NASS: Interesting Times
The North American Spine Society (NASS) is entering its 25th year.
The organization’s last two years have been about refining who and what the society represents, confronting ethical challenges that have disrupted the surgeon/industry relationships that drive innovation and, attempting to move the society into to what newly installed President Ray Baker, M.D., calls the “Intel Era of Spine Care.”
It’s not been an easy journey. Some former society leaders and members have openly criticized new NASS leaders for abandoning the cause of representing spine surgeons and instituting the profession’s toughest disclosure and divestiture requirements.
Some spine companies are wary of the society’s positions on coding and fear the organization is favoring existing procedures at the expense of new technologies to protect payments to surgeons. Sometimes the society seems it’s between a rock and a hard place.
Baker told OTW during an extensive interview during the recent NASS meeting in San Francisco that the society’s board has spent a lot of time on these issues, as well as redefining NASS’ mission statement and central operating principle.
Who Represents Spine Surgeons?
“The question came up, ‘Are we primarily a member-based or a patient-based society?’ The consensus was that, for NASS to be successful over the long run, we have to be patient centered. If we lose the patient at the center, then we’re going to lose any chance that we have to affect policy or to advocate for change and our members will ultimately lose, ” said Baker.
Now, at times, that might put us at perceived odds with the short-term interest of our members on a specific issue. But if we look at the bigger picture, we can see that in the long run we’re preserving the specialty and we’re preserving it for generations to come.
At last year’s NASS meeting in Toronto, the society’s then outgoing president, Tom Faciszewsk, M.D., announced the organization’s central operating principle would be to promote quality spine care. That announcement begged the question, “Who will represent the best interest of spine surgeons?”
NASS’ Executive Director Eric Muehlbauer, M.J., C.A.E., told OTW during the recent interview,
“It’s a bad rap for somebody to say we don’t represent surgeons, because we do. We just don’t spend 100% of our time on spine surgery issues. Not everything in spine relates to surgery. Spine care is a broad field. There is also a very distinct difference with how NASS operates compared to some other medical societies. We’re a 501(c)(3) charitable, scientific, educational, non-profit organization. We have the tax exemption from the IRS because we are supposed to do something for the betterment of society in the U.S.A.”
Muehlbauer says some medical associations act like trade associations and are out to promote the interest of their distinct membership. “Not that we’re not out to promote our members’ interests, but we also have a larger purpose and we take it seriously.”
“Does NASS represent spine surgeons?” asked Baker, an anesthesiologist before answering his own question.
“Although surgeons represent the largest constituency in NASS, we are a multidisciplinary society. By maintaining a multi-disciplinary focus we actually strengthen our seat at the table. We are one of the few societies that can come before a panel and say we aren’t a surgery-based society or an intervention-based society—we are a spine care society. We look after all interests.”
“In the short-term, ” asks Baker, “does that put us at odds with one particular group?”
“At times, ” he admitted. “With a vocal minority, ” added Muehlbauer.
“Best Year Ever”
Both men say that NASS has never been stronger and credible with payers, regulators, other medical societies, its members, and the public to be able to face the coming challenges and to be able to take advantage of the coming opportunities.
“We are not slowing down, ” said Baker. “In fact, we are probably going to have our best year ever this year. This year we have gained over 700 new members. We have over 5, 500 members, and are on track to beat 6, 000 by next year.”
The change of mission, institution of new ethics rules and criticism doesn’t appear to have changed the way NASS members vote with their feet.
We have a 97% retention rate of our existing membership,
“You know it is important to say there is a vocal minority of people who get upset at NASS—usually people who have a lot to lose. For instance, some are very upset about transparency. But when we look at the rank and file, they are not upset about this. In fact, they are expecting this. They are saying, ‘We want credible voices as our spokespeople. We don’t want to have this tied to industry anymore.’”
Even with a tough new disclosure and divestiture policy, Baker says he is personally very gratified that the society has a 100% board retention rate. “When you look at our board, you’re talking about thought leaders who I think are recognizable names. People can look and say we’re not having to scrape the bottom of the barrel. We have really top-notch board members.”
Baker hopes his term as head of NASS will be seen as a time when innovation is “reignited.”
“I think one of our challenges is to reignite innovation in a different way.”
