Adam Bruggeman, MD, of Texas Spine Care Center in San Antonio, shared insight about the government and private payer landscape related to physicians and ASCs at the 19th Annual Spine, Orthopedic & Pain Management-Driven ASC event.
Dr. Bruggeman was on a panel at the event, which was June 15-17 in Chicago, to talk about the evolving payer mix, prior authorizations, CMS, value-based care and more. Below is an excerpt from the conversation, edited lightly for clarity and length.
Question: What does your payer mix look like?
Dr. Adam Bruggeman: We're still majority commercial insurance or non-government payer entities. The challenges still exist on both sides of the coin on how to get procedures approved. We don't have site-of-service concerns [with government payers]. We do our cases where we want to do them without having to argue or bag with insurance companies about where to have them done. The downside of those commercial payers is significant and becoming more significant every day. There's growing concerns about the amount of work that's done to be able to work with better payers than ever before.
Q: What are the trends you're seeing around prior authorizations and approvals from insurance companies? How is that changing your business model?
AB: I was at the American Medical Association meetings [June 9-14] and certainly prior authorizations are a big concern. The American Medical Association, at the academy level, is lobbying every day. I was in DC for a few days supporting efforts to try to reduce prior authorizations to physicians, modeled after the Gold Card Act that passed in Texas.
The Gold Card Act, conceptually, is that if you are successful 90 percent of the time in your given field, then you do not need to participate in prior authorizations for the next six months. Then there is a six month look back and during that six month window when you didn't have anybody looking over your shoulder, did you continue to practice in a consistent manner? If you stay above the 90 percentile in the next six months, you are still on the prior authorization pathway.
Q: How are those efforts going?
AB: We had a bill passed in the last Congressional session right before the end of the session through the House with unanimous consent. The Senate picked up the bill and we had sufficient votes to pass it in the Senate. Unfortunately, the Congressional Budget Office, which scores every bill, scored it as $16 billion in costs for the healthcare system. The reason why is because they believe that with no prior authorization, physicians would be more efficient at their jobs and would see more patients and do more work, and therefore will cost the health insurance system.
The $16 billion is a big number, and that's too big for Congress to swallow. It ultimately failed and the Senate never got a vote…The executive branch is actually in agreement with the plan and would have signed the bill had it gotten to the White House. They had done a regulatory push and written basically rules on the regulatory side to pass some similar concepts, although not the Gold Card Act, but to reduce the burdens. We are waiting for the final ruling.
Q: How are you thinking about value-based care? What is the right strategy for orthopedics?
AB: Value-based care is a really broad term and I think the ultimate goal for surgeons should be to encompass the entire spectrum of care from nonoperative to operative and take risks. The word "risk" comes along with reimbursement. The best place for physicians to be going forward is to manage the team that manages the risk. That's exactly what ACOs are doing today and that's why primary care doctors are all running for Medicare Advantage plans.
I even know of primary care doctors who are shutting their practice off to anything but Medicare Advantage plans. At the academy level, we're certainly very focused on having these conversations, and CMS and HHS are very concerned about bundled payments. They don't see bundles providing the value that accountable care organizations are providing.
Ultimately, condition-based care for orthopedic surgeons and trying to subcapitate us underneath primary care doctors to try and capture that dollar and put us in charge of the parts we understand instead of always having the gatekeeper between us and our patients, that being primary care doctors who are in many ways incentivized to hold the patients and not encourage care.
Q: Value-based care and bundled payments have been an opportunity for ASCs in the last few years and now we're seeing more organizations explore different types of value-based arrangements. What do you expect from CMS over the next year or two? Where are we headed and how are you preparing?
AB: We're still waiting to hear back from them on bundles and where they're going to be in target pricing. We should be getting that information soon. I don't see value-based payments coming in the next one or two years, it's too short of a horizon for CMS and we don't expect major changes from them. But certainly we're having lots of conversations about where does musculoskeletal care fit within the accountable care organizations and how do we take control of those dollars as orthopedic surgeons and neurosurgeons.
My hope is over the next few years we can at least have the first pilots agreed upon between us and the Center for Medicare and Medicaid Innovation, and attempt to go down that road of finding the next version of bundled payments that make sense both for us as well as for the payers.