Cases migrating rapidly to ASCs, but hospitals will always be 'integral to spine surgery'

Spine

CMS, commercial payers and providers continue to push surgical procedures to outpatient settings, but many spine surgeons agree that hospitals will remain critical for the specialty.

Thirteen spine surgeons from health systems and private practices across the country share their thoughts on the future of spine care at hospitals and ASCs.

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 will artificial intelligence and machine learning look like in spine surgery in 10 years?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, Nov. 23

Editor's note: Responses were lightly edited for clarity and length.

Question: What does the future of spine surgery look like in the inpatient setting?

Barrett Woods, MD. Rothman Orthopaedic Institute (Philadelphia): There is a significant push to transition most surgical services away from inpatient facilities to lower cost outpatient centers. This pressure is being exerted on providers from many different sides, including payers, patients, practices and hospital systems. As reimbursement declines and margins become razor thin, providing care in lower cost outpatient facilities seems to be a reasonable evolution. With advancements in minimally invasive techniques, perioperative anesthesia and postoperative pain protocols, a vast array of spine surgeries can and are being performed in the outpatient setting daily. This trend will continue.  

The concern for most surgeons is patients developing catastrophic perioperative complications while home and not within the hospital where immediate intervention can be performed. Strict adherence to exclusion criteria, perioperative optimization and evaluation of a patient's social situation are critical to successfully perform spine surgery in this setting.

Jeremy Smith, MD. Hoag Orthopedic Institute (Irvine, Calif.): In the last 10 years, we have seen larger surgeries transition to the outpatient setting and we anticipate this trend will continue. Minimally invasive spine surgeries will continue to gain popularity and replace many traditional methods.

For patients who require major reconstructive or revision surgeries, there will still be a need for inpatient stays and the multidisciplinary care it provides. However, reconstructive surgery will be performed with greater precision, leading to shorter stays and quicker recoveries from these procedures. 

I believe spine surgeons over the next 10 years will perform most of their surgeries in the outpatient setting and this will help optimize value-based care. 

Colin Haines, MD. Virginia Spine Institute (Reston): The future is moving to a more minimally invasive approach. Smaller incisions and less muscle disruption can achieve the same goals that previously required larger operations. With the technology at hand, we can achieve the same results but with less collateral damage to the body, so better outcomes on a faster timeline. As a byproduct of the minimally invasive approach, the surgeries do not often require the same length of stay that they previously did.  

However, the reality is that not all surgeries are outpatient. Spinal deformity, complex revision surgeries and tumor/trauma are not appropriate for the outpatient setting. In the hospital setting, early activity protocols are critical. At our institution, we have been at the forefront of expedited recovery while still in the hospital setting, so-called enhanced recovery after surgery protocols. As part of this, we can provide pain control without IV medications using a multimodal approach, including oral narcotics, non-narcotic medications, ambulation from the post-op stretcher to the bed, early catheter removal and intensive physical therapy. The result is better pain control, quicker hospital stays, fewer inpatient rehabilitation stays and better patient outcomes.

Although the trend is towards surgery in ASCs, I believe the hospital will always be integral to spinal surgical care. However, for inpatient care to be optimized, it needs to mimic many of the aforementioned benefits that are achieved in the outpatient setting.

Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): The current trend in spine surgery is shorter, less-invasive surgeries. There also is pressure from insurance carriers — transmitted via hospitals — to classify patients as "outpatients" as much as possible. The result is that inpatient censuses will continue to drop. There will be three groups of inpatients: 

1. Those who have undergone surgeries which are typically outpatient, but are too medically ill to leave (almost always from pre-existing morbidities)

2. Those who have undergone larger surgeries that are not appropriate to be classified as outpatient.

3. Those who require either neurological monitoring or pain management for an extended period of time. In other words, the inpatient trend will continue towards patients being older and sicker, and having undergone large, complex surgeries.

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: The significant trend of migrating degenerative spine surgeries to the ASC setting will undoubtedly continue. Lumbar laminectomies, ACDFs, and single-level lumbar fusion procedures are being regularly done at ASCs currently. This will continue to grow, much as total joint procedures have done. Awake spine surgery for laminectomies and lumbar fusions have made the postoperative recovery even faster for patients to facilitate same day return to home. The inpatient setting will be reserved for patients with complex comorbidities that make inpatient stays more necessary or patients who need more long-term monitoring. Larger cases, including multilevel fusions and spinal deformity surgeries will continue to be done in the inpatient setting for now. Overall, the complexity of care in the inpatient setting will increase as the trend towards outpatient surgeries increases. 

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The post-pandemic reality of surgical volumes has had a direct effect on inpatient admissions and resultant revenue streams to larger and medium health systems alike. Staffing shortages, occupational realignments and inexperience are another new convention. The siphon effect and inurement of the for-profit medical culture have dramatically changed risk-adjusted and under-insured patients seeking care in larger more accepting institutions. The more vulnerable usually carry a higher ASA score and require more compounded attention and substructure. Assuredly, the more complex and tedium-based surgical patients will rely on the more comprehensive health systems as risk-averse behavior further defines administration of care. 

