6 Steps to Prepare for the Future of Outpatient Spine Surgery


Robert S. Bray, Jr., MD, neurosurgeon and CEO of DISC Sports & Spine Center in Marina del Rey, Calif., believes that outpatient surgery centers and spine specialty hospitals are the future of elective spine surgery. He moved out of his role as head of the Cedars-Sinai Spine Center in Los Angeles to open his own practice, and has since developed two surgery centers where surgeons perform complex minimally invasive orthopedic and spine cases.

"I believe very firmly that spine over the next five to seven years — ten years max — will transition nearly completely to specialty hospitals or outpatient centers," says Dr. Bray. "The reason I believe we can do this is because procedures are much less invasive today than they were even 10 years ago."

In addition to the technology, several factors — including an emphasis on providing cost-effective and infection-free care — will drive further growth of spine procedures into the surgery center and specialty hospital setting. Here, Dr. Bray discusses six ways surgeons and surgery centers can prepare for this future.

1. Create a rational business plan. Planning is an important part of every business venture, and surgery centers are no different. If a group of physicians wants to develop a center, they must have a detailed plan — not just deep pockets — to make the venture successful.

"The future is in surgery centers and specialty hospitals, so it's important to rationally and reasonably develop a business plan, budget and commitment to the center," says Dr. Bray. "Centers were we perform high acuity cases aren't little surgery centers where you perform 10 minute procedures; they must be designed and developed well to meet the needs of your patients."

Equipping a high end, high scale surgery center with the appropriate infection control measures and surgical equipment is a costly endeavor. Dr. Bray estimates it may take around a $9 million investment for a new spine surgery center, but having a savvy business plan could mean partners recoup those costs quickly through solid contracts.

"Put your business concepts together so the surgery center can survive as a business," says Dr. Bray. "If you can make the center survive as a business, it will flourish and have a purpose. Our center is financially solid; we have never had a non-profitable month and we are growing at an alarming rate."

2. Hire a high-quality administrator.
While physician owners may be able to cut costs in several areas of their surgery center, skimping on administrator salary isn't acceptable. "You can't do this without a really top quality administrator," says Dr. Bray. "I'm the CEO of the center, but my administrator can answer any questions you have about the center. If you are going to run high acuity cases and run them with good outcomes, you need that type of person on your side."

Karen Reiter, administrator of DISC, had 27 years of experience in the healthcare industry — including time running an implant company — before taking her current position. DISC recently expanded to open a new surgery center in Newport, and Ms. Reiter was able to lead those efforts and achieve accreditation without any deficiencies.

"The details it takes to run these places is immense," says Dr. Bray. "They are complex buildings with a high level of professionals working inside. You must have good surgeons and nurses to work with the patients, but that doesn't matter if you don't have a quality administrator to take care of everything else."

Your administrator should be proficient in business, but also understand the healthcare environment. Healthcare is a unique business with special circumstance that demands experienced professionals in order to succeed.

3. Develop in-network contracts with private payors.
Surgery centers are increasingly seeking in-network contracts with private payors to ensure long lasting success of the ASC. There are a few steps surgery centers can take to make sure they attract the best contracts available:

• Document outcomes to prove surgery can be successful in an ASC
• Demonstrate strict infection control protocols
• Provide your complication rate and risk management protocols
• Show the companies you are meeting clinical and financial benchmarks
• Emphasize cost savings associated with performing cases in the surgery center

"We just had a four-hour tour with a major private payor to go through our protocols and records," says Dr. Bray. "The company's representative decided they wanted to work with us. It's this type of detail that has to be developed because that's where the future of surgery lies. We are raising the bar for surgery centers so there's no question these high acuity cases can be performed here."

4. Pull out all the stops to fight infections. One of the biggest complications associated with spine surgery — and the source of a huge burden to the economics of healthcare — is infections. "Infections are out of control in the United States," says Dr. Bray. "We are fighting a battle against the bugs and we aren't winning with antibiotics. The bugs are smarter and faster, and it's becoming dangerous to do elective surgery in a regular hospital operating room. If we want elective surgery to survive, we must take a different path."

Some surgeons have chosen to remove their elective spine cases from the regular inpatient ward and into a spine or orthopedics specialty hospital; others have found solace in ambulatory surgery centers, which often have a lower rate of infection than hospitals. However, it takes extra effort to build a center where surgeons can perform 4,000-plus cases and without any infection—which is currently DISC's record.

"We took a different path with DISC," says Dr. Bray. "It isn't an average surgery center. We have 100 percent deep filtered air and strict nursing protocols to avoid infections. There is massive attention paid to every detail."

For example, there is a terminal employees enter before coming into the building and if nurses had been working at another hospital they are required to discard their old scrubs in favor of new, clean scrubs before continuing into the center. Patients are also separated in the postoperative area to make sure they don't spread infections from one room to the next.

"You can't put sick people in ICUs next to patients who hare having hip revisions or microspine surgery in the next room," says Dr. Bray. "This is how we can win against the bugs; we can put patients where the bugs aren't."

5. Invest in technology to improve efficiency.
We live in an age where technology is a key aspect in running any business because it can accelerate tasks and make care delivery more efficient. DISC surgery centers include a vision computer system that does inventory management, supply control management and stocking management.

"You have to be at a computerized level to look at everything across the board," says Dr. Bray. "You have to have information at your finger tips. It's become necessary in this day and age to integrate technology."

6. Seek out more high acuity cases.
Spine surgery is a high acuity, low volume subspecialty for a surgery center, which can be a great business model when done appropriately. However, once you are able to perform spine cases, consider bringing on other specialists who perform high acuity cases, such as partial knee replacements, hip scopes and shoulder reconstructions.

"We are adding high acuity, love volume cases, which bring our centers higher revenue," says Dr. Bray. We are able to perform complex cases and deliver better outcomes than in other settings because the complication and infection rate is lower."

However, adding these cases to a multi-specialty surgery center that usually does low acuity cases requires significant investment of resources. You'll need to purchase additional equipment and revise your payor mix before adding high acuity cases.

More Articles on Spine Surgery:

From Start to Finish in 3 Months: 8 Reasons Why Prairie SurgiCare Could Make it Happen
4 Tips for the Entrepreneurial Business-Minded Spine Surgeon

Podcast: Dr. Kenneth Pettine on the Society for Ambulatory Spine Surgery

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