There’s one crucial factor that will make outpatient spine surgery a success, spine surgeon Jason Cuellar, MD, PhD, said.
Dr. Cuellar, who practices in Jupiter, Fla., discussed what’s next for outpatient spine surgery and how groups should approach safety in ASCs.
Note: Responses were lightly edited.
Question: The ASC model has gained major traction in orthopedics and spine over the last decade. What do you see as the next inflection point for ASCs — is it payer alignment, robotics, bundled payments, or something else?
Dr. Jason Cuellar: In order for outpatient spine surgery to continue to succeed and expand, payer alignment will definitely be the most key factor in my opinion. Payers need to understand that outpatient spine surgery can be done safely, efficiently and in a more cost-effective way than in the hospital. However, they need to reward the ASCs with some of this cost savings and not undermine it with reimbursements so low as to make it impossible to make the business successful — a happy median must be settled upon. Bundled payments may or may not play a major role in this depending on how they are implemented. While I am a believer and supporter of technology and its advantages and advancement, I do not believe spine robots will be the next major player, but rather will be gradually improved up and made more accurate, precise, cost effective and smaller in footprint for expanded utilization in the ASC.
Q: Some predict ASCs will take on higher-acuity cases in the coming years. What clinical or operational safeguards must be in place before spine or complex orthopedic cases become routine in the outpatient setting?
JC: We are already seeing this and participating in the advancement. DISC Spine & Sports for example has a proven track record of high-acuity outpatient spine surgery in southern California and soon will be open in West Palm Beach, Fla. This is something that is very surgeon specific and dependent and I believe is primarily based on experience with patient selection and surgical efficiency and safety. For example, when performing outpatient lumbar total disc replacement we generally avoid bringing patients with BMI more than 35 to the ASC. However, physical exams can sometimes reveal body habitus variability which can alter this on an individual basis. So while we can have an operational guideline that states no outpatient lumbar disc replacement if BMI is over 30 or 35, a male bodybuilder with a flat abdomen would be someone that the reasonable and experienced team must be flexible about. I believe the spine or orthopaedic surgeon must perfect their efficiency and safety in the hospital before coming to the ASC and that is and will remain more important than having strict and inflexible operational safeguards.
Certain equipment such as cell saver and pulse ox monitoring for anterior spine surgery, videoglide scopes and ultrasound machines for anesthesia, high quality operating microscopes and fluoroscopes, however, should be a given if higher-acuity cases will be done in an ASC.
