As of January 1, I will be stepping down as SpineLine’s Editor-in-Chief. Hence, this is my last EIC message. Aside from thanking the remarkably talented editorial and production staff, and welcoming an outstanding new EIC, I would like to share some thoughts of what I perceive to be the three biggest challenges to the art and science of spine care.

I have attempted to draw attention to these topics in some of my previous EIC messages, but would like to (briefly) reiterate them.

In a Message From the Desk of The President in 20171, I somewhat uncharitably, if deservedly, characterize the RVU as Really Very Useless. Unfortunately, this out-moded reimbursement metric continues to be of remarkably little value. While the concept of the RVU is, arguably, sound, the practical implications of administering it are not.

There are many factors contributing to issues with affixing effort, and in a quantitative sense, to a particular professional activity. Arguably, the greatest are bias, and conflict of interest (COI). The first actions of the American Medical Association (AMA) after the Center for Medicare and Medicaid services (CMS) approved RVU scales, was to create the RVU Update Committee (RUC). This 32-member committee, theoretically, unbiased, was to recommend RVUs updates to CMS.

However, practicing clinicians on the panel were directly affected by their decisions, resulting in an inherent COI.2 With the downward pressure on reimbursement, effectively creating a Zero Sum game, the implications of this unequitable determination of “fair, objective” reimbursement are clear.

This Zero Sum environment has resulted into “incentives exaggeration”3 which translates to fee-for-service, quantity over quality, increasing costs, and decreasing value. Additionally, the initial proposal for RVU had three components.

The first, the work RVU, is the one currently in use. The second component addressed resources consumed, while the third component addressed risk. Clearly, the removal of the second and third components places specialists, such as spine specialists, at a remarkable disadvantage for under evaluating the RVU multipliers, particularly for complex cases.

To expect a sound concept, which the RVU is, to ever be administered in a balanced manner is, given the nature and inequity of our health care system, currently an unrealistic expectation. Perhaps the answer is in timelier reviews with increased diversity, especially specialties on review boards, or, perhaps, reconsidering a critical look at value-based care.

Again, the concept of the patient satisfaction survey is reasonable. In practice, however, the instrument used to gauge patient satisfaction and the impact of these data on physicians are unreasonable.

Measuring performance is particularly difficult, especially based on surveys and performance reviews; short-term performance indicators have been noted to induce fear and defeat teamwork.4 All survey tools rely heavily on non-medical data (eg, parking, convenience, punctuality) and all influence practitioner and institution reimbursement.

The National Commission of Quality Healthcare (NCQH) requires all health care institutions to conduct both inpatient and outpatient surveys. One of the key questions is whether or not the metrics used to assess clinical care and improve patient experience actually reflect clinical performance. In most cases, they do not: patient satisfaction scores do not necessarily equate with good, or even appropriate care.

As expected, higher satisfaction ratings also are associated with higher health care costs, “ordering the test the patient thinks they need.”5,6 Clearly, the current survey tools need to be drastically revised, focusing on quality of care and health care outcomes. Patient experience, while important, should really be looked at in a completely different light, as perhaps a tool to guide improvement in environment and amenities, not to guide reimbursement while ignoring quality and driving up costs.

In this issue, in the Invited Review, McMillan et al examine the occurrence rates of Surgical Site Infections, pre and post the COVID-19 pandemic. This is a very interesting and insightful work, is timely, and really quite overdue. Alphonso and Grauer answer a question that has long been asked in their Literature Review, as the authors address the necessity of wound drainage after anterior cervical discectomy and fusion. Tekmyster and colleagues provide a detailed and insightful assessment of preoperative and preprocedural risk assessment and, critically, discussed mitigation strategies, in their Patient Safety article.

The results of our September and October Ethics Poll and responses are summarized by Dr. Stadlan, and a new question is proposed for November/December: If a colleague is providing substandard care or inappropriate billing, what would you do?

The News Section is robust, as always, with a number of events related to the Annual Meeting.

This issue also includes an obituary of the late Dr. Jerome Schofferman. Jerome was a mainstay of NASS, particularly in professional conduct and ethics for many years. Aside from a wonderful working relationship, I certainly counted Jerome as a friend and miss him very much, indeed.

Finally, it has been my deepest privilege to work with the gifted, intelligent, and insightful individuals involved in the production of SpineLine. Jeff Karzen, Kelly Campbell, and Pam Towne have made the life of the editorial staff incredibly easy, soliciting ideas for publications, facilitating reviews, and producing the final product seamlessly. Additionally, our production designer, Jessica Vander Naald, has been absolutely invaluable.

Three of these four individuals have no character flaws of which I am aware. Jeff Karzen does, however. He is a White Sox fan. For this, he has my deepest sympathy.

This is my 35th message from the EIC.

I have really enjoyed this.

Enjoy Denver. Please, also, continue to enjoy SpineLine.