Is outpatient migration stifling spine investment at hospitals? 5 surgeons weigh in


The shift of spine procedures to the outpatient setting has gained momentum in recent years as commercial payers boosted coverage, devicemakers refocused their strategies and surgeons warmed to the idea of operating on patients at ASCs.

The COVID-19 pandemic has accelerated this trend, but is outpatient migration hindering hospital investment in spine technology, or are hospitals and health systems refocusing investment strategies to align with moving trends?

Five surgeons told Becker's what they're seeing in their organizations and markets.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next week's question: What dangers should the healthcare community be mindful of when marketing and patient care collide? 

Please send responses to Alan Condon at by 5 p.m. CST Wednesday, Jan. 12.

Editor's note: The following responses were lightly edited for style and clarity.

Question: Has outpatient migration stifled hospital investment in spine care?

Roy Vingan, MD. New Jersey Brain and Spine (Oradell): This is a very important question that may vary by hospital system. Capital outlay from the hospital will usually be weighed against two concerns:

1. What is the predicted return on investment?

2. The desire to be competitive/remain relevant in the local environment.

With loss of cases and revenue to outpatient centers, hospitals could compete with aggressive marketing of new technology that may be out of reach to many outpatient facilities. In our case, there is investment going forward, but some hesitancy is noticed.

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): We are staying ahead of this outpatient trend at NorthShore. We established a specialty hospital for spine and orthopedic surgery a few years ago. In doing so, we've combined the advantages of highly specialized care, economies of scale, a fully equipped hospital and the efficiency of outpatient surgery. In addition, we've created a seamless transition between inpatient and outpatient status and care. NorthShore is also expanding services by adding additional operating rooms dedicated to an expanded outpatient footprint, providing both hospital and outpatient services.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Not particularly. I think it has for the most part stagnated during the COVID-19 pandemic. A great deal of the "big" money that was to be made has been made. There are still ways to turn a profit but the aggressive marketing of ASCs to surgeons has really cooled off. Now, most centers are figuring out ways to stay afloat and hopefully turn a profit, but the diminution of payments by commercial payers following CMS' lead is going to create significant financial stressors on these centers. The hospitals stand to gain, of course, and I am sure their lobbying bodies are quite pleased. But, with the right mix of payers and strong financial relationships, smart ASCs can try to contract directly with employers and push out the insurance companies from that in-between space and hopefully provide a safe and valuable patient experience and outcome.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Outpatient procedures and same day spinal surgery discharge have enhanced awareness for greater volumes. Physician/patient migration to for-profit situations have hamstrung larger healthcare systems in the past and subsequently resulted in recruitment and employed modeling as a countermeasure. Complex spinal cases remain the benchmark for full-service facilities. Yet the focus on the early discharge awareness and execution of this newfound culture has enhanced 'same day' surgical outlooks. The looming crisis of staff shortages continues to hamper full ramp-ups within scheduling, but efforts continue to accommodate the busiest of surgeons. 

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): Outpatient migration has not stifled investment in spine care for those hospitals that have understood that much of healthcare is transitioning to the outpatient space. Progressive hospitals have already been planning for this by building ASCs or hospital outpatient departments. They have created [enhanced recovery after surgery] or fast track programs to expedite care through an episode. Operating rooms are equipped with the proper equipment that enable spine surgeons to perform minimally invasive surgery with a faster recovery, either through the use of an endoscope or proper imaging tools. 

Hospitals must understand, like every business, that change is the only constant. The traditional hospital business model of making revenue through inpatient admissions will exist, but in limited form. The future model of care will be outpatient focused factories that merge specialized centers of excellence with outpatient ASCs. The migration of cases to the outpatient space should encourage hospitals to rethink their business models and invest in capabilities which can achieve these goals.

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