Issada Thongtrangan, MD. Spine Surgeon at Microspine (Scottsdale, Ariz.): The inpatient setting will be more suitable in complex spine cases such as severe deformity, injection, tumor, etc. In addition, inpatient spine cases will be suitable for unhealthy patients or patients who have several comorbidities and/or need perioperative care from other specialties.

Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Inpatient spine surgery has already changed. The future will be a dramatic further escalation of these changes. The inpatient setting will cater to older patients with medical co-morbidities, highly complex spine cases, and E.D. admissions. These are patients that you anticipate will need co-management with the hospitalist service, will need a skilled nursing facility transfer, might require urinary catheter or drain management, will need pain management intervention due to pre-op opioid use, or may need blood transfusions.

Everything else is slowly migrating to the ASC’s right now. That trend will continue with more "at-risk" contracting, consolidation of healthcare, and private equity investments in ASCs. Reasonably healthy patients, including lumbar fusion cases, will migrate to the ASC’s. This will be supported by better home care options, better pre-op preparation, better patient education, and ERAS initiatives. 

Emeka Nwodim, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): The future of spine surgery in the inpatient setting remains promising as it has been throughout its history. Although many spine procedures are transitioning to the ambulatory or outpatient setting, the beauty and uniqueness of spine surgery is its variety and complexity. There will always be spine surgeries that should remain in the inpatient setting for the safety of the patient. Some examples include deformity correction, malignancy, and complex trauma. Such cases require the appropriate equipment, operating room technology, and multi-specialty support staff that primarily reside in the inpatient setting.

With that being said, I believe that hospitals and health systems should prioritize healthy relationships with spine surgeons by supporting both inpatient and ambulatory surgery endeavors. This can be accomplished, and in some already existing circumstances, by supporting spine surgeons and patients with both clinical and technological support in both [inpatient and ambulatory] settings. By doing so, spine surgeons would be able to reliably perform outpatient surgeries when appropriate, minimizing costs to our healthcare system, maximizing patient care efficiency and ultimately optimizing inpatient utilization for more complex spine surgeries. 

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: My belief is that the ASC will become a larger part of spine surgery. Consequently, the hospital will see more difficult, complex and sicker cases. I think this is why (but not the sole reason) hospitals have lobbied successfully for higher reimbursements. The inpatient setting will be reserved for large deformity cases, severe postoperative complications and emergency cases that may or may not have adequate coverage.  

I imagine if private practice continues to shrink and the government will be wondering why healthcare is still so expensive, we will see a clash of the titans between insurers and hospitals. Just as right now, the government believes doctors' fees drive the cost of care and that by destroying fee for service, they can save money, the new narrative is that hospitals are charging too much, just as the insurance companies reap bigger profits not from premiums, but from government subsidies. We are already seeing that trend.  

Then, when these two entities begin battling for revenue and the cutting of costs, patients will continue to lose. At the end of the day, the trend of inpatient surgery leaning towards more acute cases and more surgeons operating in private equity-owned ASCs will probably hasten that movement. I think the adaptability of surgeons to remain independent and partner with or start their own ASCs will be a potential route to remain viable as independent doctors. And the forces will push towards them only using the inpatient setting for their more difficult cases that will likely have longer lengths of stay. Hospitals may try to lobby for even higher increases — at which point CMS will likely balk. Will that lead to single payer? I don't know, but I think we are rounding the corner to that end. It is unfortunate for everyone, as without a doubt, a (for-profit) insurance company will assume control of that, and we all know how that song goes.

Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): The future of spine surgery in the inpatient setting will likely be more efficient and have more safety precautions. I would expect that hospital length of stays will drastically decrease as we continue to increase our efforts for minimally invasive surgery approaches that help patients back to their feet more quickly and have less morbidity. More surgeries will be performed at ASCs. With that in mind, the future of spine surgery in the inpatient setting will have a bottleneck effect, resulting in having only the more complex cases or trauma cases. Inpatient care pre-and-post operatively will likely provide patients with easily accessible information on their care with more transparency and improve the ease of understanding. 

Examples include QR codes that patients can scan with their phone or tablet to see all the desired pamphlets and informational videos about the spine surgeon's recommendations and instructions for recovery. Many institutions and organizations, including the Accreditation Council for Graduate Medical Education, have created programs, awards and fellowships encouraging the creation and implementation of ways to improve the physician-patient interaction, as well as, instituting safety measures for patients. Safety measures include the prevention of dispersing incorrect medications, improved charting methods and fall prevention techniques.

Chester Donnally, MD. Texas Spine Consultants (Addison): With more "motion-sparing" technology there should be less of a need for inpatient care. Let's get our patients in and out and do the least amount of surgery with the biggest impact.

Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): The future of spine surgery is more ASC and minimally invasive. Inpatient settings will always exist for complicated cases and complications.

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