A Path to Intelligent Medicine

Dr. Guyer’s NASS Farewell Address

As tradition required, Rick Guyer, M.D., the outgoing President of the North American Spine Society (NASS), delivered his farewell speech in Austin at the Society’s annual meeting in October.

But this was no valedictorian list of accomplishments during his term in office. Guyer brought together the large technology and economic forces shaping the practice of the spine surgeon and laid out his vision for “intelligent medicine” that will give physicians the tools they need to regain control over medical decisions made for their patients.

The Paradox of Technology and Economics

There is a paradox in medicine, said Guyer: “The technologies that makes this the most exciting time for practicing medicine are also making it one of the most stressful times because of economic challenges.”

Guyer said that computers and new technologies, which include new implants and techniques and the promise of tissue regeneration, have contributed to the science of medicine. "The spinal instrumentation arms race is proceeding at lightning speed."

He ticked off an impressive list of technology advancements:

  • The decoding of the genome "will be the stepping stone for treatments for decades to come."
  • A new understanding of the biochemistry of pain has led to newer medical strategies.
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  • Minimally invasive surgery has been steadily gaining popularity.
  • Biologics, such as bone morphogenetic proteins, "have all but eliminated scapegoat diagnosis of pseudoarthrosis."
  • Tissue regeneration of the disc is progressing every year and "is perhaps one the most promising advancements."
  • Motion preservation applications to all areas of the spine.
  • The use of rigid fusion is being challenged, even with scoliosis treatment.
  • Disc replacements have been, and continue to be, studied in the lumbar and cervical spine, with several devices being FDA approved.
  • Nucleus replacements, dynamic fixation, and interspinous spacers are also being studied.

He described a new generation of physicians employing nanomachines to deliver drugs, chemicals, and genes directly to their target cells.

“The OR of the future will use robots and real-time imaging beyond our current MRIs and CTs, giving us color images and allowing us to take the ‘incredible voyage’ into the body as we correct pathology.”

But, there is that paradox. Guyer wonders whether all this technology is a threat to a physician’s professionalism and profession.

He cautions that technology could reduce the physician to being a technician rather than a professional. In his words, “Excitement about technology is like a drug addiction.” Guyer wondered if we are “so mesmerized by this new technology that we are missing the point? Does new technology really improve spine care? Clinical outcomes have not been shown to improve dramatically in recent years, although the treatment options have increased multifold as have the costs.”

Economics of Spine

And he asks who will pay for this technology arms race?

“There is big money in spine. In 2005 dollars, between $100 billion and $200 billion per year were spent on spine care. In 2003, the total revenue of U.S. spinal device manufacturers was estimated at $2.5 billion dollars.” He said Robin Young told him that total spinal device manufacturer revenues in 2006 are estimated at $6.1 billion (globally), with a $1.0 billion operating profit margin.

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With these “staggering figures,” Guyer said there is a potential to determine the best cost-effective treatment. [The government is calling this “comparative effectiveness.”]

But, noted Guyer, traditional economic models do not necessarily exist in medicine.

As an example, Guyer said, “When a new technology is introduced, one company holds the patent and the prices are initially high. With market competition, the price decreases as the product use increases. But in spine, a pedicle screw in 1990 cost $135 and increased to $700 in 2000. In contrast, my first 250 kB Apple IIg Wozniak signed edition computer cost $3,000 in 1986 and in 2007 my quad core 2007 500 GB computer cost $1,000.”

Furthermore, Guyer said, “When dealing with medical devices, the roles of those involved with the purchasing and using of implants are also different from the traditional basic model for buying and selling. Traditionally the consumer is the one who selects the item to purchase, pays for it, and is the end-user. In the spinal implant arena, the picture is less clear. The patient is the end-user of the device, but the insurance company is the one who pays for it, with some help from the patient, and the surgeon is the one who decides the specific item that will be purchased, although he or she is not the primary end-user and pays nothing for it.”

Given these dynamics, where do the physicians fit into the economics?

