The coming year for NASS

Christopher Bono

Christopher Bono (Brigham and Women’s Hospital, Boston, USA) has been appointed as North American Spine Society (NASS) president for 2015-16. He talks to Spinal News International about his involvement in the society’s ongoing projects, collaborations with other societies, and where he thinks the future lies for the field of spinal medicine.

What are your goals for the next year as NASS president?

My main goal is collaboration. I want to move past contentious issues that NASS has been involved with. My primary goal is really to start collaborating as much as we can with other spinal societies, and in other countries—which we are doing on a continual basis. The society has these terrific projects that it is working on—the Registry, the Foundation and the coverage policy recommendations with which I was intimately involved. Those do not need to be changed or reinvented; they need to be supported and they need to continue and they need to grow.

How would NASS benefit from this greater collaboration?

I think that, primarily, it would be in US health insurance coverage decisions, because that is first and foremost in so many people’s minds. It is a big problem for practitioners, for spine surgeons, for medical device companies and for all the societies. For better or for worse, NASS probably has the greatest voice. We have spent years developing credibility with insurance companies and the government, and that has given us the ability to gain their ear, and they are listening to us. We are following a methodology, we are following evidence-based medicine, we are following the rules that someone else has made—and we are trying to maximise the support for things that should be supported. We need everybody to coalesce on that. I would love to see other societies be involved with more of our coverage recommendations work.

With respect to collaboration on NASS’ clinical guidelines, we have a guideline in the development stage right now on lower back pain that involves multiple other societies. Involving other societies makes projects like this harder to organise, but it is absolutely more powerful in the end. When you can look back and say, “well, here is a statement—and  it is not just from NASS but NASS co-ordinating with all these other societies”—who are you going to argue with? We have unified everybody altogether.

Why can it be difficult for multiple societies to agree on these kinds of collaboration?

Societies risk losing their credibility; our decisions have to be justified. So, let us start at a point where we can actually make a difference, and nudge the needle. The needle does not move in extremes, it has to move a little bit, and then a little bit more and a little bit more.

What I have tried to do within the different activities is get representatives involved from those societies, and I think that really that is the key.

Do you think that that insurance coverage is the biggest issue facing the field of spinal medicine?

I think right now it is probably the number one thing. We have a lot of government mandates right now, with electronic medical records, and outcomes reporting—these are basically hoops that you have to jump through. We have very little control over it; you comply, or you do not, and if you do not, you will be penalised. We can’t affect that mechanism. Coverage is something that we can directly influence, and it’s the end of the road in determining whether or not a treatment can be done.

Insurance companies hold all the power, because they are the money. They say “yes” or “no”, they approve or don’t approve. You can get to the point where you can get FDA approval, you can even get a code but if you cannot have insurance coverage then you’re done for a new implant or device.

When and if we universally adopt these so-called ACO (accountable care organisation)-type systems it may not be the insurance company at all who decides anymore, because then they are going to give a lump sum to an organisation, and then the hospital—the ACO—is going to determine how it is spent. So, we’ll either have to prove it to the insurance companies so they should cover it, or we’re going to have to prove it to ourselves that this is a worthwhile procedure; that it is making patients better, and that’s why you should cover it. It is not even coverage; it is just “that is why we should be able to do the procedure.”

It is not done yet, but, as of right now, it is really the number one issue that’s facing spine surgeons.

It seems that NASS is really making an effort to increase the voice of the spinal medical community. Do you see that happening?

It is looking positive – I think that we have seen nothing but an increase in voice for NASS, and people are listening. The Foundation is in its infancy, so we’re not going to know about that for another five years. But the trajectory right now is upwards. And, the mechanics of the organisation is all about publicity—to get the word out and to have public service announcements and have people know about what this foundation is doing, and thus NASS.

The various other activities—the Registry, for example—that is a little bit more behind the scenes but it will be fulfilling a need that the members are going to have very soon, when there’s a mandate to collect outcomes on your patients.

That our voice is being heard is evident in that medical device companies are now asking, “When are you going to have a published coverage policy recommendation about this? Can you modify this coverage policy recommendations based on some new literature?” And the answer will be “yes” or “no”.

All of these things mean, directly or indirectly, that they’re having an effect, and now they want to influence the process. But now the end result to me is that people are listening to these—a member was just telling me that an insurance carrier basically cut and pasted the NASS coverage recommendations for percutaneous sacroiliac joint fusion. I love hearing that. To me that is just the best thing in the world—and I don’t care if he called me because he had a problem with it; that’s fine—but what you just told me was that an insurance company is using it. And that’s terrific. Again, the voice is being heard.

More people are becoming aware of the public health burden of back pain. Do you think that this will correlate with attempts to increase the voice of spine societies?

So the answer to this is yes. But, because the public health burden will only increase, that voice has to be a trustworthy voice. That’s really where NASS has tried to maintain credibility, because that’s the single most important thing.