“Youth is when you’re allowed to stay up late on New Year’s Eve. Middle age is
when you’re forced to.”

“An optimist stays up until midnight to see the new year in. A pessimist stays
up to make sure the old year leaves.”

“If there is anything the nonconformist hates worse than a conformist, it’s another
nonconformist who doesn’t conform to the prevailing standard of nonconformity.”

Bill Vaughan, American Writer, 1915-1977

“Exercise freaks ... are the ones putting stress on the health care system.”

Rush Limbaugh, American Commentator

With this, the last SpineLine of 2009, we welcome the New Year. 2010 promises to be an eventful year in medicine and in spine care in particular. The New Year also gives us a chance to reflect on how our history impacts our future.

We begin with our President’s Message. With this issue of SpineLine, Ray Baker, MD, takes over the NASS Presidency and a bimonthly column from Dr. Charlie Branch. Dr. Baker’s first President’s Message describes the growth and maturation of NASS at its 25 year anniversary, from the first meeting of the North American Spine Association’s first meeting in 1984 to the more than 4000 attendees of the recent annual meeting in San Francisco.

As Dr. Baker reports, not only has our membership grown, but NASS continues to add value in myriad ways including professional education in the form of The Spine Journal and the SERC (Spine Education and Research Center). As we enter 2010, Dr. Baker introduces us to another major NASS endeavor, the Value and Registry projects. Simply put, our patients and payors increasingly demand we prove the value of the care we offer. Given that spine care includes not only the alleviation of pain, but also functional and deformity issues, defining value is more complex than it otherwise might appear. Once defined, the value will be documented in a number of ways including a major spine registry.

From the beginning, our organizational diversity has served us well. We bring together
specialists from different training backgrounds who share a clinical interest in spine problems. This structure allows NASS to build bridges to other professional societies representing aspects of spine care. Continuing Dr. Branch’s outreach efforts, Dr. Baker emphasizes NASS’ unique position of influence. That position comes from its wider perspective and has been strengthened by the difficult ethics and professionalism issues the organization has addressed.

Other organizations, federal entities and the AMA may respond to our broad spectrum
approach ahead of other societies with more parochial agendas. Given the AMA’s de facto position as a chief voice of medicine, contributing our viewpoint to the overall AMA
message is critical. In their Advocacy column, Drs. Alok Sharan and Douglas Slaughter, the NASS delegates to the AMA and Senior Advocacy Manager Nicholas Schilligo discuss NASS’s relationship with the AMA.

The House of Delegates, the organization’s critical body, represents the full spectrum of physician groups. Specialty and state medical organizations get a number of delegates based on the number of their members who are also AMA members. Our proportional representation is much smaller than, for example, the American College of Family Physicians. NASS has sent delegates to the AMA HOD since 1992.

From its origins in 1847 as a national medical educational standards organization, the AMA has come to be seen as the voice of medicine by the federal government. Dr. Sharan notes that the AMA leadership has supported the Obama reform proposals even before they were fully elucidated. Their argument: do not argue against something until you know all the details. The equally valid contrary argument: you shouldn’t support something until you know all the details.

Initially, the AMA planned to reject any reform proposals that failed to include tort reform. Later, the reform measures were supported despite inclusion of the controversial public option and the failure to include meaningful tort reform in exchange for a “seat at the table.” This deal begs the questions: shouldn’t organized medicine automatically get a seat at the table when matters of health care delivery are at stake? Is there anyone better at establishing the practical effects of regulation and legislation on medical practice, access, and quality?

At the NASS annual meeting, Keynote Speaker, ex-Chicago neurosurgeon and Obama health care advisor Stephen Ondra presented the government case for reform. In this issue of SpineLine, we reprint Dr. Ondra’s remarks. He explains, with vivid examples, why we need reform. And, he’s right. The critical issues for many of us include exactly what types of reform we are going to have. Dr. Ondra, who now works for the Department of Veterans affairs, pays lip service to tort reform and presents the role for organized medicine.

Meaningful reform includes not just expansion of coverage to the uninsured, but improved access to those who have coverage. Current provisions limiting insurance companies’ ability to exclude pre-existing conditions and to dump clients when they become sick are necessary and overdue. But, how much access and coverage can we afford? The ongoing Congressional debate has generated a slew of reports on the financial implications of the reform proposals. These reports, funded by interested parties on both sides of the debate, detail either tremendous cost savings or imminent health care financing collapse through increased utilization by new enrollees.

