Becker's ASC Review

67 ORTHOPEDICS How key spine trends are shaping up in 2021 By Alan Condon D ownward pressure on reimburse- ment, rising consolidation and rapid outpatient migration are some of the key trends affecting the spine field. While the Coronavirus Aid, Relief, and Economic Security Act provided critical eco- nomic relief to many orthopedic practices last year, surgeons knew that government funding would come at a price. CMS reimbursement and physician fee cuts were expected for 2021, but many provid- ers were shocked at how steep they were — initially an up to 10.2 percent decrease in reimbursement for some specialists. In December, however, CMS updated the Physician Fee Schedule to reflect the changes in the Consolidated Appropriations Act. e revised conversion factor for 2021 is $34.89, 3.3 percent less than the conversion factor in 2020. ough the most recent COVID-19 stimulus package has mitigated CMS cuts, many surgeons fear more could be on the horizon from CMS and commercial payers. "e hamster wheel is going to get driven fast- er for less," Lali Sekhon, MD, PhD, of Reno (Nev.) Orthopedic Center, told Becker's. "With so much money spent at a state and federal level on COVID relief, reducing payments for Medicaid and Medicare are in the pipeline." One strategy providers are increasingly adopting to address economic challenges is banding together to form larger groups. Over the past year, the orthopedic field has seen three supergroups of 100-plus physi- cians created through mergers in Florida, Tennessee and Texas. Although the pandemic somewhat stifled innovation last year, navigation, robotics and augmented reality technologies continue to make noise in spine. But hospitals and health systems may be less willing to fork out capital for the next "game changer" given the challenging economic cli- mate and accelerating outpatient migration trends. Smaller device companies will likely feel the pinch as hospitals look to reduce costs wherever possible. "Medical device companies will have to adapt to this new normal and offer services to sur- geons to help them transition their practice to the outpatient space," said Alok Sharan, MD, of NJ Spine and Wellness in East Brunswick. Such services include AR/virtual reality technologies to train surgeons and staff, along with digital tools to facilitate remote patient monitoring. More ASCs will likely invest in robotics as hospitals expect to lose an increasing num- ber of spine cases over the next five years, according to Vladimir Sinkov, MD, of Sinkov Spine Center in Las Vegas. "Hospitals still have a lot of capital they can invest, where surgery centers are typically starved of capital, which is why it makes sense to partner," Dr. Sinkov said. "In my opinion, outpatient migration of spine surgery will encourage surgery centers to rent or purchase surgical robots and other advanced technol- ogy to drive that exodus even faster." For hospitals, the issue now is the value on investment, according to Martin Roche, MD, of Hospital for Special Surgery in West Palm Beach, Fla. "e key now will be how companies sell their robots both to hospitals and to ASCs," Dr. Roche said. "Right now, as surgeons are investors in ASCs, they're going to be more introspective on how much money they put up front. "In certain cases the business model of how companies are selling robots will change. ey may link it to how many cases you do, which can help pay it down, and develop various 'at risk' models. I think orthopedic companies are drawing up different types of business models because they see robotics as the future as well." All these factors are likely to accelerate the trend toward outpatient surgery, in addition to new prior authorization requirements and CMS and commercial payers encouraging more cases to be done at ASCs. One thing is for certain: e future is bright for the ASC industry, which continues to bring cases to the outpatient setting. n Minimally invasive TLIF more cost-effective than open surgery By Laura Dyrda M inimally invasive transforaminal lumbar inter- body fusion is more cost effective than the open procedure, according to a study published in The Spine Journal on Jan. 22. Study authors reviewed the literature in several databas- es, including PubMed and ClinicalTrials.gov, with results from open and minimally invasive TLIF procedures to treat spondylolisthesis, lumbar instability or degenerative disc disease. There were 32 studies included in the analy- sis, with nine directly comparing the two procedures. Four takeaways: 1. Cost effectiveness for open TLIF ranged from $47,303 to $218,766 per quality-adjusted life year. 2. For minimally invasive TLIF, cost effectiveness was mea- sured at $121,105 per quality-adjusted life year in one study where it was cited. 3. One meta analysis of hospital prospective costs for both techniques showed the open procedure cost around $2,650 more than the less invasive procedure. 4. The study authors concluded both the open and minimally invasive TLIF procedures were expensive when measured against the baseline $50,000 per quality- adjusted life year, but the minimally invasive technique could be more cost-effective. n

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