Orthopedic and spine cases are leaving the hospital for outpatient centers. Will surgeons do the same?
Over the last decade, the number of independent physicians has waned. Surgeons coming out of training faced high costs to start a practice, and coupled with crippling medical school debt, many chose hospital employment.
In many markets, early-career surgeons are still taking that route.
"It's a battle because hospitals want to maintain control and we know that the care delivery model for most spine surgery now is best in the outpatient center," said Hyun Bae, MD, a spine surgeon at Cedars-Sinai in Los Angeles. "Eighty percent of spine surgery can be done in the outpatient setting. Now it's a matter of who controls that."
Similarly, the costs of running private practice increased without a similar jump in reimbursement rates, leading some surgeons to sell their practices and join the local hospital. Surgery centers have been a lifeline for surgeons who wanted to remain independent for years as an extra revenue source, and advanced technology paired with sophisticated pain management protocols have broadened the pool of patients who can safely undergo surgery in the ASC. Spine and orthopedic surgery centers are in high demand, and more new centers are planned for this year.
"The transition of traditional inpatient procedures to the ASC in orthopedics will continue to accelerate," Nikhil Verma, MD, director of the division of sports medicine and sports medicine fellowship at Chicago-based Rush University Medical Center, told Becker's. "As of Jan. 1st, total shoulder arthroplasty is now ASC eligible. With continued improvement in perioperative protocols and surgical techniques, we anticipate continued double-digit growth in our orthopedic ASCs."
The increasing patient flow into the ASC may attract surgeons who are unhappy with their current hospital arrangements, or give hospitals the opportunity to enter into a joint venture ASC with affiliated surgeons Hospitals in some markets are also struggling with capacity issues and moving procedures to ASCs is a must.
"Due to restrictions on operating room space at one of our local hospitals, we are having to be more aggressive with moving cases to our ASC," Ken Rich, MD, president of Raleigh Neurosurgical Clinic, told Becker's. "The first two years, we were very conservative to make sure we didn't have a lot of complications, but we're finding out that we can do more complex things in the ASC safely and comfortably for our patients."
Dr. Rich expects to see a 25% increase in cases at the ASC over the next year. The growth of independent physician practices may foster a more supportive environment for early-career surgeons to remain independent initially and then eventually buy in.
Andrew Lovewell, CEO of The Surgical Center at Columbia (Mo.) Orthopaedic Group, is seeing a similar lift from total shoulder replacements in the Medicare population. Surgeons at his center are planning to bring more of those procedures in, alongside an increased volume of pain procedures based on demand in the market.
"Our growth strategy for our practice and ASC both depend on us recruiting high quality physicians and providers to continue to deliver excellent care in our market," Mr. Lovewell said.
With the limited number of surgeons entering the workforce each year, the new additions will need to come from currently independent surgeons who aren't affiliated with a larger group, or surgeons leaving the hospital setting. Surgeons who have been employed by hospitals previously may also be emboldened to chart a different course in the near future. The federal government is scrutinizing the noncompete clauses in contracts that have kept surgeons employed in the past, and a few states have already banned them.
Choll Kim, MD, PhD, an orthopedic spine surgeon at Excel Spine in San Diego, has been on the forefront of minimally invasive spine surgery techniques for years and sees the outpatient space continuing to grow.
"My outpatient surgery practice will likely remain the same, at approximately 85 percent of all my surgeries. However, my colleagues continue to show great interest in performing more of their surgeries in the outpatient setting. Thus I expect continued, gradual, incremental increases in outpatient spine surgeries at our institution," he said.
Outpatient surgery centers are also poised to thrive as healthcare moves more toward the value-based care model. As the high quality, low cost site of care, some insurers are pushing for more cases in the outpatient setting.
"Growth looks favorable by 3 to 5 percent due to continued payer pressure in the market to perform procedures in the appropriate site of care," said Ronald Bullen, executive director at ProHealth Care Moreland Surgery Center in Waukesha, Wis. "Bigger payers like UHC are incentivizing providers to shift select procedures from hospital outpatient to ASC. Payers have gathered enough historical data now to promote the value of an ASC setting with owner and non-owner providers. Being positioned as a multispecialty ASC allows us the opportunity to capture these growth opportunities."
Reuben Gobezie, MD, founder and director at Gobezie Shoulder Institute at Regen Orthopedics sees this transition as a big boon for independent providers to "aggressively compete against hospital systems for self-insured employer contracts that drive value-based care."
For the moment, he is focused on recruiting private practice physicians into the ASC, with the bulk of the most successful recruitments being from private practice surgeons who had been doing their cases in the hospital moving to established ASCs.
"The reason for this transition by these physicians are often unrelated to decrease in efficiency and availability of OR block times secondary to staff shortages at large hospital systems, as well as the potential to drive more revenue through ASC ownership," Dr. Gobezie said.