Trends in Surgical Procedures Performed in Ambulatory Surgery Centers

Q&A with Domagoj Coric, MD, Choll Kim, MD, Gerald Rodts, MD, and Dwight Tyndall, MD

Ambulatory surgery centers appear well-positioned to thrive in the continuing evolving health care industry, with industry experts forecasting strong industry growth in 2017 and continued transition of higher acuity surgical procedures to the outpatient setting.1

To better understand the current and future landscape for ASCs, SpineUniverse spoke with leaders in the field, including Domagoj Coric, MD, Choll Kim, MD, Gerald Rodts, MD, and Dwight Tyndall, MD.
Three surgeons in the operating roomThe consistent growth of minimally invasive spinal surgery techniques will lead to a corresponding gradual increase in spinal procedures performed in the ASC setting.Q: Do you think the spine-driven ASC industry is primed for growth?

Dr. Coric: Yes, the push for cost-effective, outcome-driven spine surgery will result in continued movement into the outpatient ASC setting.

Dr. Kim: The slow, but consistent, growth of minimally invasive spinal surgery techniques will lead to a corresponding gradual increase in spinal procedures performed in the ASC setting. Changes in reimbursement policies also will affect this growth. Currently, the payments for spinal procedures performed at ASCs appear to remain well below that of hospital payments. As the cost of advanced spinal procedures increases, particularly with the introduction of newer technologies, the hospital-based outpatient programs will draw cases away from ASCs.

Dr. Rodts: Yes, the demands of the economy, the Affordable Care Act, the advancement of less-invasive techniques, and decreased reimbursement are but a few of the factors driving the increased number of surgeries performed in the ambulatory setting. There already are a significant number of studies in the published peer-reviewed literature showing increased efficiency, lower cost, and equivalent safety and satisfaction outcomes for procedures performed in the ASC setting, such as single- or multilevel anterior cervical discectomy and fusion (ACDF) surgery, lumbar discectomy, and lumbar fusion.

Dr. Tyndall: All stakeholders (patients, doctors, and insurance companies) are seeing the improved clinical outcomes and cost savings associated with outpatient spine surgery, and are therefore, more comfortable with the concept.

Q: Do you think the complexity or range of spinal procedures performed in ASCs will change in the future?

Dr. Coric: Yes, there will be a continued push of more complex cases into ASCs. This will be driven in large part by the larger trend toward minimally invasive surgery. Anterior cervical fusions, certainly 1- and 2-levels, have become commonplace in ASCs and more and more centers are performing minimally invasive transforaminal lumbar interbody fusion and lateral interbody fusions in ASCs.

Dr. Kim: Currently, microdiscectomy, limited laminectomies, insertion of dorsal column stimulators, and 1- and 2-level ACDFs are commonly performed in the ASC setting. Between 1994 and 2006, Best et al showed that the number of microdiscectomies and laminectomies performed in ASCs increased over five-fold.2 In selected cases, 1- and 2-level minimally invasive lumbar fusions may be performed in the ASC setting, but again the implant cost of such procedures may prohibit its application in the ASC setting, unless significant implant carveouts are established.

Dr. Rodts: Though there is a group of patients with complex spinal problems or significant medical comorbidities who will always need the resources of inpatient surgery, there is no question that the complexity of spinal procedures done in ASCs is already increasing, including multilevel ACDF, anterior cervical vertebrectomies/ fusion, less-invasive lumbar fusion techniques, and less invasive lumbar discectomy or spinal decompression.

Dr. Tyndall: There will be more lumbar fusion as well as minor deformity corrective surgeries being done. That said, larger complex deformity surgeries will most likely remain as inpatient procedures.

Q: What are the pros/cons of performing higher acuity surgical spine procedures at ASCs?

Dr. Coric: Higher acuity cases should only be performed in the ASC setting when the safety of those procedures has been established. The positives of safely performing higher acuity cases in ASCs include higher patient satisfaction and greater health care cost savings.

Dr. Kim: The safety and efficiency of performing higher acuity procedures in the ASC setting will require further study. The results of minimally invasive lumbar fusion in the ASC setting remains promising, but is as yet untested.

Dr. Rodts: The pros from the professional standpoint are increased efficiency, cost-savings, and equivalent outcomes to similar procedures performed in the inpatient setting. The cons include not being able to perform these higher acuity surgical spine procedures in higher risk patients—including those with complex spinal problems, history of previous surgery, severe neurological deficit (eg, the quadriparetic patient), and important medical co-morbidities (eg, heart disease, pulmonary, hypertension, and diabetes)—because subspecialty resources/ physicians are not readily available in the ASC setting. Thus, there will always be a fairly large percentage of patients who will need inpatient care. This is particularly true due to the increasing population of active, elderly patients who want elective surgery for their spine issues.

Dr. Tyndall: These patients often require extended stay and therefore, may be unfit for a short stay facility. One way around this issue is for an ASC to partner with an intermediate stay facility, such as a hotel, to have the patient stay extra days.

Q: Are payor relationships improving? Are there any cases for which collecting payments for procedures performed in ASCs is becoming more difficult?

Dr. Coric: There is an increasing body of evidence demonstrating equivalent surgical outcomes at lower costs in the ASC setting. This fact is increasingly being recognized by payors.

Dr. Kim: The relationship between providers and payors remains impersonal and adversarial. Creating an environment of cooperation will be just as important as creating new technology. If we can show good/equivalent outcomes at reduced cost of care, then we (as providers) have a great opportunity to forge a mutually beneficial working relationship with payors.

Dr. Rodts: Though we do not do spine surgery at Emory in an ASC setting yet, my colleagues who practice in the ambulatory setting say that they are getting more satisfactory contracts from insurers as they have demonstrated greater value in the ASC setting for healthy patients.

Dr. Tyndall: Yes and No. Most payors still do not appreciate this movement to outpatient spine surgery and therefore, are slow to embrace it. The lack of outpatient CPT codes makes it difficult to collect payments in some cases.

Q: How do you think the increased patient financial responsibility, stemming in part from high-deductible health plans, affects ASC operations and volume?

Dr. Coric: As patients become more sophisticated and involved in their healthcare decisions, there will be a continued movement to ASCs. Healthcare delivery in ASCs is generally more patient-centered and cost-effective.

Dr. Kim: Unless there are special carveouts for patient deductibles and copays as it pertains to obtaining services in the ASC vs the hospital setting, increased patient financial responsibility will not likely affect the rate of growth of spinal procedures performed in the ASC setting.

Dr. Rodts: I predict that patients will seek out procedures/surgeries to be done in the ASC setting because they will be able to potentially get them done at a lower overall price and lower deductible. But, whether cost savings are actually passed along to the patients remain to be seen. Current owners and surgeons practicing in ASCs are enjoying higher net collections as they have figured out how to cut costs (inpatient room costs, medication costs, implant costs, and staffing costs).

Dr. Tyndall: Patients need to be educated as to how to use these plans to their full benefit. Likewise, outpatient spine surgery ASCs need to better understand these plans and how to partner with patients to increase value for dollars spent.

Updated on: 02/08/18
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