Spine surgery historically has been a big open procedure requiring several recovery days in the hospital. These procedures were a huge undertaking for patients and physicians, and an expensive endeavor.
But technology is evolving to allow minimally invasive procedures performed in the outpatient setting, and none too soon for spine surgeons whose private practices see reimbursements drop while operational costs continue to increase. Coupled with stricter coverage guidelines from insurance companies, increased denial rate and hospitals employing physicians, the independent spine surgeons are turning to ambulatory surgery centers to provide better patient care and enhance their professional revenue.
"Over the past few years, the advent of more minimally invasive techniques that require less dissection, less blood loss and lower morbidity is allowing patients to recover more quickly from spine surgery," says Dwight Tyndall, MD, FAAOS, a spine surgeon at Orthopaedic Specialists of Northwest Indiana/Spine Care Specialists in Munster. "Spine surgeons can now take these patients into the ASC environment. We are slowly getting to the point where some surgeons are doing almost all their patients in the ASC, which is a facility for patients without significant other health issues."
Since the Affordable Care Act eliminated the opportunity for surgeons to own hospitals, the ASC is the last ownership option for surgeons beyond their own practices. For physicians, the most attractive aspects of an ASC include:
• Ability to control their operating environment and schedule
• Low infection rate
• Specialized staff
"If you have an integrated practice with an ASC that you work out of, your quality of life can be better," says Dr. Tyndall. "Sometimes the hospitals aren't as familiar with their surgeons, and for the most part the nurses and surgical techs in the hospitals don't work for the surgeon and therefore don’t feel obligated to the surgeons. At times it feels that in the hospitals, your patients' concern comes second. By moving to the ASC, the surgeon can have a defining say in their patient’s experience."
However, not all patients are good candidates for outpatient surgery, so independent spine surgeons with an expansive practice still need a relationship with the hospitals to perform the more complex cases. Additionally, Medicare doesn't currently reimburse for spine surgery in ASCs, so Medicare cases are taken to the hospital.
"Hospital relationships depend on the local and regional politics," says Dr. Tyndall. "Healthcare delivery is local. Whether the surgeon can operate out of their ASC as well as the hospital will depend on the surgeon's relationship with the local hospital. Some hospitals will see the ASC as a threat because surgeons are might be taking some of the better insured patients from the hospital. However, in some cases, hospitals will partner with surgeons for joint venture ASC."
However, when the relationship between surgeons and hospitals is more adversarial, the hospital may decide to hire other spine surgeons and direct referrals internally. "I think the best solution is for us all to understand we are in it together, and we're transitioning to a payment system where there's one payment point of care, so we, hospitals and surgeons need to work together to keep our costs in line while delivering great patient care and experiences," says Dr. Tyndall. "But some hospitals unfortunately don't think that way."
Current healthcare policies and legislation encourages collaborative care, pushing physicians to work for large hospitals and health systems. Some within the government would like to see a single-payer model, which fits much better if physicians are employed by a system.
"The physicians who are in private practice are at risk; you'll start seeing fewer one- and two-physician groups," says Dr. Tyndall. "Groups of 20 to 30 specialists will be more common. The larger size groups can give the surgeon an advantage over the one or two man groups when negotiating rates with insurance companies. Larger groups allow the practitioners the ability to also split the cost of running the practice, which are becoming more intense with electronic medical record systems cost and new regulations."
Private practice opportunities
However, there will be a few markets in affluent areas that will continue to accommodate single-physician groups. These groups will subsist on patients with good insurance plans and/or medical tourism. ASCs are in a prime position to capture the medical tourist dollars as the low-cost, high quality providers for patients with health savings accounts or high deductible plans.
Single spine surgeons, whether in their own practice or part of a multispecialty group, will become more valuable in markets, which are less saturated with spine practitioners. "It's an issue of economics," says Dr. Tyndall. "There aren't a tremendous amount of spine surgeons in the country, so there's a supply and demand issue. Spine surgeons who are in a very large community can still have a viable practice even if their local hospital decide to compete against them hire their own surgeons."
Dr. Tyndall and his partners decided to develop an ASC to augment their practice but more importantly to ensure they had control over the patient care environment. However, they didn't do it alone; they hired business and management experts to help.
"I developed my center with other surgeons and a corporate group that has done it before," says Dr. Tyndall. "I believe good management is invaluable. You have to recognize and know the limitations of your skill set. I am a surgeon and not an administrator, so I had to get help where I didn't have that expertise."
Surgeons are becoming more educated and business savvy, and spine surgeons are aware they've become a target for reducing the high costs in healthcare. In the future, spine surgeons will focus more on collecting patient outcomes and show how their technique and practice model benefits both the clinical and economic aspects of care. The big questions they are beginning to ask include:
• Do you have good patient experiences?
• Are you cost effective?
• What are you doing to improve?
"Insurance companies are making broad and sweeping denials for procedures that would really benefit patients," says Dr. Tyndall. "Now with the right data and surgical setting, you can say here's why spine surgeons need to exist and add value to the healthcare system: we are providing good value economically and better patient satisfaction and outcomes."
As spine surgeons bring more cases into the outpatient surgery center, they'll be able to lower costs and achieve better outcomes. A study published in the May edition of Health Affairs showed ASCs provide a cost-efficient surgical environment and could save Medicare and its beneficiaries up to $57.6 billion over the next decade. This bodes well for spine surgeons and patients, but many hospitals are weary of the change because spine has been a big part of their revenue in the past.
"It's a concern for those hospitals that frankly aren't competitive from an innovation point of view," says Dr. Tyndall. "If they could learn how to run effectively and adopt techniques to become more cost efficient and improve the patients' experience, then the whole system would be better off. Instead, some are being reactionary and rather than collaborate with physician run entities are simply trying to shut down physician-owned facilities."
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