“Every success story is a tale of constant adaptation, revision and change.” - Richard Branson
Never has this Richard Branson quote been more true than it is for the evolution of the healthcare delivery system, which will only be accelerated by the COVID-19 crisis. Historically, surgical procedures were performed in a hospital inpatient setting. With the advancement of technology, certain of these procedures moved to a hospital outpatient department (HOPD), and in recent years have moved to ambulatory surgery centers (ASCs). The initial specialties that moved to ASCs included ophthalmology, gastroenterology, pain management, urology, ENT, among others. Today, 61 percent of the procedures for these specialties are performed in ASCs. Orthopedics has trailed these other specialties, but is quickly catching up, as 44 percent of orthopedic procedures were performed in ASCs in 2015 and that number jumped to 52 percent in 2018.1
On the other hand, spinal surgeries, due to their complex nature, have largely remained inside the hospital walls, with only 10 percent of such procedures performed in ASCs in 2018. That said, spinal procedures are on a trajectory similar to orthopedics as the number of ASCs specializing in spinal surgery rose from only 35 in 2013 to 145 in 2019, an increase of 314 percent. Further, the 10 percent of spinal procedures performed in ASCs today are projected to move to 30 percent by the early 2020s, an increase of 200 percent.1
This dramatic movement in spinal procedures is being driven due to it being beneficial for patients, healthcare providers and payers, a rare win-win-win. For example, in an ASC, surgeons have greater control of the procurement process—there are fewer bureaucratic hoops to jump through. They can directly request the equipment, technology and materials they need, schedule procedures more conveniently, and assemble teams of highly skilled, specially trained staff. There are financial advantages for surgeons, too, as many have ownership in ASCs.
Patients looking for convenience, quality and comfort enjoy the benefits of an ASC. Their recovery is faster, and they have more say and flexibility in their discharge plans. With a reduced rate of infection (more than 50 percent of ASCs in the US have a 0 percent infection rate2), which is increasingly important to patients as a result of COVID-19, patients can be confident in their safety. Most patients also require fewer medications. For example, patients who underwent anterior cervical discectomy and fusion at an ASC consumed fewer doses of fentanyl, oxycodone and oral morphine equivalents. All of these circumstances lead to a 92 percent patient satisfaction rate, compared with 70 percent satisfaction rate in the hospitals. 2
Medicare and insurance carriers also generate significant savings when spine surgeries are performed in an ASC. Spine surgeries in an ASC typically cost 45-60 percent less than a hospital, and can be as much as 90 percent less. Overall, researchers estimate that ASCs deliver an annual cost savings of $40 billion per year.3
Types of Spine Surgeries
The most common spine surgeries currently being performed in an ASC today are lumbar decompressions, lumbar discectomies, and 1 level anterior cervical discectomies and fusions. These procedures are approved by both commercial carriers and Medicare, are extremely successful, and offer a cost savings to payers. Anterior cervical discectomy surgery, for example, costs Medicare $7,688 in an ASC versus $10,713 in hospital outpatient departments. 1 Thus, this procedure costs 39 percent more in an HOPD than in an ASC.
A couple of trends have emerged this year. First, there has been an increase in cervical disk arthroplasty and interspinous process distraction device with open decompression procedures, which is also on Medicare’s ASC-approved list.
Second, ASCs have experienced great success with lumbar posterior inter-body fusion surgeries for commercial carriers, with patients going home the same day of surgery. Medicare moved this surgery from the inpatient only list to the hospital outpatient list—which is a step in the right direction—but has not yet approved it for ASCs. CMS has added numerous spine codes to the ASC payables list over the past few years, particularly in situations where ASCs have demonstrated success with such cases for commercial carriers, so it seems likely that this high demand surgery will be transitioned to the ASC payables list in the near term.
Most recently, in 2020, Medicare moved the following six spine procedures off of the inpatient only list, but did not yet move them to the ASC approved list. These surgeries include:
1. Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar. CPT code: 22633
2. Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace and segment; lumbar; each additional interspace and segment. CPT code: 22634
3. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical. CPT code: 63265
4. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic. CPT code: 63266
5. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar. CPT code: 63267
6. Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral. CPT code: 63268
As our country deals with the economic challenges of the coronavirus pandemic, cost savings in all areas will be a priority. Transitioning spine surgeries to the ASC-approved list provides Medicare with a unique opportunity to lower costs while reducing patients’ exposure to infection that may be present in a more populated hospital setting.
Finally, since spine surgery is one of the higher reimbursing surgical specialties, incorporating spine into a multi specialty ASC can have a significant positive impact on the growth rate and profit margin structure for an ASC, which will ultimately lead to a considerable increase in the ASC’s equity value.
Click here for Part II of this article series for a more in-depth discussion of the steps required to incorporate spinal procedures into your ASC, and the financial implications of doing so.
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1. Ambulatory Surgery Center Growth Accelerates_ Is Medtech Ready_ - Bain & Company.pdf