Issue link: https://beckershealthcare.uberflip.com/i/1489874
17 THOUGHT LEADERSHIP based surgical patients will rely on the more comprehensive health systems as risk-averse behavior further defines administration of care. Issada ongtrangan, MD. Spine Surgeon at Microspine (Scottsdale, Ariz.): e inpatient setting will be more suitable in complex spine cases such as severe deformity, injection, tumor, etc. In addition, inpatient spine cases will be suitable for unhealthy patients or patients who have several comorbidities and/or need perioperative care from other specialties. Philip Schneider, MD. e Centers for Advanced Orthopaedics (Bethesda, Md.): Inpatient spine surgery has already changed. e future will be a dramatic further escalation of these changes. e inpatient setting will cater to older patients with medical co-morbidities, highly complex spine cases, and E.D. admissions. ese are patients that you anticipate will need co- management with the hospitalist service, will need a skilled nursing facility transfer, might require urinary catheter or drain management, will need pain management intervention due to pre-op opioid use, or may need blood transfusions. Everything else is slowly migrating to the ASC's right now. at trend will continue with more "at-risk" contracting, consolidation of healthcare, and private equity investments in ASCs. Reasonably healthy patients, including lumbar fusion cases, will migrate to the ASC's. is will be supported by better home care options, better pre-op preparation, better patient education, and ERAS initiatives. Emeka Nwodim, MD. e Centers for Advanced Orthopaedics (Bethesda, Md.): e future of spine surgery in the inpatient setting remains promising as it has been throughout its history. Although many spine procedures are transitioning to the ambulatory or outpatient setting, the beauty and uniqueness of spine surgery is its variety and complexity. ere will always be spine surgeries that should remain in the inpatient setting for the safety of the patient. Some examples include deformity correction, malignancy, and complex trauma. Such cases require the appropriate equipment, operating room technology, and multi- specialty support staff that primarily reside in the inpatient setting. With that being said, I believe that hospitals and health systems should prioritize healthy relationships with spine surgeons by supporting both inpatient and ambulatory surgery endeavors. is can be accomplished, and in some already existing circumstances, by supporting spine surgeons and patients with both clinical and technological support in both [inpatient and ambulatory] settings. By doing so, spine surgeons would be able to reliably perform outpatient surgeries when appropriate, minimizing costs to our healthcare system, maximizing patient care efficiency and ultimately optimizing inpatient utilization for more complex spine surgeries. Brian Gantwerker, MD. e Craniospinal Center of Los Angeles: My belief is that the ASC will become a larger part of spine surgery. Consequently, the hospital will see more difficult, complex and sicker cases. I think this is why (but not the sole reason) hospitals have lobbied successfully for higher reimbursements. e inpatient setting will be reserved for large deformity cases, severe postoperative complications and emergency cases that may or may not have adequate coverage. I imagine if private practice continues to shrink and the government will be wondering why healthcare is still so expensive, we will see a clash of the titans between insurers and hospitals. Just as right now, the government believes doctors' fees drive the cost of care and that by destroying fee for service, they can save money, the new narrative is that hospitals are charging too much, just as the insurance companies reap bigger profits not from premiums, but from government subsidies. We are already seeing that trend. en, when these two entities begin battling for revenue and the cutting of costs, patients will continue to lose. At the end of the day, the trend of inpatient surgery leaning towards more acute cases and more surgeons operating in private equity-owned ASCs will probably hasten that movement. I think the adaptability of surgeons to remain independent and partner with or start their own ASCs will be a potential route to remain viable as independent doctors. And the forces will push towards them only using the inpatient setting for their more difficult cases that will likely have longer lengths of stay. Hospitals may try to lobby for even higher increases — at which point CMS will likely balk. Will that lead to single payer? I don't know, but I think we are rounding the corner to that end. It is unfortunate for everyone, as without a doubt, a (for-profit) insurance company will assume control of that, and we all know how that song goes. Brian Fiani, DO. Weill Cornell Medicine/ NewYork-Presbyterian Hospital (New York City): e future of spine surgery in the inpatient setting will likely be more efficient and have more safety precautions. I would expect that hospital length of stays will drastically decrease as we continue to increase our efforts for minimally invasive surgery approaches that help patients back to their feet more quickly and have less morbidity. More surgeries will be performed at ASCs. With that in mind, the future of spine surgery in the inpatient setting will have a bottleneck effect, resulting in having only the more complex cases or trauma cases. Inpatient care pre-and-post operatively will likely provide patients with easily accessible information on their care with more transparency and improve the ease of understanding. Examples include QR codes that patients can scan with their phone or tablet to see all the desired pamphlets and informational videos about the spine surgeon's recommendations and instructions for recovery. Many institutions and organizations, including the Accreditation Council for Graduate Medical Education, have created programs, awards and fellowships encouraging the creation and implementation of ways to improve the physician-patient interaction, as well as, instituting safety measures for patients. Safety measures include the prevention of dispersing incorrect medications, improved charting methods and fall prevention techniques. Chester Donnally, MD. Texas Spine Consultants (Addison): With more "motion-sparing" technology there should be less of a need for inpatient care. Let's get our patients in and out and do the least amount of surgery with the biggest impact. Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): e future of spine surgery is more ASC and minimally invasive. Inpatient settings will always exist for complicated cases and complications. n