As of this writing, the final plan continues to be debated. The Senate bill (depicted on our cover) remains a dense, inpenetrable, morass of legalese. The public option, for now, seems to have gone away, as has Senator Lieberman’s proposal to expand Medicare access to younger patients by allowing them to “buy-in.” The changing landscape includes changing opinions by the thought leaders themselves. For example, Lieberman is the swing vote to prevent a filibuster now against his own proposal for Medicare expansion.

The bill is likely to add regulations and cost. The current senate bill proposes a 15-member Medicare committee that will further bureaucratize payment policy. While the plan decreases Medicare spending overall, and specialty care spending in particular, the costs of providing that care  will increase. Today, health administration spending by government and insurers comprises at least 7% of the health care dollar, more than twice the average of other countries.

That 7% does not include the vast sums that physicians pay to interact with payors. A recent Philadelphia Enquirer article [by Stacy Burling, Sunday, Nov 22, available here  reported that not only does a large portion of the health dollar go to insurance company overhead, physicians groups themselves spend a large and increasing portion of their revenues simply collecting fees due them.

A study this year by the Medical Group Management Association found that “interaction” with insurers, other than for Medicare, costs medical practices $21 billion to $31 billion a year. The article describes a 78–physician cardiology group with 350 employees. Of these employees, 45 do nothing but try to collect insurance payments owed the group. These 45 employees are required despite a forward looking, tightly integrated electronic medical record system. This overhead does not include the additional costs associated
with insurer interaction to confirm drug formularies and precertification requirements
for clinical testing.

While practice management costs continue to increase and reimbursements decline, do not expect much true reform in drug and implant costs. Manufacturers continue to increase their prices at an almost unprecedented rate. According to the New York Times [article by Duff Wilson, November 15, 2009], the Consumer Price Index fell 1.3% over the last year. During the same interval, wholesale prices of name-brand prescription drugs
increased 9%. Critics suggest this acrossthe-board increase anticipates future attempts to curb prices. Big pharma affected similar increases in 2006 when the Medicare drug benefit was added.

The pharmaceutical industry negotiated $80 billion in drug savings with President Obama in exchange for administration reassurances. The administration has promised not to use central or bulk purchasing for increasing discounts. With their pricing model largely intact, pharma agreed not to use their considerable media and advertising dollars to fight the President’s plan. Of course, by inflating prices ahead of time, the drug companies lose nothing. This year’s price inflation alone adds $10 billion to the nation’s $300 billion annual drug costs.

Why does the pharmaceutical industry get a “sweetheart deal” while doctors fight for scraps from the health care table? Physicians are key to health care delivery. By standing together, we could best represent our and our patient’s interests. Yet, divide and conquer tactics have put the “house of medicine” in disarray. For example, promises are made to primary care doctors at the expense of specialists. How will this evolve? The RBVS, for example, promised the rural primary care giver a bigger slice of the pie at the expense of the urban specialist. What really happened? Physicians, divided, lost control and all now practice harder and longer for less. Our patients have longer waiting room stays for shorter appointments. In my area, primary care givers often refer even the simplest myofascial back pain for MRI and specialist consultation. Does this serve the patient, the payer or the doctor? Will additional regulation and red tape help?

While our health care delivery system clearly needs reform, that reform will serve the interests of all of the stakeholders except patients and doctors. If we have to sell our soul just for a seat at the table, the final result is unlikely to help anyone.

To get effective and structural change, those people expected to affect the change need to maintain at least a modicum of control. Yet, the combination of malpractice tort risk and insurers’ demands has created an environment in which physicians are increasingly losing control over the health care they provide. In a Jackson Healthcare survey of nearly 2000 doctors from all specialties and all 50 states released in November, three quarters of the physicians felt they had lost control over the last five years. Eightyfive percent reported that the threat of medical malpractice was the primary hindrance to “practicing medicine as they see fit.” Interestingly, 62% of those surveyed disagreed with the AMA’s stand on health care reform. These responses were remarkably uniform regardless of the physician’s political leanings. [ Available at: www.jacksonhealthcare.com/online-media-room/healthcarenews/jackson-survey-reports-physicianslosing-control-of-medicine.aspx]

Increasing costs and decreasing reimbursements have led to another kind of loss of control: the gradual disappearance of private practice. When inflation is taken into account, average practice collections decreased 16.3% from 2004 to 2008. According to an American Medical News article from October, the increasing cost of starting a practice (including EMR), increasing medical school debts, and decreased negotiating power of small groups has lead to a 2% decrease in the percentage of physicians owning at least a part of their practice every year over the last 25 years. In some surveys, only 30% of physicians own a part of their practice. [Available at: http://www.ama-assn.org/amednews/2009/10/19/bisa1019.htm]

Other examples of our vulnerability to outside control are the recent RUC and the Washington State technology assessments of surgery for low back pain. Will payers continue to reimburse surgeons for axial pain procedures? If so, will they be limited as to the types of procedures they can offer or the number of levels that can be treated? Our Curve column offers a representative case. Dr. Jeff Wang presents a 41-year-old patient with chronic low back pain (CLBP). This “clean” case offers us an individual without secondary gain or complicating issues. The patient has failed appropriate nonoperative treatment and continues to have incapacitating pain. He is requesting surgery and we are asked whether we favor fusion or lumbar total disc replacement (TDR).

