Hospitals continue to lose spine procedures to the outpatient setting as CMS and commercial payers look to reduce healthcare costs and minimally invasive technologies allow for shorter surgeries with fewer complications.
Seven spine leaders discussed strategies hospitals should employ to remain competitive as spine cases continue to accelerate to the outpatient setting.
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Note: The following responses were lightly edited for style and clarity.
Question: What will spine surgery look like at hospitals in 10 years? What can/will hospitals do to slow outpatient migration?
Srdjan Mirkovic, MD. NorthShore Orthopaedic & Spine Institute (Chicago, Skokie, Ill.): Over the next decade, we should have a better idea of what surgeries are more successful using less invasive techniques. Time will help us determine the best approach and the best place for patients to have their procedures — in the hospital or outpatient surgery center. Surgeons want to distinguish themselves through a smaller incision and patients want a quicker recovery, so the perception is: less is more.
I expect we will redefine the role of less extensive surgery in the next 10 years. Does extensive surgery involve conditions such as scoliosis or multilevel stenosis, or can they be addressed less invasively? Less invasive is our goal, but we have come to terms with what is required with less. How much surgery is needed to solve a problem and relieve pain?
By 2030, I expect we will determine the criteria for same-day surgery and those that require a hospital stay, likely patients with comorbidities. We would have to rethink remote care and the extensive support system required to accommodate an outpatient surgery for a patient with conditions such as diabetes, hypertension and obesity. With more of an aging population, I believe hospitals will always play a role in spine care.
Adam Bruggeman, MD. Texas Spine Care Center (San Antonio) and CMO of MpowerHealth (Addison, Texas): Hospitals have negotiated against surgery centers for decades, leading to a dramatic difference in hospital, hospital outpatient department and ASC reimbursement. These practices and policies are driving a significant component of the outpatient migration, in addition to legislation that prevents new physician-owned hospitals from being developed de novo. Physicians will be the new drivers of healthcare for the next decade in terms of bundles and at-risk payments. Hospitals will need to find a way to bring their costs into bundles that make sense for the physicians who manage these arrangements.
Andrew Sama, MD. Hospital for Special Surgery (New York City): As spine surgical techniques become refined and less invasive, there will be a continued push to perform these procedures in ASCs or HOPDs. The benefits of ASC-based surgery are shorter turnover times between cases and increased throughput, comparable patient-reported outcomes, lower costs to payers and gainsharing opportunities for surgeons.
The incorporation of lower-cost computer navigation platforms into ASCs and [Enhanced Recovery After Surgery] protocols will allow multilevel spinal fusions to be done well — and with theoretically less risk and better outcomes — in the ambulatory setting. The lower cost of performing the same procedure in an ASC will continue to entice third-party payers to approve these surgeries in the outpatient setting only. Surgeon equity positions in ASCs incentivize them to do their cases there in the most efficient way possible.
Inpatient operating rooms will likely remain the setting for more complicated and expensive deformity and revision spine procedures over the next 10 years. Simple procedures in sicker patients with complex medical histories and comorbidities who require more intensive perioperative levels of care will also remain in hospitals.
To slow outpatient migration, hospitals need to satisfy all stakeholders by improving operational efficiencies, lowering costs through dedicated spine operating rooms with specialized spine surgical teams to achieve similar clinical outcomes and cost savings of ASCs. Safe, efficient patient surgical throughput cannot be overemphasized. Hospitals will need to demonstrate time-savings and financial benefits to surgeons while providing increased safety and improved outcomes to patients. Hospitals will have to lower inpatient costs to remain competitive in the eyes of payers. Novel and creative financial relationships will also need to be considered for inpatient surgeries to neutralize the monetary appeal of ASC ownership.
Richard Chua, MD. Northwest NeuroSpecialists (Tucson, Ariz.): Spine surgery in hospitals will be very different in 10 years. At the current rate of moving spine surgeries into the outpatient arena, and with the continued advancement of ERAS protocols, enabling technologies and minimally invasive strategies, most hospital-based spine surgeries will be complex spine procedures, or procedures for patients whose comorbidities substantially increase their risk of complications. Unless hospitals respond to improve OR efficiencies, turnover times, first case on-time starts and retain our professional OR staff, there will be a continued "bleed" of spine surgeries into the outpatient world.
Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): Spine surgery will follow the path of total hip and knee replacements. Over time, we have seen tremendous migration of these cases to the outpatient space. When possible, surgeons are able to successfully perform arthroplasty in an ASC. This is a great option for the healthy, active patient.
In spine surgery, we are seeing the same type of migration. Laminectomies and [anterior discectomy and fusions] are being performed in an ASC. As our awake spinal fusion program gets wider adoption, I predict that we will see an increase in outpatient lumbar fusions as well. Hospitals will continue to do spine surgery with a different mix of patients. Sicker and more complex cases will stay in the hospital. Cases that require more complex instrumentation will continue to be performed in the inpatient setting.
Progressive hospitals will partner with ASCs to develop combined programs. Currently, there are many joint ventures between ASCs and hospitals. In the future, hospitals should look to develop outpatient-focused factories — ASCs that perform either spine surgery or joint replacements very well. These focused factories should be connected to a disease-specific Center of Excellence. For example, a spine center connected to an ASC focused on spine surgery.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: In a decade, there will likely have been an involution of private, commercial insurance. Medicare may be more widespread, or at least some sort of universal, federal insurance. There will be widespread use of tools such as prior authorization and cut backs in terms of payment for surgery as CMS continues to try to discourage patients and physicians from having and doing surgery. Not all codes will be inpatient-only, and very likely the largest and highest-risk cases will be done in hospitals. More physicians will stop taking this universal insurance and our system will likely resemble the NHS of Great Britain. Patient satisfaction will likely go down, but apathy will rise. Private hospitals co-owned by physicians and investment firms will rise to offer private, boutique experiences for those that can afford it.
To stay competitive, hospitals will need to focus on doing good work and working with surgeon leaders who focus on good outcomes, rather than collective directorships like baseball cards. Reputations of hospitals will need to be earned, rather than reliant upon a name or affiliation. The hospital lobby will need to somehow stop the hemorrhage of cases by getting Congress to pay them more for their more acute cases or to make it harder for private ASCs to do business. But the only way in a free market for them to stay competitive, is to build efficient outpatient centers, and allow physicians to have leadership roles and to take the lead in terms of team building, OR efficiency and to hold everyone accountable.
Nitin Bhatia, MD. UCI Health (Orange, Calif.): As spine surgery and anesthetic techniques continue to improve, the opportunity to do a higher volume and a greater diversity of cases in ambulatory settings will grow. The efficiency of outpatient surgical centers, as well as potentially decreased surgery related cost, equivalent outcomes and greater patient convenience, will continue to drive spine surgery to the outpatient arena unless hospitals can match these outcomes measures.