Historically, only 5% of health care spending has been allocated to primary care. This number is much higher–14%–in comparable high-income countries.1 In the current climate, poor reimbursement results in efforts to increase practice efficiency by spending less time with patients, less time on nonbillable activities, and providing less care.

In our rural health care network here in upstate New York, many primary care practitioners actually see a patient face-to-face only once per year–usually during the annual physical–with frequent calls, and occasional telehealth visits for other problems. This results in a disproportionately poor quality of referrals, at least for spine practitioners. A common scenario is where the patient calls with a flare-up of acute or subacute back pain, for which the primary will perhaps order a muscle relaxant and an X-ray followed by a direct referral to orthopedics, without prior reasonable evidence-based care.

I recently looked at one of my clinics and, in a typical morning, 12 new patients were referred. Ten of these came from primary care and seven of them (70%) had absolutely no evaluation, treatment, or imaging prior to specialty referral. To state that this is an incredible waste of time and resources is obvious.

The spine specialist really finds themselves in the position of providing primary care for low back pain–ordering physical therapy and anti-inflammatories, which could easily have been done by the primary care practitioner. In over 30 years of practice, I have been unsuccessful in alleviating this pattern of inadequate care, despite dinners, seminars, and webinars for which people are paid and frequent grand rounds appearances. Typically the referrals will improve for about 12 months but then revert to their prior level of quality.

Perhaps the issue is not education but compensation. Shah et al2, noted that the underinvestment, driven by low reimbursement for primary care services, as well as associated administrative work, has resulted in lower access rates, less likelihood of patients establishing relationships with primary care practitioners, and “soaring” waiting times. One would naturally expect this to have a profound effect on care delivery with increasing expenses accrued through earlier referral to specialty care, increased rates of advanced imaging or hospitalization associated with specialty care, and decreased patient satisfaction.

The Center for Medicare and Medicaid Services (CMS) is attempting to address this with programs such as Medicare Shared Savings program (MSSP), and accountable care organizations (ACOs). Thus far, these have led to little savings for CMS and no increase in primary care visits.3-4 A new prospective payment model, the ACO primary care (ACO PC) Flex model will institute a prospective, as opposed to a retrospective payment model, adjust the reimbursement rates, and hopefully increase participant eligibility.

The prospective payments are of particular interest as they would be monthly population-based payments.5 One of the hypothetical benefits of this approach is that primary care practices can use funds to engage specialists in value-based contracts. These payments would be based on county averages with less affluent counties receiving a further increase in payment. Additionally, a one-time start up advanced payment of $250,000 will be offered.6

Initially, ACO PC Flex will be available only to “low revenue” ACOs, which are about one-third of existing ACOs and generally are smaller groups.1 In addition, CMS has specified that the prospective payments may be used for expanding the workforce and replace fee-for-service revenue. It prohibits funding for ACO executive compensation and payments to ACO management companies.

Clearly, CMS will have to evaluate how the ACO PC Flex prospective payment system influences specific outcome measures, both economic and medical. Should the program prove successful, it likely would be expanded to high revenue ACOs as well, which could further increase access and quality. From the point of view of this spine practitioner, hopefully this will lead to an increase in appropriately evaluated, imaged, and initially treated patients prior to referral.

In several models throughout the country, this has been shown to increase practitioner satisfaction, both primary and specialist, as well as patient satisfaction. Hopefully, these are benefits that all of us will realize.

In this issue, Dr. Scott Kreiner provides an insightful summary plummeting reimbursements and suggests steps we can all take to try to reverse this most distressing trend. This is definitely a must-read.

In the Invited Review section, Lewandowski et al, discuss follow-up in clinical trials, concentrating on short-term assessments, which the authors feel are more agile in rapidly innovative environments. This is quite interesting, as the minimum follow-up standard of 2 years, which has been in place for quite a while, probably does deserve a rethink at this point.

In the Literature Review, Pappajohn and Grauer discussed inpatient versus outpatient laminotomies, for lumbar disc prolapse, and in the Section Spotlight, Margetis et al, offer a comprehensive and insightful review of spinal cord injury guidelines. Finally, Dale Blaser discusses the 2025 AMA National Advocacy Conference in the Advocacy section.

As usual, NASS News is packed full of great information, including anniversary coverage, international humanitarian issues, new books, and surveys. Please enjoy.