From insurance “misalignment” to patient hostility, spine surgeons discuss the surprising aspects that came up in their work since 2020.

Editor’s note: Responses were lightly edited for clarity.

Question: What’s something in your practice that has surprised you the most in the last five years?

Jeffrey Carlson MD. Coastal Virginia Surgery Center (Newport News): I have been very surprised at the misalignment of incentives between commercial insurance and physicians. As doctors we have long been taught to be conscientious about costs. We have been told that healthcare is expensive, and we should not be ordering tests, imaging, procedures and consultations unless they are absolutely necessary. Advice that will help the skyrocketing costs of healthcare. In the past several years, I have negotiated contracts with the added cost-comparison knowledge found through the hospital transparency initiatives.

Surprisingly, the cost savings of non-hospital related imaging or procedures do not interest commercial insurance companies. For example, if we can do an MRI for $500 and the local hospital charges $2,000, the insurance company will try to negotiate our MRI rate to $400. Or we can provide an outpatient lumbar fusion for 50% of the hospital cost, the insurance company will want to negotiate our rate down to 40% instead of driving down the hospital cost. And even worse, the payments increase to the hospital yearly for the same imaging and procedures that can be done more cost efficiently outside of the hospital. Commercial insurance keeps raising their rates and lowering the physicians reimbursements.

This is why I am such an advocate to self-insurance, direct contracting and direct primary care. We have gone self-insured and have seen the premiums of our employees decrease, which had never happened with commercial insurance.

The Free Market Medical Association has been a voice of reason in aligning physicians and patients and cost incentives. Getting away from insurance will drive down healthcare costs, as commercial insurance is not motivated to control costs for their clients.

Tan Chen, MD. Geisinger Musculoskeletal Institute (Danville, Pa.): As an early career spine surgeon, recognizing, acknowledging, and addressing the unknown unknowns has perhaps been the most surprising in the past five years of my career. Many facets of running a successful practice are not taught during one’s training, and it has been humbling to see how much my knowledge, surgical intuition, and technical skills have developed and changed following fellowship. The practice I have today is vastly different than when I first started, and I’m excited to see my personal evolution over the next five years.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: One of the most surprising things is how certain things like restful sleep, interpersonal relationships and doing their own shopping is important to most people. There is an incredible amount of positive perception of patients that are dependent on those three things. It is very satisfying to see the smile on a patient’s face after they describe surviving a long day of Saturday shopping at Costco.

Jonathan Rasouli, MD. Northwell Health (Staten Island, N.Y.): One of the biggest surprises in my practice over the last five years has been realizing just how challenging it’s become to work with insurance companies to get patients the care they need. The influence of payers (and increasingly, hospital administrators) on clinical decision-making is staggering. I often spend more time navigating bureaucracy than treating patients, which is the part of the job I truly love. It’s deeply frustrating, and I believe it’s a growing problem for many of us in surgical practice. Unless real systemic changes are made soon, I fear this will only worsen. When you combine this with rising healthcare costs, continued consolidation of major health systems, and declining reimbursement, it’s becoming a very tough environment to practice in.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): In our practice, like others who manage the chronically ill and pain infirmed, there is a growing percentage of both hostile and aggressive interactions that have required stern discussions and, in some cases, resulted in relationship termination. This is not isolated as exchanges with other physicians and administrative managers reveal the same trends have occurred, whereby the posting of signage and notification are a prerequisite of acknowledgment and agreement of zero tolerance.

For the most part, many patients are graciously respectful and duly appreciative as outcomes and polled patient experience reveal these facts. Crediting the internet for unsavory behaviors and its availability for captured superficial knowledge, instantly ascends one as an expert because one social media search or discussion with a friend is usually indisputable truth. Having one’s ‘little amount of knowledge’ becoming ideological and unquestionable is deleterious to treatment. When charitable, experiential and magnanimous care is the starting point, being confronted with anything but appreciation turns the tables very quickly. Support for office and clinical staff is paramount, exercised by physicians and management alike.

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