Youth versus age, risk taking versus conservatism, and funding...always funding. These are just some of the factors that determine whether a patient receives the latest in technology. Says Dr. Rick Guyer, President of the Texas Back Institute and Past President of NASS, “It is true that the adoption of new technology has become faster in the last 100 years. However, the old axiom that people don’t like change is always in play. Except pioneers, of course. Thank goodness for the pioneers.”

And although he sees the future of surgery as cutting edge, alas, the other enduring issue remains: “Who will pay?” Dr. Guyer: “Looking ahead I see things such as a web of electronic data that makes it possible for surgeons to operate remotely on patients regardless of where they live. Widespread electronic medical records would provide up-to-the-second information and streamline medical care across the board. You will be able to get a genotype and identify what diseases someone is susceptible to. In general, new technology will make medical care so efficient that we’ll eventually see the benefits outweigh the costs. But in the meantime the financial issues must be solved.”

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And that is hard to do when you have a moving target. Dr. Guyer notes his own experience: “I have been involved in numerous strategy meetings prior to CMS presentations. At times industry representatives were even included in order to see what information they might bring to the table. I have come to learn that it is essentially a shell game involving both CMS and the AMA, the latter of which does the CPT coding that CMS adopts. The problem is that with Medicare, the sustained growth rate (SGR) is zero for physician reimbursement. This means that every time a code comes up that people want adopted, it takes money from another code. Then, making it worse, insurance companies work from what Medicare decided. If Medicare decides on reimbursement for something and if it goes down a certain percent, insurers tee off that. So there’s your downward moving target.”

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When Mrs. Jones goes in for spine surgery, she likely has no idea of the economic forces working for and against her. Dr. Guyer: “There are things happening on both a state and a federal level that affect how we care for our patients. One example is in Washington state, which recently held a hearing on fusions and the prospect of limiting them. Now artificial discs are being challenged by that state. To address this issue, NASS, CNS, AANS, CSRS, SRS, and SAS have organized to work together. If such changes occur in one state, it will spread to the rest of the states. And it will happen quickly. The federal government moves slowly, but not the states. Oregon is mounting a Health Technology Assessment in collaboration with 11 other states, something that could affect the treatment landscape of spine patients for years to come. And unfortunately, in some cases, the individuals reviewing the technologies are regulatory people who are not necessarily medically or clinically trained.”

Continues Dr. Guyer, “Many insurers are saying outright, ‘We won’t pay,’ as with the CHARITÉ®, which was approved in 2004. And there is the example of the ProDisc™, which was approved in 2006 and yet still has only a smattering of insurance companies that will pay for it. Two-year data used to be sufficient, then it was five years; we are now moving toward a 10-year data requirement. And this quickly trickles down to the people who are in our waiting rooms. One of my patients brought in a letter from his insurer that read, ‘We understand you had cages (actually it was a successful life-changing artificial lumbar disc) in your spine two years ago, so we are unable to give you insurance.’ In some cases insurance companies do their own technology assessments and then hold out because they are afraid that if they approve the technology it will open a Pandora’s Box. CMS also does technology assessments, where, for example, they end up saying, ‘We are not approving the artificial disc for people age 65 and older. If someone is younger we’ll consider it.’ As a physician I know that while we are having increasing success with older people, there is still a 25% complication rate with some of the more complex deformity reconstructions required. It seems, unfortunately, that the CMS premise is, ‘What can we not pay for?’”

And among some surgeons there is also a bit of conservatism. “When the average spine surgeon finishes training, he or she is comfortable with certain things. He can reproducibly perform these operations and have an attitude of, ‘Why would I want to change?’ The other group, the younger generation in our midst, says, ‘This is cool! I’ll try it.’ They have been ‘brought up’ on new technology and don’t have the hesitation that some older surgeons do. I remember a surgeon who said, ‘In my hands I can get great results with my current technology. I’ll let other doctors try such-and-such until it is proven. Then I’ll use it.’ If everyone thought like this, of course, there would be no progress. Take total hips. Almost 50 years ago Dr. John Charnley dove right in with Teflon-coated hips. While they all eventually had to be revised, he started the revolution of joint replacement that our patients enjoy today. Over 25 years ago when we started the Texas Back Institute and were doing fusions, there were no BMPs or demineralized bone products. We had to wait six to nine months for fusion and then do the opposite (anterior or posterior) and then wait another six to nine months. Nowadays we can do it with BMP and percutaneous pedicle screws, and in about three to four months the patient is well on his way to healing. There will always be something better around the corner. But the field won’t progress if everyone sits on the sidelines with a ‘wait and see’ attitude. You have to do your best with the knowledge and technology you have at the time.”

And just like a red state/blue state thing, new technology adoption depends on the person’s vantage point. Explains Dr. Guyer, “Someone’s comfort level with change is going to depend on his or her career stage. Surgeons who are younger and still building their practices are more likely to incorporate newer technology for the competitive edge, compared to an older surgeon who has a mature practice and does not feel the need to learn newer techniques to build his patient base. Motivating the ‘holdouts’ to step out of their comfort zones, however, is a dose of peer pressure. If I am the last one in my practice to do an open operation when MIS is the standard, for example, then I’m really out of sync with the times. I had better change or I won’t get patients.”

At the core of the issue is what works and what doesn’t. Explains Dr. Guyer, “Take the artificial disc, for example. Its proponents say that the biomechanical evidence shows that it can preserve motion at the affected level and lessen the stress on the adjacent levels compared to fusions. Others say that is a myth. This is why we need extensive data on technologies. But even having sufficient data doesn’t clear everything up. When The New York Times recently published its article on the ProDisc, many people had doubts about the quality of the data. There is no way to alter data with an FDA IDE, however. People want to see unbiased outcome data, but outside of the FDA IDE trials, we are terrible about collecting it as individual doctors.”

And while patients don’t usually ask to see the details of a regression analysis or chi-square test, they are pinning doctors down with pointed questions. “Patients are increasingly savvy about medical technology,” says Dr. Guyer. “They do research on the Internet, shop around for practices that have what they want, check out hospital ratings, and bring printouts to appointments. What tempers all this enthusiasm is insurance, however. If someone wants to travel to another state to see Dr. X, the insurer may put the kibosh on that. And the Internet opens up issues of misrepresentation as in unqualified doctors advertising, for example, minimally invasive surgery.”

Dr. Guyer concludes, “I think new technology will be adopted more easily in the future because we’ll be totally surrounded by it. It will be the expected norm. And as long as it’s done with prudence, patients will benefit tremendously.”