This is Scott Becker with the
Becker's Healthcare Podcast. Thrilled today to get to
visit with Carly Beam. Carly's one of the lead
journalists at Becker's Healthcare. She spends a lot of time
specifically on spine orthopedics, and she's gonna talk to us today about
some of the issues she's watching, a couple of the key issues she's watching,
and spine orthopedics and healthcare. Uh, Carly, can you take a
moment and introduce yourself? Yeah. Hi, I'm Carly. I am the assistant editor
for Becker Spine Review, and it's a pleasure to be on the podcast. Thank you so much. And I know you a teed up two wishes
we're gonna talk about today. What was the change to an Aetna
policy on lumbard disc replacement? And this, is this gonna make it harder for spine
surgeons to get this approved easier? What, what does this mean?
And tell us about the change. Yeah, so the change has
happened on February 8th, and it says now that single
level lumbard disc replacement is medically necessary
under certain criteria. And this is something that spine
surgeons are hoping will expand access to the procedure. So, so rather than this being something
that's viewed as negative for, because so many things
that come out from payers, whenever I hear a payer
policy come out, the, the typical expectation would be that
this is gonna make it harder to do something. Is this not that this will
make it easier to qualify for lumbar disc repair? How does this look? Yeah, so this, this update came in
response to a class action settlement that, um,
Aetna settled in December. The lawsuit had called out its
previous policy calling lumbar just replacement, experimental and investigational
despite the fact that the procedure has been performed in
the US for well over 20 years now. And I actually spoke with a few spine
surgeons at the Texas Back Institute in Plano about this since that's
where a total disc replacement began in the us. And on the one hand, surgeons are happy that this came, they said it's been a long time coming, but they also wish that
there could have been more to this policy. Um, for instance, it's only covering single level disc
replacement instead of multi-level. And, um, this is something that I'm
working on right now in my reporting, but I talked to a couple spine surgeons, they still feel that the
requirements to get coverage are still a bit tight. Uh, yeah, no, I think you, Carly, so
as I understand it, quite frankly, that Aetna's loosened up the policy to, to summarize what I'm hearing is
Aetna's lu loosen up the policy for this lumbar disc repair surgery, but it didn't do it out of the
goodness of their heart. It do, it did it in reaction to
class action settlement to, to sort of a lawsuit a,
around these issues. And then
to take it a step further, there's at least many of the surgeons, the spine surgeons probably feel that
this didn't go far enough to make it easier to get approval. Is is that a
fair summary of what you're saying? Absolutely. And you know, I'm looking
at the policy right now, like, you know, one thing that kind of sticks out to me
is that one of the requirements is to have at least six months of
fail conservative treatment. And at least three months of
in-person physical therapy in the past year, it specifies parenthesis not
virtual physical therapy, which I imagine especially in
recent years, the COVID 19 pandemic, that might be a tough requirement to meet. And if you are a patient who's been, who's had back pain, has been going with
conservative treatment and you know, trying to heal things, you know, knowing, finding out that virtual physical
therapy might won't cut it, you know, it could be a disappointment. Thank you very, very much. This is one issue you're following is
this Aetna policy change that really came in, result in the lawsuit.
Uh, and the end of the day, it helps to get things approved,
but likely doesn't go far enough. Tell us the other big issues that you're
watching currently in orthopedics and spine. Yeah, so the other big thing I'm following is
this new orthopedic partnership between Emerge Orel, ortho, indie
and Prolia Surgeons. And they formed what's called
pelto Healthcare Partners, PTO, standing for Physician
Empowered Leadership of
Transformational Organizations. And similar to, uh, like a PE back mso, they can
retain their independence, but they're not relying
on the external capital. Got it. So they're emerging the other
three groups to make a super group, a very large group, a national
group because, you know, Alliance on the West Coast or indies in
Indianapolis or the greater indie area and so forth. And, and now we always wonder why these
groups pick names that are AC that have acronyms, but that are extremely hard for anybody
to guesstimate what the Ackerman stands for, but that's their choice
and so forth and so on. But excited to see the growth of these
supergroups to see what this means for healthcare going forward. Definitely, I don't know if I
would call it a merger per se, since the practices are retaining
their independence and their, their independent identities still. But this also reminds me
of a partnership here in Illinois that was announced in the
beginning of the year between Northville, Illinois and Midwest Orthopedics at Rush. And they formed Ortho Midwest
and they call themselves in an anticipation. Uh, they're not
relying on private equity either, and it's a move that, you
know, again, they grow numbers, they have a, they have a stronger foothold in their
market and they still retain their autonomy. Got it. So the concept is some sort of
aggregation of management resources, some ability to stay
significantly independent and
then see where it evolves to sort of alliances versus a super
group would be how you'd look at it. Alliances, maybe investment
together in management services, but not necessarily in the
whole ball of wax at this point. Right. And I'm particularly interested
in seeing how these groups pan out in the coming years and if we'll
see similar models drop up, we, our orthopedic groups are uniting
without the private equity. And Scott, I've been working with
better since September, 2020, and in the first couple
of years I've been here, I've seen multiple private equity
groups crop up in orthopedics such as U S L P, American Orthopedic Partners and
Unite Musculoskeletal Partners. And, you know, with these two new
groups coming into the landscape, it looks like things could be
really shifting in orthopedics. Yes. At least originally, like
the Hop coast of the world, some of these large orthopedic groups
that are private equity funded, these are a couple that are trying to
combine resources at least partially without being private equity funded. And, and the only thing I would say
is when I see these alliances, often they end up at some point being
an intermediate step to figure out the longer step where they end up
with full combined groups or not, and what that looks like. And so it it'll remain to be seen how
these things work forward and what they look like a couple years
from now, won't it? Yeah, I think private equity, it's definitely one of those more
device issues in orthopedics. We've done extensive outreach and
interviews with spine orthopedic surgeons about private equity,
and some of them are saying that, you know, the right partner, uh, private equity can help a practice
grow and meet us long-term goals. But then others are worried
about bringing in outside investors, especially folks who might not
have a healthcare background coming in and, you know, buying
out these independent processes. Uh, yeah, a hundred percent. And this
is, uh, an issue. The, uh, the, the, the concept of private equity
is that, you know, the good, the bad and the ugly, and a lot of
it depends as a group, what do you, being very clear about what you want
the private equity for and why before taking it on. And that's a whole
nother discussion. Um, but no, Carl, your point is very well taken.
It ends up being very different. It really has to be clear about what
you're doing and why you're doing it. If you're gonna take on private equity
or if you're gonna do this kind of alliance e either way, the, the most successful ones come with pretty
good clarity about what you're trying to accomplish. In any event,
Carly Beam, great journalist, great leader at Becker's Healthcare. I
want to thank you for joining us today, both to discussed policy change around
lumbar disc sort of codes and surgery, uh, as well as around the alliances of these
large orps and what that's like for the market over the next few years. Carly, thank you so much for joining us today. Thank you for having me on, Scott, and I
hope to do more of these in the future.