Hello, everyone. This is Erica Spicer Mason with
Becker's Healthcare. Thank you so much for tuning
into the Becker's Healthcare podcast series.
I'm pleased to be joined today by April
Spillane, vice president of health economics at Barricade.
April's here to talk to us today about
some reimbursement
challenges and opportunities
in the spinal procedure space.
April, welcome to the podcast, and thank you
again for joining us.
Thank you. Good morning. Nice to be here.
We're thrilled to have you with us. And
before we get into our discussion,
wondering if you can tell our listeners a
little bit about Barricade. I know it's a
new technology that sounds like it's set up
to help a lot of people. So,
whatever you feel is important to share with
our listeners, I think, would be really helpful.
Yes. I am the vice president
of health economics at Intrinsic Therapeutics.
Intrinsic
Therapeutics manufactures
the Barricade device.
It's a bone anchored annular closure device. And,
essentially,
what it's used for is we close the
hole
after a discectomy.
There is a subset
of patients who have a large hole, and
they're at significantly higher risk of re herniating.
So the surgeon is able to
measure,
verify if they're high risk or low risk.
And if they're high risk, we anchor into
the bone, plug that hole and prevent
the risk of a second operation,
which is fantastic
because it really eliminates this downstream effect of
multiple surgeries,
whether that be multiple discectomies and then fusion
or just going from discectomy to fusion.
Yeah. April, thanks so much for sharing more
about your background. It sounds like you're bringing
really great experience.
I wanna also touch on something you said,
and that's kind of this idea that you
essentially oversee
all all things reimbursement for an emerging technology.
So would love to know a little bit
more about what draws you to this, and
also what problem are you trying to solve
in this work?
Yeah. I think specifically
at Intrinsic,
you know, it's really the patients, you know,
the patients and the providers
that probably make you get out of bed
and and do this every single day.
You know, in my job, we cover everything
from coding coverage payment, but also the authorization
process, and we work with physician practices
and patients.
We have a rare
scenario
where
we hear from patients and providers about
when patients actually don't get the right treatment
and what that journey is like to and
how long it takes to be able to
get the correct treatment.
So, you know, for a barricade patient,
these patients are discectomies.
They're done all day every day, but there's
a subset of discectomy patients that are at
high risk of reherniation,
and it's really devastating
when they reherniate.
I mean, just some of the stories
done where we've met with payers,
and we've had patients that didn't get access
to the treatment.
They reherniate.
They end up having a huge fusion.
Fast forward, 6 more months down the road,
you know, an an additional surgery.
And, you know, some of these patients are
just middle aged moms like myself, and they're
out of work for 18 months. And so
when you hear these stories over and over
and over again, it really
empowers
you to
get a solution and fix. And I think
every patient has the right to
the best treatment, and they have the right
to be educated
on the various treatment options there are for
their disease state.
Yeah. April, you're highlighting something so important, which
is all of these consequences of potentially delayed
surgeries or treatments and how that can affect
patients in the long run. I know it
has an impact on businesses as well, so
appreciate how you you outlined those issues.
And I know that another trend we're seeing
is certainly an increase in spine procedures in
general.
In fact, I know that over the last
decade, the total number of outpatient spine procedures
rose by a staggering
193%.
So can you share with our listeners what
you're seeing as the driving factors behind that
shift and the impact that you think it
will have in the year to come?
Yeah. The way I visualize it is I
think there's pre and post COVID.
So like I said, I've spent probably the
last 15 years in outpatient,
and specifically the last 10 in spine.
You know, I think pre COVID, you had
a lot of high recuity cases
in the musculoskeletal
and orthopedic space that were transitioning
safely and effectively
into
the outpatient setting. You started to
see patients
a lot more
engaged in out of pocket expenses.
And then you also saw
Medicare's ASC eligible list start expanding.
So I think that that was kind of
the catalyst, and we were already seeing spine
start to transition
outpatient
pre COVID.
Then COVID hit and it really just kind
of expedited the shift. In my opinion, I
was working for
a spine manufacturer at the time. I remember
it vividly, you know, the world really shut
shut down, and we didn't have
access to ORs in the hospital setting.
And so whether you were a player in
the ASC space or not, a lot of
patients and providers shifted their cases there. And
I think once it was
done safely and once there was reimbursement in
place
and the operational flow kind of
stuck over a period of time,
it really just expedited the shift. So I
think, you know, payers, providers, facilities, everyone's kind
of rolled up their sleeves
and learned to,
manage spine procedures in the outpatient setting. And
the key factors you need is you need
it to be clinically safe,
and you need it to be reimbursed and
cost effective.
Yeah. Thanks so much, April. And I I
think you've already started to touch on something
that I was curious to know a bit
more about. So you're talking about the shift
of discectomy
surgeries from inpatient to outpatient, and,
you know, you're acknowledging that ASCs need to
be equipped to handle those cases, and there
may be some benefits like faster room turnover.
Just curious if you can elaborate a bit
more on your view of that shift in
general. Do you think this is a good
thing?
Yeah. I think it's a good thing. I
think,
you know, years ago,
maybe we didn't have the appropriate staff, equipment,
infrastructure
to handle,
spine procedures,
but that's
that doesn't seem to be the norm now.
I think a lot of outpatient centers,
are equipped to handle spine, and they've got
the appropriate
staff and equipment in place.
And then, you know,
making sure
reimbursement
is a viable option as well.
So I think you've seen a lot of
ambulatory surgery centers start to either proactively on
their own or through a consulting firm
work on their managed care contracts with payers
so that they can afford
to do the spine procedures.
That combination
of factors makes it a very viable procedure.
I think the out of pocket expenses
are in the best interest of the patient.
