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16 SPINE SURGEONS Dr. Daniel Lieberman: How hospitals will react to outpatient migration and what's next for spine surgery at ASCs By Alan Condon D aniel Lieberman, MD, medical director at Phoenix Spine & Joint, spoke to Becker's Spine Review about outpatient migra- tion, how hospitals will compete in orthopedics post-pan- demic and the future of spine surgery at ASCs. Question: How much of an effect has COVID-19 had on outpatient migration of spine and total joint surgeries? Dr. Daniel Lieberman: COVID-19 is the catalyst that is rapidly accelerat- ing changes that were already occurring in the orthopedic space. For several years, spine has been slowly migrating toward the ASC, but now it's galloping over. Patients don't want to have surgery in the hospital if they can avoid it. Spine patients in particular don't need anything else on their plates. Commer- cial spine was already largely migrated, but now we're seeing it even more with Medicare patients. Innovations in robotic-assisted knee replacement and minimally in- vasive approaches to hip replacement have contributed to more joint replacements moving toward the ASC. COVID-19 has also accelerated this. We are seeing more patients coming in for robotic-assisted knee and minimally invasive hip replacements. Our center has leading joint replacement robots from Smith+Nephew and Stryker. Q: How has the pandemic affected spine surgery at your practice? DL: We now do as much joint surgery in our centers as we do spine surgery. Due to COVID-19, we are seeing more patients having spi- nal fusions in the ASC, as many of them are not willing to go to the hospital. In the past, a patient and surgeon may have opted to do the procedure at the hospital. Now, we're seeing the opposite. Patients are telling surgeons that they will not have their procedure done at a hos- pital. Similarly, surgeons are recalibrating risks for ASCs, because the risk of going to the hospital is higher. Q: What do you see as the next big trend in spine for ASCs? DL: Over the last five years, we've seen real energy pulling away from deformity correction and multilevel fusion surgery, and the entire field of spine surgery moving into much more focused interventions based on structure. I think the next horizon is focused interventions based on symptoms. What patients really are concerned about is their pain. Our surgery centers offer endoscopic dorsal rhizotomy, so ul- tra-minimally invasive surgeries that eliminate pain are really the next horizon. It's almost like we're going to see spine surgery absorb and move into more of a pain management approach, rather than a struc- tural correction approach. Q: What is the biggest shift in how patients view ASCs and hospitals now? DL: For a long time, I think ASCs were viewed as a place where you could have a minor procedure. As the sophistication of ASCs increased, they were viewed as an alternative for some procedures that were normally done at the hospital, but if the patient was really weary of the hospital it could be done in an ASC. Now, I think we're seeing a complete para- digm shi — these elective procedures are normally going to be done at an ASC, regardless of their complexity, and the hospital will be reserved for people with special medical needs, or who need more urgent care. e safety of procedures at ASCs, lower infection rates and the desire of phy- sicians to offer patients an experience in a more comfortable setting are big factors contributing to patients opting to have their elective surgeries done at an ASC. COVID-19 has also accelerated this. Q: How do you see hospitals competing with ASCs post-pandemic? DL: Hospitals are not going to stay on the sidelines. ey can't let their golden egg leave the goose. ey're going to have to be heavily in- volved in ASCs, so they're going to be another stakeholder that will get even more fired up and involved in our industry. Q: How will you be looking at growth in 2021? DL: We're seeing rapid growth in the number of surgeons who want to operate primarily in an ambulatory setting. Our physician recruitment is exponentially higher than it has ever been. We initially thought the transition to the ASC environment was going to take place over the next five to 10 years, but now I think it's going to over the next one to five years. So, we're opening a new surgery center in Gilbert, Ariz. — our biggest center yet. We've already recruited most of the physicians we need to fill it. We're seeing this as a new period of growth for ASCs, coming on top of an old period of growth. e ASC market has been getting bigger and stronger for years, and we see that continuing to increase in the future. ere is a lot more business to do. Q: At the start of the pandemic, we saw many patients postpone orthopedic surgeries due to safety concerns. Are you still seeing patients reschedule surgeries now af- ter so much time has passed? DL: It's just not viable for these patients to postpone surgeries any lon- ger. Many patients put off getting the care that they needed during the pandemic, but COVID-19 hasn't helped anybody's arthritis. A lot of those patients with ongoing joint problems are now worse off than be- For several years, spine has been slowly migrating toward the ASC, but now it's galloping over.