We have failed collectively as physicians when the Louisiana State Legislature must intervene to draft a bill making sure that only spine surgeons are allowed to perform spine surgery. The bill in debate is Louisiana HB 941. It has a fairly straightforward premise: A physician needs to be a spine surgeon in order to perform and bill for spine surgery.
Somewhat astonishingly, non-surgeons have begun performing spine surgery at such a rate that it became necessary for the leading spine organizations in the world to adapt a position statement on the issue. The consensus is again abundantly simple: Only surgeons should perform spinal fusions.
Spinal fusion, a type of spine surgery, is the joining together of two different spine bones. This is done by forming a bony bridge fusion surface and placing bone graft. This is typically supplemented by a device or instrumentation for increased stability, and it permanently alters the spine’s biomechanics and its alignment. It requires extensive training in surgical technique, constant evaluation, repetition, and a lifetime to master the nuances, including appropriate patient selection and effective complication management. Because of this, the codes were created in a way that allows physicians to bill Medicare at a level that reflects the training, nuance, and risk associated with these procedures.
Non-operative specialists, such as pain anesthesiologists and pain medicine physicians, are not trained to perform spinal fusions as the codes are written. They have not completed a surgical residency performing surgery or treating surgical patients. Pain management physicians do not undergo competency training in the surgical instrumentation of the spine, measured and indexed by the American Council of Graduate Medical Education, at the same level as spine surgeons.
The question is: Why has this even become an issue in the first place?
Our health-care system is tilted towards procedural-based reimbursement, and spinal fusion procedures reimburse better than typical pain management procedures. And evolving technologies have made spine surgery safer due to minimally, or at least less, invasive techniques, shorter hospitalizations, and fewer complications. This has also made it more ubiquitous. Almost all physicians are good people who just want to help the patient in front of them. But there is an obvious push and incentive to recruit more procedures as within one’s scope of practice.
We have seen this play out in other crossroads in health care. Optometrists, who are not physicians or surgeons, helped bring forward Alabama Senate Bill 120. The premise was to allow optometrists, who again are not medical doctors, the ability to perform eye surgery. Optometrists did not complete the same four-to-six-year residency in eye surgery as their ophthalmology counterparts. Patient safety issues were raised by the bill’s opponents.
We both underwent our neurosurgery training in Louisiana, Dr. DiGiorgio in New Orleans and Dr. Menger in Shreveport. We had the privilege of learning from some incredible mentors. But we didn’t learn spine fusion surgery from a pain management doctor. We learned surgery from surgeons. We learned about pain procedures and pain management from non-operative physicians. The distinction is salient to any practicing surgeon. (READ MORE from Richard Menger: Medicare for All, Surgery for Some)
We want to be very open that we fully support our pain management colleagues. We both work in multidisciplinary sub-speciality clinics, which have integrative care teams with pain management doctors. We could not do what we do without their assistance and expertise. Thankfully, most people with back pain do not need surgery. Our pain management colleagues are invaluable experts and partners in treating these non-surgical cases. There are very safe and effective pain specific procedures.
We just don’t support the concept of non-surgeons performing spinal fusion surgery. We would not want that for our family members.
The issue brought forth in this conversation that is worth debating is whether or not the government should be wading into this space at all. We imagine that arguments coming out against this bill from the pain management side will focus on concerns about government overreach rather than on training, education, safety, and merit. The Hayekian notions of voluntary cooperation between patient and physician are apparent, but the information asymmetry resulting in a potential market failure is of significant consideration here. In a purely free market, patients could choose who to see and how much to pay. But these are taxpayer dollars reimbursed through a Medicare billing system that was purposefully designed to reimburse physicians based on time, training, skill, effort, and risk.
Are we using those tax dollars wisely by having non-surgeons perform surgery?
The fundamental nature of this problem stems from a lack of free-market forces in the health-care system. There is distance between those who pay for care, those who provide it, and those who receive it. If a patient felt the true and full financial cost of the treatment if it did not work, he or she may very well ask the physician more questions about their actual surgical training and the physician’s use of certain high-value billing codes (if codes were still used at all). If a hospital system was completely invested in publicly displaying outcomes and price transparency, high volume physicians with poor outcomes would be halted. If a physician had to justify outcomes and code use to peers and patients, they may very well be more cautious.
We physicians owe it to our spine surgery patients that a spine surgeon perform his or her spine fusion surgery. The debate is whether or not the state legislature is the right vehicle to deliver that common-sense reality.
Richard Menger, M.D., M.P.A., is an assistant professor of neurosurgery and political science at the University of South Alabama. He is the lead editor of the textbook The Business, Policy, and Economics of Neurosurgery.
Anthony DiGiorgio, D.O., M.H.A., is an assistant professor of neurosurgery at the University of California San Francisco and is affiliated with the UCSF Institute for Health Policies Studies.
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