Baker said he recently spoke to the CEO of a small spine company and said, “You know, innovation has stalled.” The CEO responded that innovation has not just stalled, but stopped. He told Baker that it was not just in spine, but also in cardiac, in pharma, and in other areas. “There’s nothing coming out anywhere and venture capital is sitting on the sidelines. So our challenge is, how we reignite innovation?” asked Baker.
Companies have been risk averse and not sure what they can do.
“If I’m their attorney, I’m saying, sit on your hands, do nothing. But now that there is a better understanding based on corporate integrity agreement and other pronouncements indicating what’s allowable and these third-party mechanisms are being formed for research, etc. and so on. Hopefully there is a backlog of interest in funding research and development activities, but doing it through the right mechanisms, in the right ways with the right processes.”
Baker agreed that the word “value” will be added to the current coverage framework of CMS [Centers for Medicare and Medicaid Services] that asks if a device or procedure is “reasonable and necessary.”
He believes NASS can attempt to bring clarity and certainty to the situation by doing the following:
- Define value
- Work on proving value (registry, clarify CER (Comparative Effectiveness Research) parameters especially with regard to cost issues)
- Make sure that (CER) is not merely cost containment
- Work with the FDA to clarify what is needed to pass a new device (PMA versus 510(k))
- Work with CMS and insurers to provide industry with a stable 'bar' to achieve payment. (CER, RCT, Registry, some combination).
“Although these are not areas that NASS (or any other medical society) usually enters, who is better at defining quality and assessing new technologies than NASS, and who would you rather have do it, NASS or the government?” asks Baker.
Defining and proving value is where the society’s mission will cause some stress. As an example, Baker cited NASS’ activities in creating separate CPT codes.
“Say you make a new device that will decompress the spine, but will do it percutaneously and take one-third of the time of a standard open decompression. In addition it has very little associated risk. But you’re billing it as if it were the more expensive, work-intensive, risky procedure."
“In the short term, that may be very good for the device company, ” continued Baker. “But in the long term, it puts all decompression procedures on the insurer’s radar. The decompression CPT code gets on the radar for CMS and the whole family of CPT codes gets revalued and often down valued.”
There are times that we have to lose some of the low-hanging fruit in order to maintain credibility for the big things. We are just trying to protect the things that are the bread and butter of our surgeons and other members.
Vertebroplasty vs. Kyphoplasty – A Precursor
Another example of NASS’ willingness to act in defining value was its recommendation to CMS over the relative value of kyphoplasty and vertebroplasty. NASS and four other spine societies told CMS, in essence, they believed both procedures offered the same value and should be reimbursed at the same rate.
Baker said, “If you go back to that Intel model, you have two really fast processors. One costs more. We are saying, ‘Shouldn’t we call that question at some point?’ I don’t think we looked at it necessarily by saying, ‘This is going to raise our credibility, so we’re going to pick on this technology.’ But, it came up, and we had to deal with it as we saw fit. The panel that went over this did a very good job of looking at all the literature and they really could not come up with any safety or efficacy data that distinguished these two technologies. And so, in the absence of safety or efficacy data, how do we separate them?”
“This was really, in many ways, the precursor to the value question, ” added Muehlbauer
While the new society leaders have received their share of criticism in pursuing a new mission, tough ethics policies and questions of whether or not they represent the best interest of surgeons, one has to note their standing shoulder-to-shoulder with board member and spine surgeon Jeff Wang, M.D., when he came under attack by Senator Chuck Grassley earlier in the year.
We asked Baker about the high profile investigations of spine surgeons David Polly, M.D. and Wang and the roles of societies in standing up for their members.
Regarding Polly, who resigned from the board of AAOS, Baker said, “That was a much more pressing issue for them. I know that we have taken the tact with Jeff Wang that we’re going to stand by Jeff, and he has always complied with NASS’ disclosure policies. We’ve talked with him and said that we can await the final verdict of the independent investigation."
While innovation may be at a standstill in the U.S. and Ray Baker and his society may have a perilous walk across the bridge to the “Intel Era of Spine Care, ” no one will be able to say it wasn’t with eyes wide open.
Ultimately spine care professionals will decide with their membership dollars who best represents their interests. For now, the leadership at NASS is confident that their decisions and actions will help reignite innovation in spine.