Where orthopedics in ASCs is headed — Payment, pain management, CMS & more: Q&A With Dr. T.K. Miller

T.K. Miller, MD, discusses orthopedic surgery at outpatient surgery centers and where the most potential is for growth in the future.


Q: How are outpatient centers evolving?

Dr. T.K. Miller: The challenge for outpatient surgery centers lies in how we define "outpatient" and how local regulatory restrictions can impact the evolution to "non-hospital based short stay." The traditional "pure" ASCs should continue to thrive as they provide a high quality, patient centric, cost-effective access to surgical care. As we see increasing interest in surgical procedures with more intraoperative and perioperative intensity (multi-level spine, outpatient total joints, increasingly complex fracture care) centers will need to decide if they continue in the true ASC model or add the ability to provide extended length post op care — perioperative recovery, overnight stay with required services, pre-discharge services (PT, OT etc.).

Even for those functioning in the true "outpatient" model, the addition of cases of increased complexity and the typical extended postoperative recovery will redefine how cases are scheduled and the "length of day."

Q: What factors are driving the trend toward outpatient orthopaedic surgery?

TM: Improvements in perioperative pain management — the technical ability to perform procedures with minimized perioperative risk must be balanced with the ability to address patient concerns about and the real impact of managing postoperative pain. As multimodal perioperative pain protocols evolve and improve, we need to also be cognizant of the role and impact (often negative — for the patient and society) associated with narcotics as part of the care plan. Extended length analgesia and non-narcotic supplementation for pain control has the potential to broaden the what we consider to be "safe and appropriate" in the outpatient setting

Continued evolution of minimally invasive procedures — limited exposure surgery, whether spine or total joint, and the associated reduction of postoperative "negatives" — bleeding, narcotic requirements, perioperative infection risk, activity and ambulation compromise as compared extended approach or non-muscle sparing surgeries drives an increasing number of procedures for consideration as outpatient acceptable.

Pay for performance — as P4P includes not just traditional clinical outcomes but also patient satisfaction, those providers and facilities that provide the "best package of care" should rightfully market for and capture an increasing volume of traditionally hospital-based procedures. As the small scale, patient centered care model is the foundation of successful ASCs (as compared to traditional hospital based surgical care), ASCs offering comparable (or better) clinical outcomes should be increasingly appealing to patients and insurers.

Q: Where is there most potential for growth in outpatient orthopedic centers in the future?

TM: This is probably best stated by reviewing the change in CMS’s recent actions and anticipated approach to a number of currently inpatient-only procedures. CMS is not only proposing the removal of "inpatient only" for additional spine procedures (of increased complexity, instrumentation dependent or more segmental levels), there is clear support for removal of IP only for total knee arthroplasty. Even with recognition that medical comorbidities often seen in this (insurance) population will dictate that appropriate care for many patients will remain hospital based, the ability to provide additional outpatient spine and arthroplasty services to even a segment of this patient population, as opposed to it being available only to commercially insured patients, will significantly redirect volumes to the ASC environment.

Learn more from Dr. T.K. Miller at the 15th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference + The Future of Spine in June 2017! Click here for more information.

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