Here are five things to know about bringing spine surgery into the outpatient setting.
1. Pick your team well. By selecting the team that works together, everything flows better, says Mr. Zorn. You should rarely see rotation of OR staff during a procedure. "In many hospital ORs outside of the United States, a team has come together because they like the type of cases and who they work with it seems," says Chris Zorn, vice president of sales for Spine Surgical Innovation and executive director of Minimal Incision-Maximum Sight (MIMS) Institute. "Obviously no surgeon will be forced to work with team members he/she doesn't want in room, anywhere. In ASCs you are recruiting the best you know. It matters."
2. Pull out all the stops to fight infections. One of the biggest complications associated with spine surgery — and the source of a huge burden to the economics of healthcare — is infections. "Infections are out of control in the United States," says Robert S. Bray, Jr., MD, neurosurgeon and CEO of DISC Sports & Spine Center in Marina del Rey, Calif. "We are fighting a battle against the bugs and we aren't winning with antibiotics. The bugs are smarter and faster, and it's becoming dangerous to do elective surgery in a regular hospital operating room. If we want elective surgery to survive, we must take a different path."
Some surgeons have chosen to remove their elective spine cases from the regular inpatient ward and into a spine or orthopedics specialty hospital; others have found solace in ambulatory surgery centers, which often have a lower rate of infection than hospitals. However, it takes extra effort to build a center where surgeons can perform 4,000-plus cases and without any infection—which is currently DISC's record.
"We took a different path with DISC," says Dr. Bray. "It isn't an average surgery center. We have 100 percent deep filtered air and strict nursing protocols to avoid infections. There is massive attention paid to every detail."
For example, there is a terminal employees enter before coming into the building and if nurses had been working at another hospital they are required to discard their old scrubs in favor of new, clean scrubs before continuing into the center. Patients are also separated in the postoperative area to make sure they don't spread infections from one room to the next.
"You can't put sick people in ICUs next to patients who hare having hip revisions or microspine surgery in the next room," says Dr. Bray. "This is how we can win against the bugs; we can put patients where the bugs aren't."
3. Choose vendors carefully. Carefully choose which vendors to form the strongest relationships with as you transition cases into an ASC. There may be five main implant vendors occupying the outpatient spine space, but it would benefit you to trim your preferences down to two. "Create a loyalty to one or two vendors to help with pricing," says Marcus Williamson, president of the spine division of Symbion Health Care. "As you look at the cost of the implants, for you and your patients' out-of-pocket expense, you want to work exclusively with fewer than three vendors for surgical cases.
Vendors can also help introduce spine surgeons into the market. "If they have a cervical fusion product, implant or cement, they can co-brand the device with you, which helps you make an introduction into that market," says Mr. Williamson. There are three types of outside-the-house arenas surgeons focus on as they break through into the market:
• Direct-to-physician — vendors can help coordinate meetings or lab that physicians receive educational credits because vendors have the CEU designation for diagnosing and treating conditions.
• Direct-to-patient — vendors can co-brand the surgeon's name with their marketing materials for direct-to-consumer efforts.
• Direct to health plan — vendors can work with you to present information about procedures and technology used during spine surgery for better coverage and the patient's utilization of benefits in the surgery center setting.
4. Understand the payors and cater to what they want. Find out what is important to the payor, either during the previous negotiations or through ongoing dialogue, and focus on those areas to show improvement. "When we did that back in 2003, we learned a payor was very interested in pay-for-performance," says Tom Faith of The C/N Group. "We offered a pay-for-performance component. One of our contracts boosted our reimbursement rate by 2 percent." The surgery continued to set quality goals and changed the criteria depending on what the payor was focused on at the time. They have been successful in keeping the rate increase for the past several years.
5. Consider 23-hour extended stays for high-risk procedures. For more complex procedures, such as the ACDFs and posterior lumbar fusions, have patients stay at the ASC overnight for 23 hours (if your ASC has been approved for it) and allow them to go home first thing in the morning, says Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco. Additional measures might be needed, such as measuring neck circumference of the ACDF patients postoperatively, to make sure they aren't experiencing difficulties before discharge.
