Dr. Daniel Lieberman: How hospitals will react to outpatient migration and what's next for spine surgery at ASCs

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Daniel Lieberman, MD, medical director at Phoenix Spine & Joint, spoke to Becker's Spine Review about outpatient migration, how hospitals will compete in orthopedics post-pandemic and the future of spine surgery at ASCs.

Question: How much of an effect has COVID had on outpatient migration of spine and total joint surgeries?

Dr. Daniel Lieberman: COVID is the catalyst that is rapidly accelerating changes that were already occurring in the orthopedic space. For several years, spine has been slowly migrating toward the ASC, but now it's galloping over. Patients don't want to have surgery in the hospital if they can avoid it. Spine patients in particular don't need anything else on their plates. Commercial spine was already largely migrated, but now we're seeing it even more with Medicare patients. 

Innovations in robotic-assisted knee replacement and minimally invasive approaches to hip replacement have contributed to more joint replacements moving toward the ASC. COVID has also accelerated this. We are seeing more patients coming in for robotic-assisted knee and minimally invasive hip replacements. Our center has leading joint replacement robots from Smith+Nephew and Stryker.

Q: How has the pandemic affected spine surgery at your practice?  

DL: We now do as much joint surgery in our centers as we do spine surgery. Due to COVID, we are seeing more patients having spinal fusions in the ASC, as many of them are not willing to go to the hospital. In the past, a patient and surgeon may have opted to do the procedure at the hospital. Now, we're seeing the opposite. Patients are telling surgeons that they will not have their procedure done at a hospital. Similarly, surgeons are recalibrating risks for ASCs, because the risk of going to the hospital is higher. 

Q: What do you see as the next big trend in spine for ASCs?

DL: Over the last five years we've seen real energy pulling away from deformity correction and multilevel fusion surgery, and the entire field of spine surgery moving into much more focused interventions based on structure. I think the next horizon is focused interventions based on symptoms. What patients really are concerned about is their pain. Our surgery centers offer endoscopic dorsal rhizotomy, so ultra-minimally invasive surgeries that eliminate pain are really the next horizon. It's almost like we're going to see spine surgery absorb and move into more of a pain management approach, rather than a structural correction approach. 

Q: What is the biggest shift in how patients view ASCs and hospitals now?

DL: For a long time, I think ASCs were viewed as a place where you could have a minor procedure. As the sophistication of ASCs increased, they were viewed as an alternative for some procedures that were normally done at the hospital, but if the patient was really weary of the hospital it could be done in an ASC. Now, I think we're seeing a complete paradigm shift — these elective procedures are normally going to be done at an ASC, regardless of their complexity, and the hospital will be reserved for people with special medical needs, or who need more urgent care. The safety of procedures at ASCs, lower infection rates and the desire of physicians to offer patients an experience in a more comfortable setting are big factors contributing to patients opting to have their elective surgeries done at an ASC. COVID has also accelerated this. 

Q: How do you see hospitals competing with ASCs post-pandemic?

DL: Hospitals are not going to stay on the sidelines. They can't let their golden egg leave the goose. They're going to have to be heavily involved in ASCs, so they're going to be another stakeholder that will get even more fired up and involved in our industry.

Q: How will you be looking at growth in 2021?

DL: We're seeing rapid growth in the number of surgeons who want to operate primarily in an ambulatory setting. Our physician recruitment is exponentially higher than it has ever been. We initially thought the transition to the ASC environment was going to take place over the next five to 10 years, but now I think it's going to over the next one to five years. So, we're opening a new surgery center in Gilbert, Arizona — our biggest center yet. We've already recruited most of the physicians we need to fill it. We're seeing this as a new period of growth for ASCs, coming on top of an old period of growth. The ASC market has been getting bigger and stronger for years and we see that continuing to increase in the future. There is a lot more business to do.

Q: At the start of the pandemic, we saw many patients postpone orthopedic surgeries due to safety concerns. Are you still seeing patients reschedule surgeries now after so much time has passed?

DL: It's just not viable for these patients to postpone surgeries any longer. Many patients put off getting the care that they needed during the pandemic, but COVID hasn't helped anybody's arthritis. A lot of those patients with ongoing joint problems are now worse off than before. We have patients who have been sitting at home with out-of-control carpal tunnel syndrome whose nerves are damaged and really need decompressions. They're essentially saying that they can't wait anymore. Many of these problems that have been put off for six to nine months, not only are they not going away, they're progressive problems.

I think also the vaccine being on the horizon is part of patients' mindsets. People are starting to see the light at the end of the tunnel for COVID and are thinking, "Hey, I've got to be able to walk to get out of the tunnel." People are emotionally and logistically starting to make plans to move on with their lives, anticipating that vaccines will be deployed in the next weeks to months.

Q: How do you expect the winter months to play out in Arizona as COVID cases continue to spike across the country?

DL: We're really skilled at dealing with heavy duty winter epidemics in Phoenix. Arizona is a retirement state. Our hospitals every year get an influx of about a million visitors from cold weather states in the U.S., as well as Canada. It's normal for us to deal with an influx of patients with upper respiratory disease in the winter and our hospitals are extremely well-equipped and able to handle it. Like many states, Arizona kind of jumped the gun in the spring and shut everything down, not knowing what to expect.

The real harm that came to the community from that soon became apparent: the increases in untreated in heart attacks, reductions in cancer screening, and reductions in child immunizations. I don't think the government is going to make the same mistake again and shut everything down in an attempt to prepare the extra beds for COVID. I think we're just going to have to deal with what comes our way like we always have.

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