When Ki-Eun Chang, MD, arrived at the military hospital where he now practices, there was no endoscopic spine equipment. He was also working within a government purchasing process that he says tends to be “kind of slow on getting stuff.”
Now, 90% to 95% of his practice is endoscopic. He performs both uniportal and biportal procedures, and three or four of his partners have adopted the technique.
“It’s become our standard of care almost here,” he said.
Dr. Chang, a neurosurgeon at Naval Medical Center San Diego, has also helped surgeons at UC San Diego and a local Kaiser Permanente group launch endoscopic programs. He told Becker’s how surgeons can negotiate a program into existence, how to frame the return on investment and why training programs without one will fall behind.
The biggest remaining barriers to wider adoption are CPT reimbursement and cost. Until those improve, Dr. Chang said a successful program depends on three things: “the buy-in, the champion surgeon and then just the numbers argument.”
Start with what’s on hand
Cost is the first obstacle for most programs. Dr. Chang’s advice is to begin with equipment the facility already owns.
Although his fellowship training was in uniportal endoscopy, he started his program with biportal surgery because it needed almost no new capital.
“One of the benefits of biportal surgery is you could just use what you already have at your institution,” he said. “Every institution has an arthroscope, like a shoulder scope or a knee scope. So we use the same scope to do our biportal surgery, and you could use your spine instruments that you already have.”
For uniportal surgery, he described an existing vendor relationship. A vendor was already contracted with the hospital through its sports medicine and orthopedic surgeons, so his team got a uniportal set as a loaner. The hospital avoided buying a full tower because the vendor’s endoscope works with the hospital’s existing Stryker camera system. The team has since bought a couple of trays. Loaner costs still run about $2,000 to $3,000 per case, which is more than traditional approaches, but Dr. Chang considers it a worthwhile investment.
He said this approach is an especially strong argument for ASCs.
“Especially in the ASC setting, every cost matters,” he said. “Anything that could cut the cost is amazing. And if you already have all the equipment, that is definitely a sales pitch for anybody wanting to do an ASC or hospital system.”
Sell the total cost, not the capital cost
If administrators look only at the price of the equipment, the program can be a hard sell. Dr. Chang recommended showing what endoscopy saves the system over time.
Some endoscopic procedures can prevent larger, more expensive operations.
“There are certain pathologies like foraminotomies in the neck or foraminotomies in the lumbar spine that could prevent a potential fusion surgery, which is a higher cost for the hospital,” he said.
Recovery also matters. Many of Dr. Chang’s patients are active-duty service members, including Navy SEALs, who need to return to duty quickly. He now places fewer restrictions on patients after surgery than he did even with tubular surgery. His patients also report less pain right after surgery and use fewer opioids.
“Those are the avenues that you need to really stress: This could potentially be cost-saving in the long run,” he said. “Less risk of infection means less risk of readmission, and that’s the cost. You have to look at the overall cost to the system — of patients, how they do and benefit.”
Endoscopy can also help a facility compete for patients.
“If you’re an academic institution or a big hospital system like Kaiser or Hoag, they want to advertise themselves as the latest and hottest spine commodity, and that is endoscopy right now,” he said. Surgeons can also argue that greater efficiency will support higher case volumes.
Surgeons should expect to keep negotiating after the program is approved.
“Every end of fiscal year they’re like, ‘Hey, why is this costing this much again?'” Dr. Chang said. “So we always have to go back and find a new negotiating line.” In his experience, administrators usually adjust once they see the results.
“It’s not that much money, to be honest with you, compared to the things we do,” he said.
Find a champion and build the team
Every successful program Dr. Chang has seen had one dedicated surgeon leading it. At Oakland, Calif.-based Kaiser Permanente, a surgeon involved in the purchasing decision pushed for a system designed by the aforementioned vendor. The Southern California group’s case was also easier to make because Kaiser’s Northern California region had already approved one.
Support from colleagues can matter as much as a single advocate.
“If you’re the only person doing it in your practice, it’s sometimes hard, but if you have a team approach and everybody believes in it … it’s easier to make that transition,” he said.
Operating room staff tend to adapt quickly, because many scrub techs already know arthroscopic surgery from orthopedics, he said. The harder part is training surgeons: Dr. Chang could name only two or three programs in the country that train residents and fellows in endoscopy. Most surgeons learn through industry courses and labs, company guides who attend early cases, and networks of experienced surgeons. For biportal surgery, those networks include the South Korean surgeons who pioneered the technique.
“Some surgeons think industry programs are taboo, but I think it is so important for innovative work like endoscopy, because you have to learn somewhere,” he said.
The cost of waiting
Dr. Chang expects endoscopy to become essential in academic spine care, and said those not already investing in training programs might fall behind.
“If you have a department of minimally invasive spine surgery, I think you have to have the least invasive spine surgery, which is endoscopy,” he said. “I think it’s a disservice to residents and trainees to not have that in their experience.”
Hiring already reflects this demand. Programs are recruiting new graduates who may have done only about five endoscopic cases in training, then giving them room to build a program.
“These programs are desperate,” he said. “They want to establish an endoscopy program.” He expects endoscopy to be an essential part of any training program within 10 years.
He still said that while he expects endoscopic spine to become less of a niche, he does not believe it should be touted as the only avenue of minimally invasive spine care, stating that more traditional procedures still have an important role.
“To assume that this is going to be the standard of care that everyone has to do it is an overstatement,” he said. For training programs and multidisciplinary spine programs, however, he expects it to be the standard.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
