Q: In your experience, what are some of the essential pieces of equipment and their average costs for starting a spine service line in ASCs?
Beth Johnson: Here is what centers will need:
- Adequate imaging equipment, i.e. C-arms. New C-arms cost around $130,000. I would not recommend purchasing a refurbished C-arm. The amount of time that the C-arm is needed in the surgical suite is minimal, so if the facility already has a C-arm that they are using in other specialties, it may suffice.
- Lumbar and cervical retractor systems. New lumbar retractors can range between $5,000 and $10,000; new cervical retractors and distractor sets range between $15,000 and $25,000. Make sure you shop manufacturers because you will find a wide variance in pricing, especially on the cervical retractors.
- Instruments. Anterior cervical decompression and fusion instruments will run around $12,000 per set. Laminectomy instruments are approximately $15,000 per set.
- Wilson or Andrews Spine Frame. They range from $2,000-$2,500.
- Microscope. Try to find a refurbished or demo microscope. Prices range from $50,000-$80,000. Many surgeons will use loops instead of a microscope.
- Cervical implants. These run $900 and up per patient. Many payors will not reimburse for these implants in an ASC setting, unless separate payment arrangements have been negotiated. If the ASC is able to purchase in volume, it will have greater success in obtaining reasonable pricing from the implant manufacturers. Negotiate consignment arrangements with the manufacturers for the implants and loaner instrumentation.
- High power drills. Attempt to negotiate loaner drills by agreeing to purchase a minimum number of drill bits annually. Be cautious of drill bit pricing. This is considered a supply and is not reimbursable.
Q: Are there ways in which ASCs can minimize these costs?
BJ: The most effective way to minimize costs is to buy in volume, if possible. Buy refurbished when available. Negotiate consignment and loaner arrangements. Also, consider manufacturers who may not be the well-known industry leader; these companies are typically more willing to work with an entity on price.
Q: What are the average payments/reimbursements ASCs receive for spine surgeries?
BJ: The reimbursement for a spine procedure is all over the board. It varies region by region, in network versus out of network and payor to payor. This is why it is so important to pre-certify and pre-authorize all procedures performed in the ASC and to fully understand the patient’s benefit plan.
Q: What are the average surgery times for common ASC spine procedures?
BJ: Most procedures require 45-90 minutes of OR time.
Q: What kinds of staff members are needed for spine procedures in ASCs?
BJ: Centers will need, typically, one scrub technician, one assistant and one circulating nurse in addition to an anesthesia provider and the surgeon.
Q: What kinds of anesthesia are needed for spine procedures?
BJ: Normally general anesthesia is required.
However, patient selection is critical. You need to rule out through pre-op phone calls and anesthesia assessment any high-risk factors such as obesity, uncontrolled medical problems (hypertension, diabetes, coronary artery disease, etc.), history of bleeding disorders, obstructive sleep apnea, history of difficult intubation, history of anesthetic complications (malignant hypertension) and recent fever or infection. It is imperative to exclude any patients who have difficult airway issues from surgery at an ASC, especially when performing an ACDF.
Post-operative nausea and vomiting remains a major morbidity associated with surgery and results in unplanned hospital admissions. Multimodal therapy is effective at reducing unanticipated hospital admissions secondary to intractable PONV. Pre-emptive therapy includes: zofran, reglan, decadron, use of versed and propofol at induction and avoidance of nitrous oxide. Rescue therapy includes: promethazine, a second dose of zofran, scopolamine patch, IV fluids and oxygen. Try to avoid antiemetics that may cause central nervous system effects (promethazine only when needed) and use zofran on all patients (reglan and decadron unless contraindicated).
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