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30 Executive Briefing: Outpatient Spine Surgery in ASCs Sponsored by: PARADIGM SPINE 5 Minimally Invasive Spine Surgery Trends for ASCs to Know By Heather Linder H allett Mathews, MD, MBA, is the Executive Vice President and Chief Medical Officer of New York City-based Paradigm Spine, LLC, a non-fusion spinal implant and device technology manufacturer. Dr. Mathews is also a board-certified orthopedic spine surgeon. Here are Dr. Mathews' five outpatient surgery trends that will have a substantial impact on spine physicians. 1. New innovation can make performing outpatient spine surgery easier. The pedicle screw for minimally invasive spine surgery, particularly fusions, has been routinely accepted for many years as the best method of fixation. However, Dr. Mathews says, pedicle screws are not necessarily a mainstay of decompression for spinal stenosis in outpatient spine surgery. "Pedicle screw fixation techniques are less invasive than older traditional methods, but there is a gap of evidence to prove they are always needed," he says. "Some of these devices can be placed in an outpatient setting, but surgeons are challenging whether pedicle screws are the best device to do that." Surgeons are discovering the concept of stabilization without fusion and are not necessarily performing fusion as their first choice for restabilization. Last fall, Paradigm Spine received FDA premarket approval for its coflex® Interlaminar Technology as a non fusion stabilization device for moderate to severe, one- or two-level lumbar stenosis with up to grade 1 spondylolisthesis in adult spine patients. The coflex procedure is designed as a less invasive approach, and does not require an inpatient stay. New devices, such as the coflex, are an example of motion preserving innovation pushing spine surgery into an outpatient setting, he says. "Older techniques, more traditional open techniques, have not proven to be better than newer, less invasive techniques with level one evidence as noted in the coflex® PMA study," he says. "The older technologies are being challenged and spine surgery is trending toward the outpatient setting." 2. Patients are searching for low-cost spine care. Historically, physicians have had little involvement with reimbursements at their facilities, Dr. Mathews says. Costs were not in the purview of a practicing physician, but now surgeons must be very aware of reimbursements and payors requirements. "The economy has challenged many elective and non-emergent procedures. Payors have exercised more control of pre-certs and denials of surgeries. Facilities are seeking favorable pricing for implants because of declining reimbursements from payors. More physicians are employed by institutions every year aligning the surgeon with the facility challenging the payors," he says, "This vertical restructuring of stakeholders brings the physician into the discussion and creates opportunity to perform appropriately invasive and cost saving procedures in the appropriate care setting." For physicians employed by ASCs, cost containment has become a greater priority. Physicians are looking for the "purist and safest, data driven, most financially-correct way to perform surgery," Dr. Mathews says. If they have not yet begun, surgeons need to shop around for lower implant costs, cut operational waste and work with payors ahead of time to ensure a patient's procedure is appropriately covered. Smaller settings have the advantage when it comes to lowering procedure costs and increasing efficiencies. "Surgeons need to make sure payors understand in advance that outpatient costs and savings versus inflated institution costs are well outlined," he says. "A smaller setting with more control in an outpatient surgery setting can lower the cost of healthcare, improve outcomes, and the surgeon gains efficiency. It's a win-win for all parties and a nudge toward performing more procedures in the outpatient setting." 3. Surgeons are more willing to adopt new techniques today. Typically, spine surgeons fall into three categories with technology adoption, Dr. Mathews says — there are traditionalists that adhere to the principles they were taught, there are fast followers and rapid adopters of new technology, and there are innovators of product, procedure and technique. Dr. Hallett Mathews While he does not foresee this changing, Dr. Mathews says surgeons must acknowledge there are economic forces challenging older techniques and outside pressure to stay current with new technologies. Patients are also driving market changes, including a move toward less invasive procedures. Patients are challenging traditional fusion as their only option of restabilization. Dr. Mathews says he has never had a patient come to his office wanting a spine fusion. In fact, medical education has taught surgeons how to overcome patient fears of fusions. He agrees that fusions are needed in some patients, and he offers that the coflex® PMA has segmented this patient group needing stabilization with fusion and those who can enjoy motion preservation with coflex®. Surgeons should also clearly communicate the definition of "minimally invasive" spine procedures. Dr. Mathews prefers the term "appropriately invasive," as varying size incisions are needed to address different pathologies. "The pathology needs to be addressed, and surgeons can apply concepts to become more minimally invasive for tissue sparing with fewer deleterious effects," he says. "Fifteen years ago, 'minimally invasive' meant through a tube. Now there are certain retractors that allow you to expand the tubular concept to become more appropriate for less tissue trauma." 4. Not all new technology will be beneficial. One concern about less invasive tech-