Spine surgery is increasingly moving into the outpatient setting, which can provide both quality and cost benefits. After the surgeon has learned minimally invasive technique, here are five tips to begin bringing cases into the outpatient setting.
1. Consider vendor contracts. Carefully choose which vendors to form the strongest relationships with as you transition cases into an ASC. There may be five main implant vendors occupying the outpatient spine space, but it would benefit you to trim your preferences down to two. "Create a loyalty to one or two vendors to help with pricing," says Marcus Williamson, president of the spine division of Symbion Health Care. "As you look at the cost of the implants, for you and your patients' out-of-pocket expense, you want to work exclusively with fewer than three vendors for surgical cases.
Vendors can also help introduce spine surgeons into the market. "If they have a cervical fusion product, implant or cement, they can co-brand the device with you, which helps you make an introduction into that market," says Mr. Williamson. There are three types of outside-the-house arenas surgeons focus on as they break through into the market:
• Direct-to-physician — vendors can help coordinate meetings or lab that physicians receive educational credits because vendors have the CEU designation for diagnosing and treating conditions.
• Direct-to-patient — vendors can co-brand the surgeon's name with their marketing materials for direct-to-consumer efforts.
• Direct to health plan — vendors can work with you to present information about procedures and technology used during spine surgery for better coverage and the patient's utilization of benefits in the surgery center setting.
2. Understand how payor contracts impact the center. Surgery centers are increasingly seeking in-network contracts with private payors to ensure long lasting success of the ASC. There are a few steps surgery centers can take to make sure they attract the best contracts available:
• Document outcomes to prove surgery can be successful in an ASC
• Demonstrate strict infection control protocols
• Provide your complication rate and risk management protocols
• Show the companies you are meeting clinical and financial benchmarks
• Emphasize cost savings associated with performing cases in the surgery center
"We just had a four-hour tour with a major private payor to go through our protocols and records," says Robert S. Bray, Jr., MD, neurosurgeon and CEO of DISC Sports & Spine Center in Marina del Rey, Calif. "The company's representative decided they wanted to work with us. It's this type of detail that has to be developed because that's where the future of surgery lies. We are raising the bar for surgery centers so there's no question these high acuity cases can be performed here."
3. Patient selection. Selecting the appropriate patient for spine surgery in the ASC is crucial for optimizing your success rate. Patients who have comorbidities, such as cardiac problems, shouldn't be brought to the ASC. Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco, also steers patients with a body mass index of more than 30 or a significant dependence on pain medication (taking more than eight narcotics per day) to the hospital setting. These patients are at a higher risk for complications, so it's too risky to perform their surgeries in an ASC.
"For every case it is different, but as a rule I tend to have lower risk patients for outpatient spine surgeries," says Dr. Naraghi. "An important part of that is pain management for the patient. If the patient has a high pain management requirement, I would be very careful about doing those procedures as outpatient procedures because controlling the pain is going to be hard."
4. Training ASC staff. Spine surgery is a different type of procedure than most procedures performed in the ASC, and surgeons must make sure the staff members are experienced and prepared to work with them. Even after you begin bringing spine cases to the ASC, you must train your staff on each new type of procedure before performing the case. Dr. Naraghi holds an in-service day at his ASC before bringing a new procedure to the facility so the staff will understand the different components of the surgery.
"It's common to have an in-service and ask the device company to bring in the equipment for the procedure so you can do a dry run and make sure everyone understands what will happen when the patient arrives," he says. "When a new procedure starts in the ASC, you might be missing something and that could mean the case might not go smoothly. Have a checklist for the procedure and make sure the components can adapt to the ASC. Once you start ahead of time, you can find the kinks and it isn't an issue; but if problems occur during the actual surgery, it could be a major complication."
For example, if a wrong-sized cannula is pulled for the case and the surgical team doesn't realize it until the surgery has begun, finding the appropriately sized cannula will take time and the patient will most likely need admittance to the hospital.
5. Schedule cases early in the day. Spine cases scheduled late in the day can have a negative effect on staffing costs. "Schedule cases early in the day to give the patient additional time to recover if they are same day cases," says Ken Pettine, MD, co-founder of Colorado's Rocky Mountain Associates in Orthopedic Medicine in Loveland, Colo. "[That way], they do not require an overnight stay, [meaning] you have to call in a night shift." If you schedule spine cases early in the day, surgeons will still be able to complete a case that becomes unexpectedly difficult.
