Spine Surgeon Robert Bray Predicts a Major Shift of Volume into ASCs

Nationally, just 1-3 percent of spine surgeries are performed in an outpatient center, but Robert S. Bray Jr., MD, believes that rate will climb in the next decade as surgeons, payors and patients alike discover the lower costs and high quality of minimally-invasive surgery in an ASC.

"The ASC is where the future of spine surgery is," Dr. Bray maintains. "This will literally be a game-changer over the next 10 years."

As proof of his prophecy, he points to the money coming from spine surgery into his own ASC, located in Marina del Rey, Calif., near Los Angeles, which Dr. Bray and several other surgeons founded three years ago.

"We are very financially successful," he reports. "Even in this economy, we're still growing month by month."

And as spine surgery moves to ASCs, Dr. Bray predicts that the nature of ASCs will change. "Outpatient settings, once mainly the realm of low-acuity, high-volume procedures, like ophthalmology, are now making room for higher-acuity, lower-volume spine procedures," he says.

Dr. Bray and his colleagues spent $12 million on the facility, renovating 55,000 square feet of an empty office building. The three-OR facility, called DISC, which stands for "Diagnostic and Interventional Spinal Care," is staffed by five spine surgeons and six orthopedic surgeons, all of whom are co-investors in the center.

"We started off cautiously," he recalls. "We were hoping to do 20 percent to 30 percent of spine cases on an outpatient basis. Now I do 95 percent of my practice at the ASC. I go into the hospital one to two mornings a month."

Dr. Bray and his partners do most kinds of spine surgery on an outpatient basis, from discectomies to pedical screw fusions and artificial discs.

Pioneer of minimally invasive spine surgery

Dr. Bray first started performing minimally-invasive surgery while he was a neurosurgery resident at Baylor College of Medicine in Houston in the 1980s. He trained under Robert Grossman, MD, who made the residents take off their glasses and perform every surgery under a microscope. "Use a microscope," Dr. Bray was urged. "The microscope is the key."

Using a small incision, the surgeon uses the microscope to look down a narrow path that is up to six inches long. Muscles can be nudged aside rather than cut. Less blood is lost. The patient undergoes less trauma and recovers faster.  

But when Dr. Bray moved to Los Angeles in 1989 and brought the technique with him, many colleagues thought it was too risky and initially rejected the approach.

Dr. Bray would not give up. He discontinued brain surgery and focused entirely on spine surgery using the microscope. He helped design microscopes and tools to accommodate the new technique, even traveling to Germany to meet with officials at Carl Zeiss AG about adopting their microscope. Managing the Institute for Spinal Disorders at Cedars-Sinai Medical Center in Los Angeles, he saw length of stay drop from six days to 1.5 days.

Achieving impeccable outcomes
As he shortened lengths of stay in the hospital, shifting surgeries to an ASC began to seem possible to Dr. Bray. California's rules on ASCs made the transition easier because the state allows patients to stay up to 23 hours in the ASC.

But before moving spine surgery to an ASC, Dr. Bray wanted to instill the highest levels of quality and safety. With spine surgery, it is exceedingly important to prevent infections because an infection can go straight to the brain and is a life-threatening problem.

While planning the new ASC, Dr. Bray underwent a minor procedure as a patient in the hospital that resulted in a virulent infection. "It nearly cost me my life," he recalls. "It was a wakeup call."

Dr. Bray cut no corners in designing the ORs in the new ASC. They contain 100 percent HEPA air and have a UV treated high volume exhaust. After 36 months of operation and more than 3,000 procedures, there have been no infections in them. The ASC has never had to transfer a spine a patient to the hospital.
 
Dr. Bray attributes this success to a number of precautions (along with OR design):

  • The facility is kept clean by not allowing other kinds of surgery such as GI or urology. Performing these procedures in the same OR as spine surgery increases the risk of infection.
  • Surgeons carefully select patients for the ASC, avoiding those who are in poor health or psychologically unprepared for outpatient surgery.
  • He is also a strong believer in written protocols for virtually all aspects of care, from wound care to mobilization. Dr. Bray, his colleagues and staff track results and modify treatment to steadily improve outcomes.
  • The same nurse follows the patient throughout the surgery process at the ASC, from pre-op to post-op. This minimizes mistakes and improved patient satisfaction. "One nurse very closely controls the patient's pain and urine functions," he explains.
Starting off 'out of network'
The new ASC has been operating "out of network," with no contracts with insurers, which is typical for spinal ASCs in their first years. Insurers are still leery of performing these procedures on an outpatient basis and the ASC does not want to lock itself into low rates that the insurers initially offer.  

"When you're out of network, the insurer reviews each case independently," Dr. Bray says. "They say 'this code is not outpatient.' I say, 'Who are you to tell me that?' So they ask me to send them paperwork to prove what I say." The ASC has sent cases and cases of paperwork to insurers and he personally has spent hours "educating" insurance representatives and showing them his outcomes.

"It takes a while to convince insurers," he says. But after three years of sterling outcomes, some of the major insurers are coming around and the ASC is in negotiations with them for contracts.

Meanwhile, the DISC ASC does not accept any Medicare patients because Medicare still does not pay for spine surgery on an outpatient basis. Dr. Bray states: "Realistically, I cannot do cases from any insurer that pays $2,000 or $3,000 because that is below cost."

With these payment restrictions, ASCs that seek to be "pure spine" often can stay open only a few days a week, which makes it difficult to find staff and make the operation financially viable. The DISC ASC solves this problem by supplementing spine with sports and orthopedic surgery on the knee, hip, shoulder and other joints, as well as some joint replacements. As a result, the ASC has had enough volume to maintain a full schedule and it became cash-flow positive ahead of schedule, in Jan. 2007.

What the future holds
Dr. Bray thinks the trend toward outpatient spine surgery will accelerate as patients get more comfortable with the concept, insurers become less skeptical and Medicare recognizes more outpatient spine procedures. However, the trend is slowed in states that do not allow overnight stays at ASCs, which Dr. Bray says are still necessary after surgery.

He advises that existing ASCs entering spine surgery will need larger ORs to accommodate extra equipment, such as a C-arm and microscope. Dr. Bray's ORs are almost 600 square feet but he thinks spine surgery ORs can be as small as 400 square feet.

Dr. Bray says spine surgery is on the way to being a specialty in its own right. So far, however, spine surgeons are trained in either orthopedic or neurosurgery residency programs and then take a one-year spine fellowship. Dr. Bray has personally trained 27 spine fellows, split evenly between orthopedic and neurosurgeons. But the two-step training process means that residents who want to be spine surgeons have to learn skills they will never use, such as brain surgery in neurosurgery programs or hip replacements in orthopedics programs. Dr. Bray hopes that someday there will be a single spine surgery residency program.   

Learn more about Diagnostic and Interventional Spinal Care.

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