Spine in ASCs: Where are We Headed?

by Elizabeth Hofheinz, M.P.H., M.Ed., January 30, 2020 Will tumbleweeds soon drift through the halls of traditional hospitals, bereft of their normal deluge of orthopedic patients? We’re headed that way, says Alex Vaccaro, M.D., Ph.D., M.B.A., President of Rothman Orthopaedics in Philadelphia, Pennsylvania, tongue in cheek. “What really will happen is that healthier patients will be treated at lower acuity facilities that are safe and less expensive than traditional full-service hospitals. Tertiary care facilities will specialize in more complex patient care such as revision joint arthroplasty, spinal deformity, multiple trauma and musculoskeletal infections.” “Part of the new wave of value-based healthcare is the move to outpatient (OP) surgeries, with approximately 70% of all orthopedic surgeries now being done in these settings. Ambulatory surgery centers (ASCs) are on the rise precisely because utilization of such facilities is a safe, effective way of saving resources. In fact, one estimate is that by doing spine procedures in an ASC results in a roughly 30% savings.” While no place for trauma, deformity, or infections, says Dr. Vaccaro, spine patients who are sufficiently healthy with no or very few comorbidities can safely be treated in an ASC. “These facilities can serve a substantial number of spine patients if the protocols for sleep apnea and cardiopulmonary issues are followed. Anesthesiologists use an airway protocol for individuals with apnea, and if someone is deemed at high risk for airway difficulties, they are referred to a higher level of care facility. If someone is classified as ASA (American Society of Anesthesiologists) 1 or 2 then they often can safely undergo spine surgery at an ASC. If someone is a 3, and if they can, for example, reduce their blood pressure or lose weight, then perhaps that person would be a candidate for an ASC spine surgery.” Dr. Vaccaro, who has overseen the launch of 12 ASCs at Rothman, told OSN, “It’s been an interesting evolution, with the initial step being to get the government on board. Then hospitals had to be convinced, not an easy task because they aren’t interested unless they have a stake in the revenue cycle. This means that a partnership is necessary to incentivize all stakeholders to move in the direction of outpatient value care surgical centers.” “We are now taking ASCs to the next level with specialty care suites,” said Dr. Vaccaro. “For example, we are in partnership with NueHealth to develop ASCs with two or three rooms attached so that if someone undergoes surgery and doesn’t go home that day, then he or she can stay for a night or two in an attached suite. It ends up being one tenth the cost of a hospital stay (no hospital admission penalties, transfer penalties, etc).” But hospital administrators may not be so open to the ASC pitch. “It’s challenging,” said Dr. Vaccaro, “but we are convincing hospitals to forget the inpatient model, close inpatient beds, and develop ASCs in partnership with physicians. We bring the patients, the commercial insurance industry is on board for ASC reimbursement, and we work to make sure that patients are medically optimized. It’s a win-win all around.” Constantin Schon is CEO of Silony Medical Corp. based in Doral, Florida. “I think that for patients,” stated Schon, there are several exciting aspects to undergoing spine surgery in an ASC. “Having a shorter hospital stay and quicker postoperative mobilization improves outcomes and reduces the chance of infection. And because of the lower cost environment in ASCs, the burden on the healthcare system is reduced. In addition, patients have increased access to simple procedures. Most important, however, is that as we move procedures into ASCs, we do not compromise on patient safety.” As for where he sees things going in the next five years, Schon commented to OSN, “I believe insurers will have dedicated ASC coverage plans and that ASC networks will grow and partnerships with hospital systems will grow so as to ensure patient safety. I also envision ASCs as adjusting their infrastructures so that patients can stay more than 24 hours. Lastly, it is likely that suppliers will adjust their offerings to cater to the needs of ASCs.” Luke Diehl is Chief Executive Officer at HD LifeSciences in Woburn, Massachusetts. Commenting on the trend of spine surgeries in ASCs, he noted, “Talented surgeons and new surgical techniques can make spine surgery much less intimidating for patients, and I think ASCs fit into the same category. They offer patients a less scary brand of spine surgery. I think that we will continue to see growth in the ASC market as patients seek outpatient procedures, minimal recovery time, and treatments that may prevent or postpone a more extensive surgery.” “Medical device manufacturers will attempt to capitalize on this shift by providing technologies that may decrease the cost of ASC-based treatments, such as rep-less distribution models, sterile-packed implants and instruments, and streamlined surgical techniques. In addition, we will continue to see companies invest in technologies that expand the range of symptoms that can be addressed in an outpatient ASC setting. These include expandable interbodies, less invasive surgical approaches, and treatments designed for use by pain management physicians.” “One potential impediment to the growth of the ASC market will be the quality of care they can provide. Several factors have combined to make ASC's a hotbed for new technologies, techniques, and treatments. As the market continues to grow, patients will rely on ethical engineers, judicious physicians, and thorough clinical training programs to ensure that new advancements are introduced safely and marketed appropriately. I have no doubt that healthcare providers and insurers will monitor clinical outcomes and patient satisfaction very closely.” A 2020 study summed things up well, including some concerns: “This setting is attractive from the payer perspective as remuneration rates are generally less than for equivalent hospital-based procedures. Opportunity for physician ownership and increased surgeon productivity afforded by more specialized centers make ASCs attractive from the provider perspective as well. These factors serve as extrinsic motivators which may optimize and improve quality of surgical care. Much data supports the safety of spine surgery in the ASC setting. However, health care providers and policy makers must recognize that current regulations regarding safety and quality are less than comprehensive and the data is predominately from selected case-series or comparative cohorts with inherent biases, along with ambiguities in the definition of ‘outpatient.’”1 Dr. Vaccaro explains, “Groups such as the Rothman Institute study all patient care episodes for quality assurance to make sure that, through a navigational process, the right patient is treated at the right facility at the appropriate time once medical optimization is completed. All outcomes are then followed to insure the best and safest care experience possible.” Research shows that many are interested in riding the ASC wave, with one recent study saying that ASCs provide ‘an exciting and burgeoning avenue for innovation, cost-reduction and value-creation.’’2 Spine in the ASC…get ready for the ride… References: https://journals.sagepub.com/doi/full/10.1177/2192568219849391https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790808/#r3

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