More Articles on Spine Surgery:
100 Hospitals With Great Neurosurgery & Spine Programs
6 Factors for Positive Employee Culture at Spine Groups
Innovative Trends in Spine Surgery Technology: Q&A With Dr. Lawrence Dickinson
1. Consider vendor contracts. Carefully choose which vendors to form the strongest relationships with as you transition cases into an ASC. There may be five main implant vendors occupying the outpatient spine space, but it would benefit you to trim your preferences down to two. "Create a loyalty to one or two vendors to help with pricing," says Marcus Williamson, president of the spine division of Symbion Health Care. "As you look at the cost of the implants, for you and your patients' out-of-pocket expense, you want to work exclusively with fewer than three vendors for surgical cases.
Vendors can also help introduce spine surgeons into the market. "If they have a cervical fusion product, implant or cement, they can co-brand the device with you, which helps you make an introduction into that market," says Mr. Williamson. There are three types of outside-the-house arenas surgeons focus on as they break through into the market:
• Direct-to-physician — vendors can help coordinate meetings or lab that physicians receive educational credits because vendors have the CEU designation for diagnosing and treating conditions.
• Direct-to-patient — vendors can co-brand the surgeon's name with their marketing materials for direct-to-consumer efforts.
• Direct to health plan — vendors can work with you to present information about procedures and technology used during spine surgery for better coverage and the patient's utilization of benefits in the surgery center setting.
2. Understand how payor contracts impact the center. Surgery centers are increasingly seeking in-network contracts with private payors to ensure long lasting success of the ASC. There are a few steps surgery centers can take to make sure they attract the best contracts available:
• Document outcomes to prove surgery can be successful in an ASC
• Demonstrate strict infection control protocols
• Provide your complication rate and risk management protocols
• Show the companies you are meeting clinical and financial benchmarks
• Emphasize cost savings associated with performing cases in the surgery center
"We just had a four-hour tour with a major private payor to go through our protocols and records," says Robert S. Bray, Jr., MD, neurosurgeon and CEO of DISC Sports & Spine Center in Marina del Rey, Calif. "The company's representative decided they wanted to work with us. It's this type of detail that has to be developed because that's where the future of surgery lies. We are raising the bar for surgery centers so there's no question these high acuity cases can be performed here."
3. Patient selection. Selecting the appropriate patient for spine surgery in the ASC is crucial for optimizing your success rate. Patients who have comorbidities, such as cardiac problems, shouldn't be brought to the ASC. Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco, also steers patients with a body mass index of more than 30 or a significant dependence on pain medication (taking more than eight narcotics per day) to the hospital setting. These patients are at a higher risk for complications, so it's too risky to perform their surgeries in an ASC.
"For every case it is different, but as a rule I tend to have lower risk patients for outpatient spine surgeries," says Dr. Naraghi. "An important part of that is pain management for the patient. If the patient has a high pain management requirement, I would be very careful about doing those procedures as outpatient procedures because controlling the pain is going to be hard."
4. Training ASC staff. Spine surgery is a different type of procedure than most procedures performed in the ASC, and surgeons must make sure the staff members are experienced and prepared to work with them. Even after you begin bringing spine cases to the ASC, you must train your staff on each new type of procedure before performing the case. Dr. Naraghi holds an in-service day at his ASC before bringing a new procedure to the facility so the staff will understand the different components of the surgery.
"It's common to have an in-service and ask the device company to bring in the equipment for the procedure so you can do a dry run and make sure everyone understands what will happen when the patient arrives," he says. "When a new procedure starts in the ASC, you might be missing something and that could mean the case might not go smoothly. Have a checklist for the procedure and make sure the components can adapt to the ASC. Once you start ahead of time, you can find the kinks and it isn't an issue; but if problems occur during the actual surgery, it could be a major complication."
For example, if a wrong-sized cannula is pulled for the case and the surgical team doesn't realize it until the surgery has begun, finding the appropriately sized cannula will take time and the patient will most likely need admittance to the hospital.
5. Schedule cases early in the day. Spine cases scheduled late in the day can have a negative effect on staffing costs. "Schedule cases early in the day to give the patient additional time to recover if they are same day cases," says Ken Pettine, MD, co-founder of Colorado's Rocky Mountain Associates in Orthopedic Medicine in Loveland, Colo. "[That way], they do not require an overnight stay, [meaning] you have to call in a night shift." If you schedule spine cases early in the day, surgeons will still be able to complete a case that becomes unexpectedly difficult.
More Articles on Spine Surgery:
100 Hospitals With Great Neurosurgery & Spine Programs
6 Factors for Positive Employee Culture at Spine Groups
Innovative Trends in Spine Surgery Technology: Q&A With Dr. Lawrence Dickinson