"Five years ago there were a few companies heavily focused on it, but now most companies have robust minimally invasive platforms to address the increasing interest and demand," says Frank Phillips, MD, director of the division of spine surgery at Rush University Medical Center and co-founder of the Minimally Invasive Spine Institute at Rush. "The technology advancement is there for MIS techniques, but surgeon training in this space remains a challenging issue."
More and more patients are demanding it. "Minimally invasive spine surgery is market-driven and patients demand this of their surgeons. At the same time there are limited venues for traditional "open" surgeons to receive advanced and adequate training in MIS techniques. MIS surgeries involve a different skill set and some excellent open surgeons aren't ready or able to perform MIS procedures on their patients," says Dr. Phillips. "With MIS surgery, the surgeon has to look at a small part of the anatomy combined with X-rays and assimilate this into a three-dimensional appreciation of the anatomy. It's hard if you aren't trained appropriately."
The science behind MIS
Surgeons have been slow to embrace minimally invasive spine surgery for several reasons; experienced surgeons can achieve good outcomes with open procedures and it takes considerable time and effort to train in minimally invasive techniques. However, as literature has accumulated showing minimally invasive techniques achieve the same or better outcomes as open procedures, there is increased pressure on surgeons to master these techniques.
Over the past few years spine journals have published numerous articles comparing less invasive surgery to open procedures, finding almost across the board that patients are achieving similar outcomes in terms of pain scores and functionality while losing less blood, spending fewer days in the hospital and returning to work and activities more quickly than with open procedures. Dr. Phillips was the editor for a Spine special edition in June 2016 focused specifically on minimally invasive spine procedures.
"Arguably, for a number of spine procedures, well-validated minimally invasive techniques are the gold standard," says Dr. Phillips. "There is robust evidence supporting this assertion. There are many articles comparing MIS to open surgery with conclusions showing there is less analgesic consumption postoperatively and better peri-operative outcomes for MIS patients, and it costs less." Dr. Phillips emphasizes that this applies to those techniques and procedures that have been studied and validated and not necessarily to the many "fringe," unsubstantiated, so-called MIS procedures currently being marketed.
Innovation in minimally invasive techniques occurred rapidly in the early 2000s, but over the past five years there have been primarily incremental improvements in technology.
"I think you'll see over the next decade that robotics and image guided surgery will evolve and become an important component of MIS surgery," says Dr. Phillips. "There is also tremendous energy around applying less-invasive techniques in the treatment of complex spinal deformity. Collection of effectiveness, safety and cost data will be imperative to ensure insurance coverage for procedures. Insurance companies are typically unwilling to cover procedures that increase cost or volume and it is beholden on the spine community to work proactively to ensure our patients have access to these procedures."
Insurance companies are now also acquiring data at the individual surgeon level to approve or deny spine procedures. "We are not there yet, but we are heading in a direction where individual surgeons will be held accountable for their outcomes and costs," says Dr. Phillips.
The outlook for minimally invasive procedures is rosy because data shows they are clinically sound and cost-effective; younger surgeons are also learning the techniques during their training and are excited to apply them.
"Younger surgeons today are often learning the minimally invasive skill set during residencies and fellowships. They are supervised during the learning curve and gaining considerable experience in MIS," says Dr. Phillips. "This is the ideal path to gaining MIS expertise so the younger surgeons can make the jump to performing these techniques in their own practice."
The less invasive procedures lend themselves to the outpatient setting, which is a huge opportunity for spinal care. Across the country, pioneering spine surgeons are performing cases in ambulatory surgery centers safely and effectively, but it will take time before most surgeons are technically proficient enough to make the switch.
"Undoubtedly outpatient spine is the future," says Dr. Phillips. "The biggest deterrent right now is the ability to reproducibly perform more complex surgeries in the ASC.. It's about managing perioperative analgesia and postoperative pain. There is no surgical reason why we can't do spine surgeries as an outpatient, but peri-operative pain management is critical."
At Midwest Orthopaedics at Rush we are fortunate to have had the multimodal analgesia approach for outpatient Joint Replacement developed at our institution. The surgeons now apply this approach to their spine patients to facilitate ASC surgeries. It is a matter of time until the cost savings of ASC surgeries are so apparent that payers will demand these procedures be performed in the lowest cost venue, says Dr. Phillips.
The next step for many ASCs is bundled payments.
"When you look at value-based health care, the ASC is the perfect opportunity for bundled payments, allowing the surgeon to manage the whole bundle in a transparent way," says Dr. Phillips. Since Medicare added outpatient spine surgery codes in 2015 more commercial payers are willing to negotiate on outpatient spine procedures.
"The payment methods have to evolve so that the bundles provide appropriate reimbursement for the implants," says Dr. Phillips. "Without an ASC carve-out for implants and biologics, these procedures are difficult to justify in the current bundled payment structures. Ultimately, when the payers realize the savings and efficiencies, they will need to figure out how to make spine surgery work in the ASC environment because it translates into global savings."
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