by Elizabeth Hofheinz, M.P.H., M.Ed., July 22, 2019
Continuing with last week’s theme of prudence when it comes to performing spine surgeries in an ASC, we now look at some misconceptions and pitfalls of these ventures.
OSN spoke with Reginald Davis, M.D., a neurosurgeon with The BioSpine Institute in Tampa, Florida, who has some experience with spine ASCs. “It is necessary to address issues such as safety in ASCs as these surgeries are on the rise in these outpatient settings. There is data indicating that between 2003 and 2014, the proportion of lumbar discectomies performed in ASCs rose from 0.7% to 10.6%, while posterior cervical decompression laminotomies (first level) increased from 0%–23.4%.”1
When asked what surgeons might misunderstand about performing spine surgery in an ASC, Dr. Davis, a former assistant professor of neurosurgery at Johns Hopkins in Baltimore, noted, “In their enthusiasm, surgeons may overestimate the potential reimbursement of these procedures in an ASC. First, there is the fundamental issue of whether insurance carriers will authorize a given procedure in an ASC setting. While lumbar spine fusion and spinal cord decompression are covered, there are no guarantees when it comes to something as complex as a lateral lumbar interbody fusion.”
“As for the surgeons, they might assume that the facility fee and reimbursement closely mirror that of the hospital reimbursement, but there are regulations and insurance discounting with ASC. Surgeons might be shocked to learn of this discrepancy.”
Indeed, according to one source, reimbursement for lumbar fusion varies greatly: inpatient: $26,190; hospital outpatient department: $10,617; ASC: $5,070.2
Concerning the in- or out-of-network issue, Dr. Davis notes, “If you are working with an out-of-network contract then you would be reimbursed absent the patient copay. In the event of an out-of-state, out-of-network situation, you receive no reimbursement because you are out of network. While you assumed that the in-network contract would hold, in fact the check goes to the patient. Read the fine print as each contract because things vary from one state to another. An out-of-network ASC versus an out-of-network hospital situation is a different thing altogether.”
From the ground up…
For those considering construction of a spine ASC, logistics can be a hurdle as well, says Dr. Davis. “A spine ASC must be built to specification and conform to state laws. You are required to register a certificate of need, the details of which vary from state to state. Yes, the turnkey aspect of these facilities can be enticing, and ASCs are the darling of the venture capitalists. But staffing the facility is expensive and the cost of continuing operations adds up quickly.”
Ensuring fair play…
“Being an employee of an ASC is difficult unless you are assured sufficient marketing/access to patients. Typically, the surgeon aims to be part owner or have a share in the profits. It comes down to basic contract negotiations. You must possess a deep understanding of the market costs and potential profits. I have seen situations where all the physicians agree to be equal partners, but then trouble arises if profits are extracted based on what you refer. And if there is a fixed portion as far as referrals, then physicians can feel taken advantage of—the point being that you need to ensure that everyone has the same work ethic. Otherwise it will come to: ‘You are doing nothing, and we have to divide the profits evenly with you?!’”
I’m going where?
While the safety of some spine procedures in select patients has been demonstrated in the literature,3,4 “caution” remains the word of the day.
“Surgical planning is always critical, but perhaps even more so in the ASC. Aiming for zero complications within the offices of an ASC requires taking many factors into consideration: the time required for the procedure, anesthesia, equipment, the size of the patient, etc. These are all things that, in the event of an emergency, can be more readily addressed in a hospital environment. You must plan for emergencies by establishing transfer agreements, having someone at the hospital to accept your patient, etc. This essentially represents double time for the staff.”
“As a spine surgeon who performs some procedures in an ASC, when you meet with a patient preoperatively, it is imperative that you are completely transparent and tell them the procedure will take place in an ASC. And if you are a partner or part owner be clear about that as well. The last thing you want is for them to grasp things at the last minute, a la: ‘You mean I’m not going to a hospital?’ or ‘Does my doctor have a conflict of interest?’”
You will want to steer some patients to a hospital, however, says Dr. Davis: “Although technology is ever-evolving, as with any spine procedure, those done within an ASC run the risk of blood loss, significant time under anesthesia, and other issues. In a multilevel instrumented procedure, there is a significant risk of those things happening. These are big operations that involve a lot of scar tissue and various potential medical comorbidities.”
“Once a patient leaves the center the continued care becomes episodic. If the patient goes to a hospital for an entirely different issue, then continuity of care may become thorny. Sometimes the ER doctor involves his or her specialist who may or may not be feeling cooperative. This person may have an attitude of, ‘You dump your patients on us…we’re not going to share information with you.’ If you are not an attending surgeon at that hospital then you have some potentially uncomfortable circumstances, including liability and interruption of the patient/doctor relationship.”
“Good medicine is not enough.”
In the proverbial good ‘ole days, says Dr. Davis, providing high-quality medical care was sufficient. “In today’s climate, you must have heightened situational awareness to handle all of the things that are constantly changing in the medical, economic, and legal arenas. We must be flexible enough to adjust to those changes. Unfortunately, gone are the days when we could rely solely on good medicine. There was a time when if you took superb care of your patients then that was sufficient. Now, you must be savvy in a myriad of ways or everything can come back to bite you.”
“There are easier ways to make a living than spine ASCs,” says Dr. Reginald Davis. “Go into it with your eyes wide open.”