How technology, CMS are affecting site of service in spine surgery

Alan Condon -  

As spine surgery continues to accelerate towards the outpatient space, it is becoming more evident that fewer procedures will be performed in the inpatient setting.

Complex procedures such as spinal deformities, tumors, trauma and infections will always be optimized at hospitals as well as procedures that involve patients with complex medical comorbidities.

But ASC and surgeon leaders have demonstrated over the past decade that procedures such as multilevel arthroplasties, complex fusions and spinal decompressions can be safely done in the outpatient setting, largely made possible by advancements in minimally invasive surgical technology and techniques.

In the next five years, Michael Gordon, MD, of Hoag Orthopedic Institute in Orange County, Calif., predicts that most one- and two-level cervical spine surgeries and one-level lumbar fusions will be outpatient. He expects improvements in imaging technologies to be a significant driver of this movement, with "ease of use, reliability and cost," particularly in robotic platforms coming into play.

"Inpatient surgery will be predominantly multilevel fusion and decompression surgeries on an aging population with multiple comorbidities," Dr. Gordon said. "Complex reconstructions and tumor surgery will be the most commonly performed inpatient procedures."

Brian Gantwerker, MD, of Craniospinal Center of Los Angeles, told Becker's that CMS effectively "sounded the death knell for inpatient spine" when the agency decided to eliminate the inpatient-only list by 2024.

"Surgery centers will contain the bulk of surgical cases, both in terms of minimally invasive surgery as well as two-level lateral and most multilevel arthroplasty cases," Dr. Gantwerker said. "I sincerely hope surgeons will continue to use good judgment as to who should and should not have surgery on the inpatient side. "

However, CMS could slow the migration of some spine procedures to the outpatient setting after it proposed in July to bump 298 musculoskeletal-related procedures back to its inpatient-only list next year and also halt the elimination of the list. Of those 298 procedures, 71 relate to spine surgery.

The proposal has been described as "an obvious step backwards" by many ASC administrators and orthopedic surgeon leaders have called for the agency to revisit the proposal with more input from physician stakeholders.

"Making blanket statements that this procedure must be done inpatient, or this procedure must be done outpatient, is not the right approach," Owen O'Neill, MD, president of the board of directors at Golden Valley, Minn.-based Twin Cities Orthopedics, told Becker's. "The right approach is that the physician, who takes care of the patient and has an informed, shared decision-making process with that patient, decides where the best site of service is for many of these procedures."

Hospital and health systems will be encouraged by the proposal to halt the elimination of the inpatient-only list, but realize the significance of developing a broader outpatient strategy.

Minneapolis-based Allina Health is one such system that is expanding its outpatient network, where it plans to move many of its higher-acuity spine and orthopedic cases, away from hospital outpatient departments.

Hospitals and health systems will become more heavily involved in setting up and managing ASCs to recapture lost revenue from these higher-acuity cases, but deciding who their physician and ASC partners are will be critical to their success in the coming years.

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