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Current & Critical

3 Questions on the Spine Reimbursement Environment

By Carolyn LaWell, ORTHOWORLD

The spine market’s evolving reimbursement landscape can be hard for device companies and surgeons to navigate. While at NASS, we asked reimbursement expert Kim Norton for a high-level view of the reimbursement shifts taking place today. Ms. Norton is Vice President of Reimbursement for Simplify Medical and serves as a consultant, including in reimbursement and payor relations for Aesculap. 

What are the greatest challenges and opportunities in spine reimbursement today?

Ms. Norton: I think the number one spine reimbursement challenge today is the ability to understand changing and shifting medical policies. What policies include and what they don’t include; who is making policy decisions, and whether they’re actual commercial payors or third-party prior authorization companies like Evicore or AIM or NIA Magellan, who have become bigger players in the spine prior authorization world and have their own guidelines. It’s become more challenging for surgeons and patients to figure out which policy affects them and what the “rules of the game” are from one day to the next. It’s causing some chaos, I think, in the spine reimbursement world. This shift needs to be explored and there needs to be advocacy and education.

The greatest opportunity for spine in general is Ambulatory Surgery Centers (ASCs), and that correlates with reimbursement. More and more procedures are moving to ASCs. That poses opportunities and challenges, challenges in terms of how implants fit within existing fee structures, but also opportunities in terms of more companies coming in to manage bundled payments and negotiate with payors around bundled payments that cover the cost of the implant and the procedure. This also ties some risks for the surgeon and the facility to outcomes. There’s a huge opportunity for surgeons, facilities and device companies to get more engaged in this new arena.

You have spent years working in artificial discs. How is reimbursement changing in that space?

Ms. Norton: In the cervical disc world, we’re at 99% coverage from commercial plans in one- and two-level indications. I think many people just aren’t aware of that yet. Lumbar, interestingly, has really grown in the last two years. We were at about 25% coverage in terms of commercial health plans, and now we’re at over 65%. Some states have almost 100% coverage. A lot of surgeons aren’t aware that some of the barriers have fallen in terms of coverage. What we’re trying to do is just educate surgeons about the fact that reimbursement has gotten better.

How are you staying on top of these changes? What advice do you have for others?

Ms. Norton: Honestly, the folks from whom I learn the most are the people doing it every day—the billing staffs in the surgeons’ offices, the front office staff, those who interact with payors on a day-to-day basis. I can read policies all day long, but I don’t know how they’re actually being implemented—they do! My advice for others in terms of staying on top of all of this is to talk with surgeons and their staff, and review policies often (most of them are available online). The trade associations (MDMA and AdvaMed, for example) are also doing all they can to advocate for positive change in the reimbursement environment, so staying in touch with them is key. And, of course, reading from as many sources as possible, including yours!

Carolyn LaWell is ORTHOWORLD's Chief Content Officer.