive area is a key area for the future," he says. "We take a multidisciplinary approach to service, from physical therapy to chronic pain management."

In terms of its evolution, spine care is in many ways where cardiovascular care was several years ago. Complex procedures with long lengths-of-stay are being replaced by minimally invasive procedures and a shift to outpatient care. While inpatient spine services are set to grow at roughly 3% a year, the minimally invasive market is projected to expand at a compound annual growth rate of 30% from 2006 to 2012, and some procedures, like artificial disc implants, may grow 40% a year, says Marcy Rogers, CEO of San Diego-based SpineMark Corporation.

Like many other service lines, spine care is set to capitalize on an aging baby boomer population that will need—and want, in the case of electives—more medical care, and this demand has helped make back pain the second-leading reason for a visit to a doctor's office and one of the top reasons for ED visits.

This convergence of procedural advancements and rising demand could lead to a boom in spine care centers in the coming years. But it's not all about minimally invasive procedures yet, as complex surgical cases still bring in considerable revenue. Spine care service line directors are tasked with coordinating the two types of procedures to maximize revenue and meet both the caseload needs of physicians and care needs of patients. "Juggling and balancing those treatment types and making sure they're all in sync is our main goal," Franz says.

Success Key No. 1: Bridge the ortho-neuro gap
Physician alignment has become almost a universal challenge; it is a top obstacle to most service lines. But because spine care blurs the line between orthopedics and neurology, it has a very unique set of turf battles and physician relations challenges. Doctors from different groups—or sometimes even individual physicians within a facility—often dispute procedural domain or question whether the service-line approach will really improve volume.

One way to deal with turf disputes is to simply draw clear lines of demarcation. For instance, third-party payers sometimes consider cervical issues to be the domain of neurosurgeons and lumbar to fall under orthopedics, and cases can be triaged along those categories. Facilities where there is more parity in the respective skills of the two specialties often simply rotate procedures to physicians equally as they come in.

The downside is that, even when the interspecialty disputes are tempered, the segregated approach can still cause problems. Alegent Health works with a large orthopedic spine group on about 60% of all cases and a neurosurgery group for 30%. Despite an amenable working relationship between the two groups, reconciling their respective philosophies and approaches remains a challenge, says Jarrod Johnson, vice president of orthopedics and neurosciences for the nine-hospital health system in Omaha, NE.

"We went through a process of looking at preop and postop care for patients ... and we tried to put together one spine protocol for the system and couldn't do that because there were differing doctor philosophies," he says. "One example: If you are a smoker, our orthopedic spine guys wouldn't operate on you, because they said the outcomes are bad, but the neurosurgical guys would take the case. We had to create two different protocols and are in the process of developing a system of care that would eliminate variation in care to spine patients and improve clinical outcomes."

That may be a necessary evil depending on the competitiveness of a given market, but for the most part spine care is moving toward fuller integration. At the University of California-San Francisco Medical Center, which has one of the largest spine care programs in the country and performs about 1,400 surgeries and 13,000 outpatient visits per year, neuro- and orthopedic surgeons work on certain cases in teams as "co-surgeons."

The four neurospine and six orthospine surgeons are all based out of the UCSF medical group, but even without intensely competitive market forces, the two specialties tended to previously work in silos, says Eula McKinney, director of the spine service line at UCSF. Pairing them together as co-surgeons on cases not only reduced communication barriers, but it decreased the amount of time spent on surgery and led to a measurable improvement in outcomes. And it worked because physician champions from both sides spearheaded the effort and convinced their colleagues to give the co-surgeon model a shot, McKinney says.

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