In favor of TDR, we have Dr. Rick Guyer from the Texas Back Institute. Dr. Guyer has enormous experience with both fusion and disc replacement procedures, but reports that TDR offers a speedier recovery. Dr. Lou Jenis from Boston notes that TDR is technically more difficult and its list of contraindications continues to grow. Thus, in the absence of convincing data proving TDR superiority, we should offer “tried and true” fusion techniques. Interestingly, Dr. Jenis recommends a stand-alone ALIF in this patient, which ostensibly would offer a postoperative recovery profile similar to that mentioned by Dr. Guyer for TDR.

Neither discussant seems concerned about a retroperitoneal approach in a 41-year-old male. Of course, recent data, from very experienced centers, suggest that retrograde ejaculation rates are very low. Given its technical constraints, my concern is over TDR outside the leading study centers with high surgical volumes. In my area, TDR is not available because insurers have chosen not to cover the procedure. Will this change with increasing mid– and long-term data? Will we continue to rely on the Europeans to walk
the minefield of new spine technologies ahead of us?

In our coding column, Drs. David O’Brien and Christopher Kauffman, cochairs of the NASS Coding Committee, explore alternative procedures for back pain. Specifically they discuss coding for transpedicular decompression, percutaneous disc decompression and annuloplasty. The transpedicular decompression CPT code, 63056, was added in 1980 to describe a posterior transpedicular approach to thoracolumbar fractures. Here, decompression of the neurologic structures is performed by resecting the vertebral bone
and the discs above and below. Later, the Wiltse approach to far lateral compression was incorporated. This code is valued at 38.43 RVUs and describes 170 minutes of
operative time and seven postoperative hospitalization days. The transpedicular code cannot be used to describe newer, less invasive endoscopic techniques for decompression of foraminal or extraforaminal disc herniations. For these mainly outpatient procedures, an unlisted code (64999 or 22899) is required.

Percutaneous disc decompression describes a similar posterolateral approach as
63056. This code, 62287, is used in percutaneous disc decompression procedures.
The extruded disc fragment is not accessed directly. Rather, a device is inserted into
the center of the disc percutaneously with fluoroscopic guidance. Once in the center of the disc, a variety of techniques (eg, laser, coblation) remove tissue decompressing
the nucleas. This approach, theoretically, indirectly “sucks” the protruded material to suck back into the disc. The percutaneous disc decompression code is used once no matter how many levels are treated and whether a unilateral or bilateral approach is used. The surgeon may not bill a cosurgeon, but may bill code 77002 for fluoroscopic guidance.

Annuloplasty, like percutaneous disc decompression, utilizes a percutaneous, fluoroscopically guided catheter placed through a posterolateral portal. Here, rather than removal of nuclear material, the device seeks to treat discogenic pain and annular tears. The codes 22526 and 22527 cover IDET only. Unlike PDD, fluoroscopic guidance is part of the CPT code.

In 2010, SpineLine will increase its coverage of those meetings of interest to spine care providers. Not only have economic factors made attending multiple meetings each year increasingly difficult, optimal spine care requires an understanding of the latest advances in allied specialties. Surgeons, for example, will benefit from an update on pain management and rehabilitation topics. Physiatrists will benefit from an overview of new procedures that may benefit some of their patients. The next five issues will review aspects of the NASS, neurosurgical, orthopaedic, anesthesia, PM&R, and other meetings.

Of course, the annual NASS meeting, offers “one stop shopping” for much of this information. In this issue, Dr. Faisel Zaman from Utah gives us a blow-byblow account of the recent San Francisco meeting from an interventionalist’s point of view. He provides “take home” messages from the Symposia and General Sessions he attended and an excellent attitude for those of us planning for next year’s meeting. I especially enjoyed historian David McCullough’s excellent Presidential guest lecture, “History as a Source of Strength.”

As always, we at SpineLine invite your comments and criticisms. If you have a topic or would like to review a practical, scientific, economic, technologic or medicolegal issue in spine care, please drop us a line! [spineline@spine.org] Our online presence will increase over the coming year and we will be looking to increase “real time”  communication about our rapidly changing spine community. 

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