'The overarching view is vast': 5 surgeons' predictions on outpatient orthopedics


Outpatient orthopedic procedures have become more normalized in recent years, and some surgeons believe that trend will continue to accelerate. Growth in the ASC market, the COVID-19 pandemic and physician ownership opportunities are among the factors surgeons believe will grow outpatient orthopedics.

Five surgeons told Becker's how they envision outpatient orthopedics over the next five years.

Note: Responses were edited for style and length.

Question: What will outpatient orthopedic surgery look like in five years?

Kiran Alluri, MD. University of Southern California Spine Center (Los Angeles): In the next five years, there will without a doubt be growth in outpatient orthopedic surgery. Market analysts have predicted that the ASC market will more than triple between now and 2025. Lastly, the COVID pandemic has likely accelerated this growth in an attempt to avoid inpatient hospitalization and conserve hospital-based healthcare resources.

Specific to spine surgery, many procedures are already performed in ASCs on an outpatient basis, such as lumbar decompressions/discectomies, cervical laminoforaminotomies/discectomies, and single-level anterior cervical discectomy and fusions (ACDFs) or cervical disc arthroplasty (CDA).

I think there will be added growth to outpatient spine procedures in the form of multilevel ACDFs/CDAs and single- and multilevel lumbar fusion. Some surgeons are already performing multilevel ACDFs/CDAs and lumbar fusions in the outpatient setting, but I think there will be continued pressure for more surgeons to adopt this trend. This is in large part going to be driven by efforts to contain healthcare costs. Some studies have demonstrated that outpatient surgery can decrease the cost of a given procedure by 30 to 60 percent, and in some cases 90 percent compared to inpatient cases. Furthermore, CMS is phasing out more than 60 inpatient-only spine codes by 2024, which will likely further contribute to the increase in outpatient spine surgery. Lastly, future CMS-mandated cost-saving initiatives and bundled payments may be widely implemented across spine surgery to incentivize physicians to decrease costs in a shift away from a fee-for-service model toward value-based care. In the outpatient ASC setting, physicians may have more control over cost-containing measures such as negotiations with vendors on implant pricing, etc., which may further encourage surgeons to perform safe procedures in the outpatient ASC setting as reimbursement models continue to evolve.

The key to continued growth in outpatient surgery is developing replicable multidisciplinary pathways that identify patients that can safely undergo outpatient surgery for a given procedure. In spine surgery, there is robust data demonstrating the safety and efficacy of certain procedures in the outpatient setting, but there needs to be continued efforts and research devoted to expanding the list of procedures that can be safely performed, particularly multilevel ACDF/CDA and lumbar fusions. The continued evolution of minimally invasive techniques, multimodal perioperative anesthesia and analgesia, and cost-saving healthcare initiatives are all key components that will continue to drive an increase in outpatient orthopedic procedures.

Niranjan Kavadi, MD. Orthopedic surgeon in Oklahoma City: Outpatient surgery numbers will keep going up in the future. I will not be surprised to see an increase to an extent of 20 to 30 percent in five years. What is critical to perform surgery in an outpatient setting is precise perioperative planning. As more residents and a newer breed of surgeons get trained in ambulatory surgical settings, we will see an increase in the numbers. Primary knee replacements and uncomplicated spinal fusions are already being performed at a significantly higher volume in an outpatient setting than a few years ago. As a spine surgeon, I am also excited to see increasing acceptance of endoscopic spine surgery in the mainstream. With the advantages of keeping the healthcare costs low, ability to offer high quality care, and potentially quicker recovery, it's a win-win-win situation for the healthcare facilities, surgeons and, most importantly, for the patients.

Tim Ekpo, DO. Henry Ford Health System (Detroit): The evolution of orthopedic surgery to the outpatient setting has changed dramatically over the past decade. Currently there are many factors driving surgeons to do more surgery in the outpatient setting.

Medicare reimbursements: The list of procedures moving from inpatient only to outpatient has pushed a lot of surgeons to consider taking these patients to ambulatory surgery centers as an alternative to providing the same services in the hospital setting.

Efficiency: Many surgeons are able to be more productive in the outpatient setting. The turnover times are much quicker and most staff are incentivized to be efficient in a cost-efficient and patient-centered model.