Guyer says there are pressures on physicians from the government and insurance companies, whose policies dictate the doctor’s work. When adjusted for inflation, physician income has declined 7% from 1995 to 2003, and cuts to Medicare reimbursements are threatened every year.

Benchmarks and Intelligent Medicine

Physicians have gotten to this point because they have chosen to be passive and have allowed insurance companies and other entities outside the medical community to make decisions about patient care. Said Guyer, “We have long practiced medicine as a cottage industry. We have approached our practices as pieceworkers competing against each other, instead of working as a group and using that power to guide our own destiny.”

He asked if physicians have really made use of this new great technology to practice intelligent medicine and put into place physician-created benchmarks to evaluate themselves.

“We have the power to control our destiny by actually creating the benchmarks, collection sources, and self-policing our industry. If we do not, others will,” said Guyer.

With performance and quality measures and tiered networks being pushed by insurance companies, Guyer says physicians need to learn how to promote themselves using data and become practitioners of “intelligent medicine.”

Guyer told his audience, “We are not being smart. We are not using data collection to our advantage. In many cases, we cannot prove that what we do really works.”

In addressing this paradox of technological temptations and economic challenges, Guyer says he first looks at what spine surgeons seem to agree on:

  1. Unhappiness with declining reimbursements;
  2. Struggling to keep up with new technologies and having adequate information on what to use when trying to provide their patients the best available care, particularly when the patients are asking for the newest thing;
  3. Disliking denials when trying to get approval from insurers; and
  4. Deciding to accept the situation rather than being active to address it…at least to date.
  5. But he also said, “We can take responsibility for beginning to track our own practice outcome data, showing its successes, failures, complications, etc. Medicine is based on the scientific method, but we have not used the same evaluation process on ourselves. Where are our metrics? Performance can only improve with performance measures.”

Guyer noted that everybody is measured these days and physicians shouldn’t be any different.

And here is where he sees the opportunity for physicians to take charge: “Our business product is ourselves, but have we studied ourselves? And have we proven ourselves? Have we figured out our value for price? Are we getting what we are worth? Invest in yourself and demonstrate your value by obtaining your practice data to show the insurance companies, so that we can compare our data with everybody else's data and improve the practice for all.”

Central Data Repository

Guyer said until there is a central repository or registry for the data concerning patient care, including what treatments patients are receiving and their outcomes, and until comprehensive data can be captured in relation to the costs for various treatments, physicians will be forced to rely on only a partial or short-term data set to evaluate their performance.

He urges all of the stakeholders—physicians, investors, payers, manufacturers, and hospitals—to work together. “There must be ongoing evaluation to refine indications to provide each patient the best care. Patients meeting rigorous selection criteria should be able to receive the optimal treatment without being limited by their insurance. Manufacturers must balance the demands of investors for revenue with the losses that may follow over aggressive use of the product. Physicians must adhere to appropriate patient selection and take responsibility for data collection of their results,” concluded Guyer.

Guyer proposes that universally accepted and mandated measures must be designed by the physicians because data is the ammunition that will result in better patient care, easier approvals to treat patients, and better reimbursements. “However,” Guyer stated, “our guns are currently empty and we are feeling vulnerable.”

Saying it sounds crazy, Guyer challenged his audience to imagine a J.D. Power rating of physicians. “But there is nothing to fear if you are a good, ethical physician. We have been criticized as a profession for not policing our own. Let physicians’ documented actions and reportable outcomes help to control their actions.”

He asked, “Who is better equipped to determine the best data to gather than physicians themselves? The best solution, I believe, is through professional societies with cooperation from the other stakeholders.”

NASS recently formed a Quality Spine Care Committee to accomplish these goals.

Practice Based on Data

In conclusion, Guyer said, “We must practice the best possible medicine based upon the best available data and, of course, ensure that our patients take part in the decision-making process. In addition, we must commit ourselves to providing the appropriate data so that we can raise the quality of spine care for all of our patients. We have a very bright future. It is ours to seize and if we put as much effort into this as we have into our training to get to this point, we will be able to make a difference…. We cannot wait for future doctors to accomplish these goals, because we are the future!”

Written by Walter Eisner