Sustainable medicine will come about when device manufacturers, surgeons and insurance companies work together to provide healthcare that emphasizes quality, cost efficiency and patient outcomes. Those three points are now fixed in our lexicon, but how are they shaping orthopaedics?
Robert S. Bray, Jr., M.D., CEO and Founding Director of DISC Sports & Spine Center and a neurological spine surgeon, offered that outlook for sustainable medicine and answered that question when we asked him to revisit predictions from his OMTEC 2014 keynote.
We recalled a few of the topics he’d outlined two years ago: orthobiologics, insurance and distribution. One theme became evident: the desire for device manufacturers to claim a greater role in the mix. Collaboration must occur in more meaningful ways, and that will require engineers, supply chain and regulatory folks to talk with surgeons, hospitals, payors and even manufacturing competitors. This collaboration needs to be emphasized by leadership.
“My hope is that in five years or less there will be much better communication effectively among government, vendors, developers, the centers that deliver care and the payors,” Bray says. “This will be the new trend. In order to win, they all have to come together.”
During his keynote, Dr. Bray spoke of the search for the Holy Grail in orthobiologics. His update: We have yet to find it. What has changed, though, is surgeon perspective of orthobiologics’ role in the overall procedure. He points to specifics.
One, surgeons are beginning to look at the biologic and the implant as one charge to the patient, as opposed to two separate products. Two, the spine industry is seeking better implant integration to bone, and is therefore moving away from PEEK and toward the use of metal like titanium, structured surfaces like nano and manufacturing techniques like additive. When better integration is achieved, less orthobiologic is required. This holistic approach to the products used during the procedure limits cost and maximizes effectiveness.
”The implant makers need to work with the biologics makers,” Bray says, “looking at what biologics work best with their implant. As implants become more osteointegrative and participate in the fusion, the amount of biologic will probably be significantly less. The total cost of the implant is going to be important, and the fact that the implant integrates and is matched with the right biologics is where we’re headed.”
In 2014, Bray mentioned payor pushback on orthobiologics—specifically, the need to have a product pre-approved before surgery and the variation of approved orthobiologics amongst insurance companies. Standardization is still needed today, Bray says. He suggests that manufacturers can better assist surgeons with approval by working more closely with insurance companies to push for this standardization.
The questions manufacturers need to ask include, what do we have to do meet your criteria? What level of data and studies do we need to produce? How can we work together to make sure that what we’re making is cost-efficient for you, so that you’ll approve it for our surgeons’ use?
“The insurers need to be at the table with the implant manufacturers to help define and standardize the criteria. Until we get that, we’ll be blocked by bureaucracy. The [implant] companies have been ineffective in helping us get things approved,” Bray says. ”I hope we see a change in the politics, and that the system simplifies, competition decreases and that insurers come to the table with the manufacturers to look for that cost-effective solution that is sustainable.”
Bray founded DISC in 2006 with the foresight that medicine would move to outpatient and specialized surgery centers. Numbered are the days of fighting with insurance companies to cover a procedure at a surgery center, he says, adding that insurance companies are starting to incentivize surgeons to do procedures at ASCs that have data showing their outcomes and cost efficiency.
Bray expects this to continue as the delivery of medicine becomes more focused in the next five years. For manufacturers, this shift means a change in sales and distribution.
“There will be a dramatic move to specialize care,” Bray says. “Spine will be done by spine centers and cardiovascular will be one entity—there will be specialty centers, whether they are within a hospital or within an ASC. The centers that specialize, that do it well and do it in numbers have proven time and again that they get better outcomes. You’ll see that the generalist who does a little bit of everything will do less. There will be a consolidation to centers that can meet quality markers. And, we will see a strong emphasis on quality and cost efficiency—Medicare is widely on to this topic, with their new ways of looking at quality outcome markers.”