Spine surgery in the ASC: A win for patients and physicians

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The trend of surgical services migrating from high-acuity settings to ASCs is poised to continue.

This is due to improved patient experiences, greater physician autonomy and better economics. Adding to the growing appeal of ASCs is increased use of robotic-enabled surgery, which improves outcomes and productivity. 

Becker's ASC Review recently spoke with Kenneth Nwosu, MD, an orthopedic spine surgeon at NeoSpine in the Greater Seattle area, about ASCs' attractive value proposition, the role of robotic technology in enabling ASCs to perform complex procedures and the rationale for performing spine surgeries in ASCs.

ASCs on the rise 

Over the last several years, ASCs have become an increasingly attractive destination for physicians and patients. Health system leaders have taken note of this trend and are increasing investments in these facilities accordingly. More than 60 percent of hospitals and health systems nationwide plan to increase investments in ASCs, according to a 2022 survey of hospital executives and clinical leaders. 

As Dr. Nwosu explained, the value proposition of ASCs is a win-win-win: "It's a win for providers to operate in an environment they have more control over, which reduces burnout. It's a win for patients because the environment consists of other patients who are less sick and it's less expensive."

Outpatient spine surgery is no exception. An ASC is an attractive option for spine surgery patients because — when patients are properly selected — they can enjoy equivalent surgical outcomes as they would in a hospital, but in an environment that is more accommodating, less costly and less susceptible to propagating drug-resistant infections. Patient selection requires screening for comorbidities or other circumstances, such as obesity or opioid use, which expose individuals to higher risk of complications.

Technology can help spine surgeons optimize patient selection and perform less-invasive procedures

There are two types of technology necessary to successfully transition spine surgery patients from HOPDs to ASCs. One type is software-based and facilitates proper patient selection by quantifying a patient's risk of needing hospitalization within 24 hours of having undergone surgery. 

"It's difficult for the human mind to quantify all of the different variables that determine whether a patient ends up staying in a hospital or going home," Dr. Nwosu said. "When you have an AI instrument that can do that for you in a split second and give you that information, that's extremely valuable." 

The other technology combines software-based solutions and physical instrumentation, which supports navigation, robotics and endoscopy. "These three [modalities] allow us to perform spine surgeries in a less invasive fashion, which is associated with less pain, less infection and less bleeding," Dr. Nwosu said. "All of these variables reduce the risk of a patient needing to be admitted into the hospital after surgery." 

He added that robotic guidance allows spine surgeons to precisely place pedicle screws with much higher accuracy than they can in traditional open surgery — a consideration that is highly relevant when treating adjacent segment disease, for example.

There is another intangible but invaluable benefit to using robotic surgery, Dr. Nwosu said: "The most important benefit of robotic surgery is the cognitive relief it provides. It's hard to quantify but easy to qualify. Ask any surgeon and the amount of energy they have left to do another surgery is much higher when you're doing the previous surgery robotic versus non-robotic."

For advanced technology-enabled ASCs to thrive, payers must support the care delivery model

Longstanding health policies and practices are hard to change. One of those regulations restricts the type of procedures CMS covers when performed at an ASC, even as enabling technologies have advanced enough that most of those surgeries can be performed at a non-hospital setting at no higher risk — yet at lower cost. Further, CMS reimburses ASCs at a lower rate than it does HOPDs for identical surgeries. 

To incentivize the incorporation of novel technologies that improve the patient and physician experience while reducing costs, Dr. Nwosu is hopeful payers will see the value of spine procedures performed in ASCs and will reimburse appropriately. 

"We all talk about healthcare costs and how they are ballooning at a rapid rate," he said. "Payers have a lot of leverage to drive down costs by doing more cases in the ASC . . . the value proposition is clear. It's going to happen eventually, but I think it should be happening much sooner than it has been happening."

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