The business of spine surgery: ASC success strategies for surgeons

CMS Releases Proposed 2021 Medicare Hospital Outpatient and ASC Rule

Spine surgeons interested in investing in an ASC have the opportunity to realize significant profit over the next five years. Not only is spine surgery one of the higher reimbursing specialties, but complex procedures are moving from hospitals to ASCs with increasing frequency. According to a Bain & Company article, the percentage of spinal procedures performed in ASCs was expected to increase from 10 percent in 2019 to 30 percent by the mid 2020s.

Support for this outpatient migration came with the Proposed 2021 Medicare Hospital Outpatient and ASC Rules which included a three-year transition to eliminate the inpatient-only list, beginning in 2021 with 266 musculoskeletal-related services which included 80 spine procedures. The CMS final rule effectively expands patient healthcare choices and opens outpatient facilities to perform higher acuity procedures.

Numerous benefits in the outpatient setting encourage this continuing trend. ASC patients are experiencing quicker recovery thanks to advances in technology and enjoying a more boutique healthcare environment; surgeons are achieving autonomy, flexibility, and the benefits of financial investment; and payers have recognized an overall reduction in healthcare costs in the ASC setting.

A 2019 survey of academic spine surgeons found 49% had investments in freestanding surgery centers. This will only increase, as the market is expected to grow at a compound annual growth rate of 4.9 percent through 2024. Now that COVID-19 has accelerated the move of spine cases to the ASC setting, the outlook for this discipline is exciting – and competitive.

We had the opportunity to sit down with Dr. Rasouli, nationally recognized and board-certified spine surgeon to discuss his insights on the keys to success in the ASC.

How Has Spine Transitioned to the Outpatient Setting?
Spine surgeries had historically been complex, high acuity, high blood loss surgeries that required a long hospital stay and rehab. Same-day surgery was unheard of. When I started handling more cases in ASCs, procedures were taking two to three times longer in the hospital setting.

A few years ago, we started performing more surgeries in the outpatient setting with success – in outcome and in patient satisfaction. We then brought more complex cases to the outpatient setting. Multilevel spinal fusions, multilevel cervical disc replacements, anterior procedures – we performed them all safely.

By the time COVID-19 finished its first and second waves, our anesthesiologists had improved their efficiency and developed pain management techniques that rendered hospitalizations unnecessary. In the past year my cases have shifted from 80 percent in the hospital to about 90 percent in ASCs. Those numbers have sustained even after the 2020 crises eased.

Essential Technology
When investing in an ASC, spine surgeons should consider the devices and technology they use. Will it help you improve patient outcomes in an outpatient setting? Will it add real value to your practice?

I was the first surgeon to use the new generation of ProDisc-L Total Disc Replacement (TDR) system. Its modular endplates allow us to mix and match angles, sizes, and heights. As a result, we can bring more patients that need disc replacement to the ASC. We can also perform the procedure more safely because you can tailor the prosthesis perfectly to the patient’s anatomy.

Technology investments extend to anesthesiology and pain management. Regional anesthesia blocks pain to the area of surgery for two to three days. Using this technique can reduce or eliminate the need for narcotics.

Digitally assisted surgery shows promise in helping surgeons better visualize a case. While robotic-assisted surgery can add time to a procedure, advanced technology such as augmented reality (AR) can save time. AR goggles allow surgeons to see the patient’s body in vivid detail so they know exactly where to place screws or a prosthesis before making an incision. This speeds up surgery and lowers risk of complication.

How to Succeed as Spine Surgeon in an ASC
Surgeons, patients, and payers alike all want to see more spine surgeries move to ASCs.

As complex cases continue to shift to the setting, surgeons interested in working outside the hospital environment can thrive. To do so, not only do they have to assemble a team of experts to help with the business and financial aspects, they have to have the right skill set.

That skill set involves efficiency with repetition. Can you perform a multi-level disc replacement procedure in 30 minutes or are you more comfortable with four hours? Can you perform multiple surgeries a day without error?

A new generation of surgeons trained in ASCs have this skill set. They have perfected their technique and are ready to offer patients a boutique, private experience in the ASC setting. Seasoned professionals who work primarily in the hospital will need to refine their technique if they want to succeed in ASCs.

For spine surgeons moving to ASCs and residents aspiring to this path, remember you’ll be judged by your patients and by the community according to your results as a surgeon. It’s not just how much you know, it’s how you execute.

The spine surgeons of the new generation must be gifted academically and technically. A surgeon who takes four hours to perform a single case may not a good fit for an ASC. To thrive in what I call “rapid recovery spine surgery,” you need to be able to perform 10 surgeries in a day. This skill set, combined with the right technology and a smart business strategy, will give your ASC a competitive advantage.

Alexandre Rasouli, MD, is a nationally recognized, board-certified spine surgeon who specializes in the surgical and nonsurgical management of cervical, thoracic and lumbar disorders of the spine, degenerative disorders, spinal trauma, adult and pediatric deformity, spinal oncology and minimally invasive surgery. His spine centers are affiliated with Cedars Sinai Medical Center and Long Beach Memorial Medical Center in the Los Angeles, California, metro area.

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