Healthcare economics is an important part of providing patient care and shaping healthcare policy going forward. Here are eight ways spine surgeons can positively impact healthcare economics.
1. Less invasive procedures. Minimally invasive spine procedures can have several clinical and economic advantages for patients. A study published in the November 13 issue of The Spine Journal examined transforaminal lumbar interbody fusion open and minimally invasive procedures and found:
• Shorter surgical time for minimally invasive procedures
• Shorter hospital length of stay for minimally invasive procedures
• Shorter anesthesia and EBL time for minimally invasive procedures
• Lower direct hospital costs for the minimally invasive procedures
Additionally, the literature shows patients have a lower risk of infections and complication after minimally invasive techniques, which lowers the costs associated with a single patient even further.
2. Complication rate. Complications in spine surgery are associated with significantly increased costs. A study examining spine surgery patients at an academic medical center during a six-month period in 2008 found the average cost of care was higher when patients had complications. Major complications were more costly than minor complications and systematic malignancy and preoperative neurological comorbidity were associated with a $7,979 and $5,508 increase in cost of care respectively.
Pulmonary complications cost an average of $7,233 more; instrument malposition cost $6,968 more; new neurologic deficit cost $4,527 more; and wound infections cost $4,067 more.
A retrospective review of patients who underwent minimally invasive TLIF with rhBMP-2 also found complications were associated with substantial financial cost to patients, with reoperation costs reaching $14,784 per encounter for neuroforaminal bone growth and $20,267 for pseudarthrosis.
3. Performing cases in ASCs. In most situations payers reimburse ambulatory surgery centers less than hospitals and hospital outpatient departments for spinal procedures. ASCs are able to function as a low-cost provider of elective procedures. Some surgery centers are now posting prices online to compete with hospitals and attract self-insured companies and individuals.
According to data from Richard Wohns, MD, JD, MBP, of NeoSpine in the Puget Sound Region of Washington, the entire cost of a cervical discectomy and fusion in a hospital is $119,529.23, compared to the same procedure in the ambulatory care setting priced at $37,956.80. He also found patients undergoing the procedure in the hospital environment were responsible for nearly $86,000, compared with patients in the ASC who were responsible for around $12,645.
The study included a 42-patient cohort with 40 percent of the procedures performed as conventional open surgery in a hospital setting, 30 percent as minimally invasive surgery in a hospital and 30 percent as minimally invasive surgery in an outpatient setting.
4. Implant choice. One of the biggest costs for most spinal surgery procedures is the implant. A study led by surgeons at the University of California Irvine Health and presented at the AAOS 2013 Annual Meeting found that the average cost of pedicle screws was $878, with a range of $400 to $1,843 per patient; anterior cervical plats ranged from $540 to $2,388 per patient and posterior interbody cages ranged from $938 to $7,200.
Dr. Wohns' study also examined implant price; he found implants required for surgery in the hospital setting cost roughly $65,000, when compared with the implant price in the ASC totaling less than $3,000. Choosing a less-expensive implant can make a huge difference in the total cost of a spinal procedure, especially if the implant is a "gold standard" available at wholesale or generic pricing.
5. Patient selection. Appropriate patient selection is important for good quality care as well as keeping costs manageable. Many surgeons and spine centers are developing protocol for patient treatment, and outcomes registries are making it easier to examine the effectiveness of different treatments on patients. In some cases, patients can recover with conservative techniques while in others successful surgery has been shown less costly than long-term unsuccessful conservative treatment.
A study presented at the American Academy of Orthopaedic Surgeons annual meeting earlier this year examined the economic impact of patients undergoing surgery for disc herniation. The researchers found surgery resulted in more than $5,000 of cost savings due to higher earnings for patients who underwent surgery. Surgical patients also missed three fewer days of work when compared with patients who underwent nonsurgical treatment.
6. Early ambulation. Patients who are able to ambulate more quickly after surgery are associated with quicker recovery and return to daily activity times. Less invasive procedures and new pain management techniques allow patients to ambulate more quickly after surgery without pain or side-effects of anesthesia and narcotics after surgery.
7. Sending patients home. Spinal fusions topped the charts of the costliest surgical procedures performed in hospitals, according to an Agency for Healthcare Research and Quality report with data from 2011, showing spinal fusions represented $12.8 billion, or $16,600 per hospital stay. The longer patients stay in the hospital, the higher costs they incur.
A 2013 study shows hospital length of stay after posterior lumbar fusion is variable, between three and seven days on average. Researchers found the only preoperative variables associated with increased length of stay were age and ASA scores. History of heart disease was associated with a shorter hospital stay, and intraoperative complications were not associated with longer stays.
8. Patient education and expectations. Patient expectations play a crucial role in outcomes and recovery. Surgeons often find when patients have appropriate post-surgical pain and functional expectations they are more satisfied with their procedure and more willing to begin the rehabilitation process. As a result, their outcomes are better and they're more likely to return to work quicker.
A 2011 study published in the SAS Journal examined patients undergoing elective spine surgery with and without attending a patient education class preoperatively. The study showed 96 percent of the patients in the PE group were satisfied with their pain management versus 83 percent in the control group. There was better overall satisfaction in the PE group.
Another 2010 study published in Spine examined the impact of patient expectations on the treatment outcomes for spinal trauma. The study demonstrated appropriate patient outcomes could potentially maximize outcomes.