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DI Payer Insights - Spinal Surgery: Current and Expected Trends in Payer Management & Reimbursement of Spinal Surgery - 2Q '15

DI Payer Insights - Spinal Surgery: Current and Expected Trends in Payer Management & Reimbursement of Spinal Surgery - 2Q '15

The $12b US spinal surgery market has been marked by headwinds in the last few years as a lack of "price sustaining" innovation from the largest implant vendors and payer pushback on the efficacy of certain procedures has limited growth. Recently, these pressures seem to have eased slightly as the market has returned to low, single-digit growth.

While it is widely held that pressure on access/volumes from payers has "eased" when it comes to spinal surgery, this seems only insofar as policies and practices have not become more onerous in recent months. Certainly none of our work with payers, nor recent conversations with hospital administrators suggests that payers have loosened their policies or lessened their focus on utilization!

Thus industry participants have been rather sanguine in their outlook versus recent years. There is, however, an ominous cloud lurking in the distance that could potentially bring darker days…

The confluence of several trends (increasing cost transparency, high (going higher) deductible plans, hospital employed physicians, ACA/ACOs, and new reimbursement pilots) are giving rise to the potential for incentive disruption, the likes of which, this physician preference market has never seen. If realized, this tectonic shift will cause participants throughout the supply chain of Spine Surgery to have to adjust, sometimes radically, their way of delivering value.

In this report we explore the current payer landscape for spinal procedures with a particular focus on payer expectations for alternative reimbursement prospects in spine.

Who would benefit from this report?

  • Hospital system executives
  • Implant manufacturers
  • Surgery Groups
About this survey/Methodology

This DI Payer Insights survey focuses on the trends and expected changes in utilization management and payment for spinal surgery. The survey was conducted in the 2nd Quarter of 2015. The survey was conducted with 10 respondents, each holding a Medical Director position at a major health plan and cumulatively represent over 71 million covered lives. The survey covers 9 surgical areas of focus in 4 major categories and addresses reasons for and anticipated change in focus/management, current reimbursement methods, changes in reimbursement, and the impact of various trends in payment methodologies.

The 9 areas of focus and 4 categories are:

Lumbar Spine Surgeries
  • Lumbar fusions using autologous bone grafting
  • Lumbar fusions using bone morphogenic proteins (BMP)
  • Lumbar fusions using artificial disks
Cervical Spine Surgeries
  • Cervical fusions using autologous bone grafting
  • Cervical fusions using bone morphogenic proteins (BMP)
  • Cervical fusions using artificial disks
Minimally Invasive Spine Surgeries
  • XLIF procedures (extreme lateral interbody fusions)
  • Minimally invasive spinal surgery
Spinal Stimulators
  • Implantation of spinal stimulators

Review and Introduction
About this Survey
Topic 1: Areas of Focus, Reasons for Focus
Topic 2: Anticipated Changes in Level of Management
Topic 3: Current Reimbursement Mechanisms
Topic 4: Expected Changes in Price of Procedures
Topic 5: Expected Cost Impact of Alternative Reimbursement Mechanisms
Topic 6: Current and Expected Penetration of Alternative Reimbursement Mechanisms
Parting Thoughts
Appendix A – Payer Responses Grouped According to Size of Payer
Appendix B – Payer Responses: Lumbar
Appendix C – Payer Responses: Cervical
Appendix D – Payer Responses: Minimally Invasive
Appendix E – Payer Responses: Spinal Stimulators
Appendix F – Spinal Industry: Facts and Figures

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