It's a little cheaper.
And I I just think it's, overall a
good thing.
And I think it's just kind of organically
happening. We've really, really seen discectomy,
almost completely shift outpatient at this point.
Mhmm.
Yeah. Fascinating.
And you you touched on how reimbursement
challenges are are top of mind for ASCs
and spine leaders as the as the shift
is progressing. So
aside from I I think you had mentioned
that some ASCs are proactively or even on
their own working on managed care contracts so
they can, of course, afford the procedures.
Are there any other trends or opportunities
regarding reimbursement that you're watching here?
Yeah. I think the facilities can negotiate and
work proactively
on the payment side and the contracting side.
You know, the part that I'm I'm really
monitoring and that I'd like to see
get a little better is the policy side.
You know, I think I'm curious to watch
kind of the checks and balances between the
commercial payers and
kind of the
government over overseeing,
things in the commercial space.
You know, it's been an interesting few years
you've really seen,
prior authorization kinda go away. I think people
have
pros and cons to that depending on which
side of the aisle you're on.
And then we've really seen kind of
medical
policy
change to where,
you know, some commercial payers are, you know,
writing policy on their own, others are outsourcing
it. And so that's become
a little vague as well.
And I think just the combination of those
two things, it's become,
I would say, more risk for patients and
providers or it feels riskier
to move forward with new
they end up having
to either get paid or appeal on the
back end. So I've I've I think that
that conundrum is gonna be interesting to watch
over the next couple of years in how
we're gonna handle it in health care.
Mhmm. Yeah. Appreciate you sharing that with our
listeners, April.
And kind of in the same vein, I
know oftentimes when we talk about reimbursement,
codes come into the conversation as well. So
are there any
new medical codes that you think are important
regarding
discectomy is that you think our listeners should
know about, especially as they might impact financial
viability and and patient care more broadly?
You know, I think there's been kind of
coding in place for standard discectomy.
I can speak to the Barricade procedure.
We were fortunate
to have a procedure code assigned by Medicare
so that facilities have a code to bill
for the procedure.
We also have ICD 10 codes to
to really report annular defect size, which is
is really what's needed,
to and required to meet medical necessity.
And then the societies,
have been working to,
get a a new CPT code in place,
and we anticipate that that's gonna go into
effect in 2026.
So that's kind of been a major
milestone
as well,
for our procedure, which again, complements,
your traditional discectomy. This is just for patients
who are at higher risk with a large
defect.
Yeah. Absolutely.
I I think it's it's great to learn
more about kind of some of these milestones
that you're seeing,
especially just to help better set the stage
and better equip ASCs for handling this, you
know, this influx of spinal procedures.
This has been so helpful.
I mentioned that I mentioned that CMS created
a procedure code for this the work of
the discectomy and implanting,
a bone anchored angular closure device.
So that's kind of opened the gates for
both Medicare and the commercial payers to be
able to have a code to reimburse facilities
right now.
And then we've got the ICD 10 codes
to report medical necessity based on the defect
size.
Some of the other things that we've done
internally,
we have a patient journey program,
which actually
supports practices and patients through the authorization
and appeals process.
We do a lot of front end and
back end education to facilities
to make sure that
they are educated
on the coding and reimbursement, and we actually
follow-up and offer
the option,
to verify that payment
is in place or if an appeal is
needed. We have that as well. And then
we've implemented
a risk sharing model as well for our
facilities,
which again, kinda coincides with those other 2
programs.
And I think what that's done is allow
facilities and patients and providers,
to move forward with the surgery,
give the patient
the appropriate treatment,
and, it really just mitigates the the financial
risk.
So just I guess I'd like to hear
more from you, April, to close out our
conversation.
Anything else in regards to Barricade and innovation
in your work that you're excited about and
that you think will really make a difference
at ASCs,
in the years to come?
Yeah. I think in 2025
is gonna be unique here. You know, we
worked pretty diligently
with the team at CMS
about
just a a reporting concern with c codes.
They looked into this in the final rule.
They did modify,
and put a new policy in place. And
so,
you know, we're gonna see not just to
BARRICADE, but overall that hospitals are required to
report
a device,
when it's a device intensive
procedure.
How that pertains to BARRICADE is we had
lost device intensive status
because of inadvertent misreporting, and now we've regained
it. And that, has really correlated to about
a $3,000
increase in the ASC setting.
What that does is it opens the door
for beneficiary
access,
in the Medicare patient population
for the BERICADE procedure,
which is fantastic. You know, patients and facilities
who wanna do this procedure can do it.
They can afford to do it. It's more
cost effective.
And, I think that that's a big game
changer for surgery centers. They're already doing discectomies.
They can now offer Barricade. They can afford
to offer it,
and the reimbursement increase is makes this a
very viable opportunity for them. And then as
we all know,
many commercial payers kind of follow suit or
have their own formulary for payment based off
of Medicare.
So I think it's a great time for
surgery centers who are interested in this technology
to take it. I also think, you know,
BARRICADE certainly fills an unmet clinical need for
large defect patients,
and it's very marketable.
Patients are smart. They research. They wanna know
the pros, the cons, the risks of any
type of procedure. And so for those that
are indicated
and would need this as a treatment option,
this is a great thing for surgery centers
to market
to their patients.
Yeah. April, thank you so much for for
sharing your insights today. It sounds like there's
a lot of exciting opportunities for ASCs on
the horizon
when it comes to discectomies
and especially,
for patient access. As you mentioned, opening up
more procedures and opportunities for Medicare members,
certainly essential,
in the years ahead. So thank you again
for for your time and your insights today.
Thank you for having me.
And we'd also like to thank
for sponsoring today's episode.
Listeners, you can tune into more podcasts from
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