More Articles on Spine Surgery:
From Start to Finish in 3 Months: 8 Reasons Why Prairie SurgiCare Could Make it Happen
4 Tips for the Entrepreneurial Business-Minded Spine Surgeon
Podcast: Dr. Kenneth Pettine on the Society for Ambulatory Spine Surgery
1. Pick your team well. By selecting the team that works together, everything flows better, says Mr. Zorn. You should rarely see rotation of OR staff during a procedure. "In many hospital ORs outside of the United States, a team has come together because they like the type of cases and who they work with it seems," says Chris Zorn, vice president of sales for Spine Surgical Innovation and executive director of Minimal Incision-Maximum Sight (MIMS) Institute. "Obviously no surgeon will be forced to work with team members he/she doesn't want in room, anywhere. In ASCs you are recruiting the best you know. It matters."
2. Pull out all the stops to fight infections. One of the biggest complications associated with spine surgery — and the source of a huge burden to the economics of healthcare — is infections. "Infections are out of control in the United States," says Robert S. Bray, Jr., MD, neurosurgeon and CEO of DISC Sports & Spine Center in Marina del Rey, Calif. "We are fighting a battle against the bugs and we aren't winning with antibiotics. The bugs are smarter and faster, and it's becoming dangerous to do elective surgery in a regular hospital operating room. If we want elective surgery to survive, we must take a different path."
Some surgeons have chosen to remove their elective spine cases from the regular inpatient ward and into a spine or orthopedics specialty hospital; others have found solace in ambulatory surgery centers, which often have a lower rate of infection than hospitals. However, it takes extra effort to build a center where surgeons can perform 4,000-plus cases and without any infection—which is currently DISC's record.
"We took a different path with DISC," says Dr. Bray. "It isn't an average surgery center. We have 100 percent deep filtered air and strict nursing protocols to avoid infections. There is massive attention paid to every detail."
For example, there is a terminal employees enter before coming into the building and if nurses had been working at another hospital they are required to discard their old scrubs in favor of new, clean scrubs before continuing into the center. Patients are also separated in the postoperative area to make sure they don't spread infections from one room to the next.
"You can't put sick people in ICUs next to patients who hare having hip revisions or microspine surgery in the next room," says Dr. Bray. "This is how we can win against the bugs; we can put patients where the bugs aren't."
3. Choose vendors carefully. Carefully choose which vendors to form the strongest relationships with as you transition cases into an ASC. There may be five main implant vendors occupying the outpatient spine space, but it would benefit you to trim your preferences down to two. "Create a loyalty to one or two vendors to help with pricing," says Marcus Williamson, president of the spine division of Symbion Health Care. "As you look at the cost of the implants, for you and your patients' out-of-pocket expense, you want to work exclusively with fewer than three vendors for surgical cases.
Vendors can also help introduce spine surgeons into the market. "If they have a cervical fusion product, implant or cement, they can co-brand the device with you, which helps you make an introduction into that market," says Mr. Williamson. There are three types of outside-the-house arenas surgeons focus on as they break through into the market:
• Direct-to-physician — vendors can help coordinate meetings or lab that physicians receive educational credits because vendors have the CEU designation for diagnosing and treating conditions.
• Direct-to-patient — vendors can co-brand the surgeon's name with their marketing materials for direct-to-consumer efforts.
• Direct to health plan — vendors can work with you to present information about procedures and technology used during spine surgery for better coverage and the patient's utilization of benefits in the surgery center setting.
4. Understand the payors and cater to what they want. Find out what is important to the payor, either during the previous negotiations or through ongoing dialogue, and focus on those areas to show improvement. "When we did that back in 2003, we learned a payor was very interested in pay-for-performance," says Tom Faith of The C/N Group. "We offered a pay-for-performance component. One of our contracts boosted our reimbursement rate by 2 percent." The surgery continued to set quality goals and changed the criteria depending on what the payor was focused on at the time. They have been successful in keeping the rate increase for the past several years.
5. Consider 23-hour extended stays for high-risk procedures. For more complex procedures, such as the ACDFs and posterior lumbar fusions, have patients stay at the ASC overnight for 23 hours (if your ASC has been approved for it) and allow them to go home first thing in the morning, says Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco. Additional measures might be needed, such as measuring neck circumference of the ACDF patients postoperatively, to make sure they aren't experiencing difficulties before discharge.
More Articles on Spine Surgery:
From Start to Finish in 3 Months: 8 Reasons Why Prairie SurgiCare Could Make it Happen
4 Tips for the Entrepreneurial Business-Minded Spine Surgeon
Podcast: Dr. Kenneth Pettine on the Society for Ambulatory Spine Surgery