More spine procedures are shifting into the outpatient setting as physicians are becoming more comfortable with less invasive procedures. Surgeons are training in minimally invasive technique and performing outpatient procedures during their fellowship, which makes the leap to ambulatory surgery centers easier and more attractive.
There are other factors pushing spine cases outpatient as well; new pain management technology and spine innovation has made the transition possible, and payers are looking for high quality, low cost care settings.
"Everyone is looking to decrease costs for spine procedures, and ASCs receive lower reimbursement than hospital outpatient procedures," says Stephen Hochschuler, MD, co-founder of Texas Back Institute in Plano. "With image intensification such as the O-arm and robotics, people are comfortable doing quality outpatient procedures because they are going to be more percutaneous."
Patients are also ahead of the curve when it comes to outpatient spine surgery. With the internet at their fingertips, patients are seeking out information about back pain and treatment to find the most beneficial care. People are asking for minimally invasive procedures and going to surgeons who perform them at outpatient centers.
"My impression is with some of the new technology, like robotics, outpatient spine surgery becomes much safer," says Dr. Hochschuler. "Additionally, the portable CT scan makes this a different world. Surgeons are getting used to it and it's becoming the paradigm of care. Years ago I decided to do myelograms outpatient and people thought I was crazy. Now everyone does them outpatient. Change is difficult to accept, but younger surgeons are accepting it more."
In addition to the imaging and pain management technology, lateral procedures also make outpatient spine surgery attractive. The lateral approach allows spine surgeons to avoid issues they face going through the abdomen or other traditional approaches.
Here are six key observations on where spine surgery and back pain treatment is headed:
1. Not all patients are a good fit for ASCs. "Start taking the healthy patients to the outpatient surgery center and then take older patients there as you feel more comfortable, if they're a good fit for outpatient surgery," says Dr. Hochschuler. "Begin with injections — nobody needs the hospital for injections. Then expand to laminectomies and discectomies. Whether they are percutaneous or open, that's a fail-safe procedure. Then go to fusions but make sure you have a good vascular surgeon with you if they are anterior fusions."
2. The right expectations can make-or-break an outpatient case. "You have to be very conversant about what outpatient surgery means, what the benefits are and why you want to treat them in the outpatient setting," says Dr. Hochschuler. "Make sure they are truly prepared with the right expectations."
3. Keep an eye on implant costs — they will be coming down. Implant costs are the bulk of overall cost per case, and for years smaller companies and distributors have been offering their specialized products for a discount. Now even the big companies are launching ASC-specific divisions including Johnson & Johnson's DePuy Synthes Select and Smith & Nephew's Syncera. Much like iTunes and Netflix disrupted traditional music and movie industries, device companies with lower cost structures and rep-less models are making a splash in healthcare today and forcing change.
4. Surgery centers run better than hospitals because of surgeon investment. "ASCs are one of the few opportunities surgeons still have to invest, and when surgeons own part of the facility they demand it run better," says Dr. Hochschuler. "At our specialty hospital, which we still have ownership in, we run outcomes tests and ask how patients felt about their stay. The ownership also gives physicians an ancillary source of income."
5. Finding proper alignment will be the next focus in spine care. "Years ago, we weren't as concerned about proper anatomic alignment. We just stabilized the spine," says Dr. Hochschuler. "When you have proper alignment with the lumbar curve, all of a sudden the patient's balance comes back and they're able to do their therapy. These patients can recover more quickly and return home safely."
There is also new technology such as AlignMed’s patented NeuroBand Technology with the Posture Shirt. The shirt is designed to relieve pain, improve balance, increase the range of motion, improve flexibility and increase recovery rate. The technology is working to improve core alignment and thermogenesis.
6. Non-operative solutions like core strengthening, conditioning and bracing will be crucial. "I think we're going to see the adoption of technology that is cheap, to prevent back problems and allow for better outcomes preoperatively and postoperatively," says Dr. Hochschuler. "I have core strengthening and balance for my patients to go through and make sure they have the right posture. The American Heart Association was extremely successful in their prevention campaign, and we should be the same way with back pain."