Q: Has the transition to outpatient spine surgery been embraced by all providers?
Chris Zorn: There is certainly a trend in many regions of the United States to perform outpatient cervical and lumbar spine surgery. However, this trend is more of a local phenomenon. It is a combination of the strength of certain spine surgeons in a region and their relationship with hospitals in the community, as well as the state regulatory climate and payors. For example, some states will only provide approval for cases that can be discharged before dark of the same day of surgery and some approve a 23-hour overnight stay, assuming the proper staff is on site to manage any clinical issues. Some states only approve single level cervical fusions. Therefore, it is a mixed bag from state to state and region to region. If a patient has to be discharged by evening of the same day you have to be highly selective with regard to the patients you treat in an outpatient setting.
Q: What has been the impact of this transition to outpatient spine care?
CZ: Outpatient spine surgery has the potential to provide a more cost-effective way to treat patients and deliver services. All discussions about healthcare reform fit within this idea of finding more cost-effective ways to deliver procedures and therapies outside of traditional methods. Current healthcare reform efforts should accelerate the trend. The aging population and the potential to have more patients covered by insurance coverage are also potential accelerants. It is very important to note that not all patients are candidates for an outpatient spine procedure and not all spine surgeons want to perform these cases in an outpatient setting. The surgical team has to be very tightly knit and work very cohesively. Cases need to be scheduled appropriately to plan for post-procedure care and pain management and certainly the patient has to be well versed in the expected outcomes and activity restrictions.
Outpatient spine care came about as a result of advances in minimally-invasive surgical techniques. Although this is a term that is loosely defined, minimally-invasive techniques are intended to be less destructive and allow the surgeon to expose the minimum amount of tissue in the effort to correct the spine disorder. Minimally-invasive procedures typically require less recovery time, smaller wounds, less analgesia and therefore are less costly. A few years ago, a simple microdiscectomy took place in an inpatient setting and had an average three-day length of stay. Now that same procedure can be done in an outpatient setting in as little as 40 minutes with 3-4 hours of post-op care with rehab in another outpatient facility. What used to require a two-inch long incision, or more, now may only require a 20 millimeter incision, or less. The patient recovers faster and consequently gets back into the workforce quicker. The minimally-invasive technique is less destructive, more effective, less costly and allows for a quicker recovery. Again, it is important to note that not all patients, procedure and surgeons are candidates for outpatient spinal surgery procedures.
Q: Do you expect this trend to continue?
CZ: The current political climate in regard to healthcare reform has created growing pressure and opportunity to provide procedures more cost-effectively, which for many less complex spine procedures means moving procedures to the outpatient setting. Patients potentially can get pain relief and return to full function faster, payors can save money and surgeons can treat more patients so outpatient spine surgery does have great potential for growth. There is greater pressure than in the past for payors to hold delivery systems to be more productive and do more for less. With health insurance reform there will be the possibility of doing more procedures on more patients as insurance coverage potentially widens. Currently you have a good environment for procedure volume growth, but at possible lower procedure margin. Cost-effective outpatient facilities, well-staffed and well-managed, should do quite well. Those without good cost control, patient selection protocols and good and open communication channels with local payors will struggle. Assuming the outpatient market continues to expand, the impact on hospitals will be that the less complex spinal procedures will, for certain patient segments, leave the hospital and their case mix will become more complex with cases remaining in the hospital for good reason: to utilize the comprehensive patient care resources available in those facilities.
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