Patient outcomes: Depending on the procedure, patient outcomes and satisfaction are often many times higher in the outpatient setting. Many patients prefer to have their procedures done and recover in the comfort of their own home as opposed to a bed in the hospital. Since the COVID-19 pandemic, patients also view the outpatient surgical setting as a "safer" alternative to an inpatient setting.

Ownership and joint ventures: Other factors driving procedures to the outpatient setting include ownership in an ambulatory surgery center. Physicians have an opportunity to directly help guide in the care of their patients and processes within the facility they hold a stake in. There can also be a financial upside to centers that are profitable.

COVID-19: Over the past two years, this has probably been one of the biggest drivers in moving procedures to the outpatient setting. When our hospitals were ravaged with patients receiving care for COVID-19, there were still many patients that were dealing with chronic, debilitating orthopedic conditions. Due to staffing and bed shortages, the only alternative to taking care of many of these patients was the ambulatory surgery center. This forced many surgeons to provide care in a setting that they may not have been as comfortable with for some procedures. Ultimately I view it as a positive thing for both surgeons and patients alike. We were able to care for our patients with the equivalent of, if not better, outcomes, and surgeons recognize that they are capable of sending these patients home the same day in a safe manner.

The overarching view for the future of outpatient orthopedic surgery is vast. As we continue to raise the bar, the type of procedures we do will continue to expand. The continued development and evolution of multimodal pain protocols and less invasive techniques will also drive procedures to outpatient surgical centers. I would not be surprised if in the next decade we see the pendulum swing in the opposite direction and most orthopedic cases are done in the outpatient setting and the minority of cases done at the hospital as an inpatient.

Lance Brunton, MD. Excela Health Orthopedics (Latrobe, Pa.): It will largely depend on the regulatory environment and market competition in a given geographical area, combined with the stability of ancillary staff at designated outpatient facilities. As more orthopedic cases are removed from the CMS inpatient-only list, including complex spine and joint reconstructions, both patients and surgeons will seek systems and facilities that deliver the most satisfying care episode at the best value. Massive amounts of capital will continue to be directed toward refurbishing old and constructing new free-standing infrastructure projects to promote comprehensive musculoskeletal services, maximize efficiency, and provide a consistently exceptional outpatient experience for all stakeholders.

While it is unlikely that the moratorium on physician-owned specialty hospitals will be lifted in the next five years, orthopedic surgeons will be most enticed by hospital systems willing to entertain joint ventures on modern physician-led centers and ortho-centric ambulatory surgical facilities for equity sharing, advanced technological offerings, co-management agreements, and market share growth. Excessively bureaucratic systems that stifle productivity, autonomy and entrepreneurism will be incapable of recruiting and retaining the best and brightest surgeons, nurses and support staff, leading to an inevitable decline in care quality, market advantage, and overall reputability of the enterprise. Discerning patients and employers will search for the highest-performing "destination centers" that predictably deliver the best-quality care at the lowest cost for a given elective orthopedic procedure. An emphasis on injury prevention, weight management, fitness programs and conservative pain management strategies to fend off the necessity of more invasive and expensive orthopedic interventions will require ongoing collaboration and coordination with our physiatry and primary-care sports medicine colleagues. In my subspecialty of hand surgery, a trend toward more wide-awake procedures under local anesthetic without tourniquet control is improving patient safety, bolstering operational efficiency, and minimizing total expenditures by eliminating extraneous instrument processing and anesthesia services.

Finally, as patient expectations evolve, the outpatient arena will be challenged to enhance appropriate access and expedite the care of the acutely-injured musculoskeletal patient by shifting the first point of contact away from emergency rooms and generic urgent care centers to specialized centers equipped to handle rapid evaluation and same-day definitive management by orthopedic providers. As patients live longer and stay more physically active, the demand for outpatient orthopedic services will remain high for the foreseeable future, and the majority of those services will be delivered in non-traditional sites that resemble hotel resorts more than hospitals.

Jason Weisstein, MD. Yavapai Regional Medical Center. (Prescott, Ariz.): Outpatient orthopedic surgery will continue to grow across all subspecialties over the next five years, especially as more studies validate its safety, value and outcomes. Many insurers already prefer outpatient orthopedic surgery for specific procedures, and I expect that there will be increased pressure on surgeons to utilize the outpatient arena over the upcoming years as continued cost savings are demonstrated.

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