Safety measures, protocols and advanced technology make it possible for more spine procedures to be performed at ASCs, outside of the traditional hospital setting. While outpatient migration is widely touted by surgeons as a positive trend, it is not without its challenges.
Six spine surgeons discuss outpatient migration and hurdles involving value-based care, billing and site-of-care decision-making:
Note: Responses are lightly edited for style and clarity.
Frank Phillips, MD. Rush University Medical Center (Chicago): I've done lumbar fusions for a number of years in the surgery center, but I think [outpatient growth] has been fairly slow in spine surgery compared to sports and other areas of orthopedics. The COVID situation is accelerating that. I think it's a combination of it being more efficient, and hospitals having to deal with COVID. There's also a real patient fear about going into 'COVID hospitals' for elective surgery. The surgery centers are a good out for both the surgeon and the patient, and we've had no pushback from patients coming to the ASC, but have had people nervous going to the hospital. I think this has got to accelerate spine ASC surgery.
Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): The original value-based programs were started by CMS in renal disease, hospital purchasing and readmission, reduction of hospital-acquired conditions and developing of a physician value modifier. Benchmarking to these standards is important to the outpatient ASC world, particularly for spine and other high-acuity cases, but the model of implementation still needs to be developed. It centers on careful and accurate data collection; benchmarking against known hospital standards (while showing the ASC model exceeds these); diligent case costing and pricing transparency; and linking this to quality markers and outcomes analysis. Most important, it's reducing this to a digestible model that the patients can understand. The ASC model is set to develop and push forward the limits of new, value-based models. It is up to us to document the information and provide it to the payers and patients in a meaningful package.
Another issue is that in some payers or plans, there is no pre-authorization required for the same surgery if it is being done in the ASC versus in the hospital. However, many ASCs and surgeons won't take the risk as they might not get paid for the service.
Kern Singh, MD. Midwest Orthopaedics at Rush (Chicago): If you're not doing outpatient spine surgery right now, you're behind, and if you're doing it now, you're behind in five years. The evolution of it is only beneficial for the patient and the healthcare system alone. Delivering cost-efficient, high-quality care and high-quality outcomes for patients is here, and I think what it has done is it changed the playing field. It's allowed surgeons to continue to maintain their autonomy independent from large healthcare systems or hospitals. Acquisitions allow them to deliver the care to the patients that are demanding a higher level of service, a higher level of return to function.
How does it evolve? I think that the market share is still very small, but I think it's continuing to grow. It's dominated by so many market pressures that it's inevitable. At the end of the day, what it really does, no matter how much it changes, is it places the surgeon back in command. They're the gatekeeper to the patient, and I think it allows them to continue in an autonomous fashion where they can continue to deliver high-quality care that they can control. I think that is most important. Oftentimes, the challenges we face in healthcare as physicians and clinician extenders, is that we may be dictated about what we can or can't do in large healthcare systems.
David Essig, MD. Northwell Health (Great Neck, N.Y.): While spine surgeries typically represent around a quarter of orthopedic surgeries, they do represent nearly half the profits in many instances. Some of the challenges with regards to billing will involve the preauthorization process. However, with some of the updated CMS rules, preauthorization is not needed for certain codes. Other challenges involve cost-sharing agreements with major carriers. Whether these involve bundled payment agreements or other episodic care agreements will depend upon the strengths and resources of the outpatient centers.
Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): Spine surgeries, beyond interventional procedures, are now migrating to the ASC setting of care. In the past several years, Medicare has allowed more procedures, not only simple decompressions but also fusion surgery, in the outpatient or ASC setting. Many spine surgeons utilized minimally invasive techniques and got great outcomes similar to when the surgery was done in the hospital setting.
Coding standards that are primarily designed for Medicare complicate the coding pathways that must be adopted into outpatient/private payer contracts. Differing payment methodologies for outpatient and ASC facilities require that surgeons and facilities communicate and provide relevant coding pathways for services and devices they use in more complex spine surgeries.
Sigurd Berven, MD. University of California San Francisco Health: Ambulatory care surgery offers significant cost and efficiency advantages compared with traditional hospital-based care. The important priority in developing ASCs is to keep the patient centered in decision making. There is a significant risk of moral hazard in ambulatory surgery where there is a disassociation of risk and benefit regarding the parties of patient and provider. Keeping the patient centered and prioritized in decisions regarding care needs to guide how we choose the appropriate cases for ASCs.