Becker's Spine Review

9 THOUGHT LEADERSHIP What's holding back outpatient spine growth? By Carly Behm O utpatient spine surgery has grown significantly in recent years thanks to new technologies and the adoption of minimally invasive techniques. However, some factors in the healthcare industry are slowing its trajectory. Six spine surgeons spoke with Becker's to discuss what's holding back outpatient spine migration. Note: Responses were lightly edited for clarity. Question: What is one factor holding back outpatient spine migration? Harel Deutsch, MD. Co-Director of the Rush Spine Center (Chicago): I would say that pain management after surgery is one of the key factors limiting spine migration. Spine surgeries are painful and different patients have different responses to surgeries, with some patients having exaggerated pain responses requiring more immediate nursing care. While generally, most patients could have outpatient surgeries, it can be difficult to predict which patient will need a longer stay. Joseph Ferguson, MD. MedStar Health (Washington, D.C.): It's really the partnership with anesthesia. You look at the places that are doing high volumes of outpatient surgery, and it's the continuum of care from the time the patient hits the surgery center until the time that they leave and how effective we are at preoperative and postoperative pain control. There's pain medicine that we administer preoperatively. We've learned a lot from our total joint colleagues about how to do anesthesia during surgery and then the recovery time after anesthesia and then pain control after the patients are discharged from same-day surgery. All of that is really almost outside of the surgeon's control, or most of it. We can do local pain medication at the time of surgery to help with that. But that's in conjunction with a lot of the things that the anesthesia providers do before, during and after the surgery. Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): One factor holding back outpatient spine migration is the reluctance of some healthcare providers to adopt new technologies and techniques. Many traditional surgeons may be hesitant to change their practices and adopt minimally invasive procedures, which can limit the availability of outpatient spine surgery options for patients. Additionally, insurance coverage and reimbursement policies may not always align with the shift towards outpatient procedures, creating barriers for both healthcare providers and patients. Arya Shamie, MD. UCLA Health (Los Angeles): One significant factor holding back outpatient spine migration is the concern over patient safety and postoperative care. Complex spine surgeries often require extended monitoring and management of potential complications, such as bleeding, infection, or neurological issues, which are more easily managed in an inpatient setting where immediate medical intervention is available if needed. Alok Sharan, MD. Spine and Performance Institute (Edison, N.J.): There have been a lot of incentives that are pushing many spine surgeries to be performed outpatient. One factor holding it back is the lack of standardization in how we optimize patients prior to surgery. We have started an IV nutrition program that has been helpful for post-op recovery. Beyond the use of nutrition to help with wound healing, we are seeing tremendous results when we use a combination of amino acids along with nutrition to reduce inflammation. Many patients who undergo surgery with our awake spinal fusion protocol are going home within four hours of surgery, and are taking minimal opioids post surgery. As we are learning to optimize patients better prior to surgery, I am predicting that we will soon be able to offer opioid-free spinal fusion surgery. William Taylor, MD. University of California San Diego Health: We need to develop navigation and robotics that work well in the outpatient setting. n controlling their consumption. is is not to demonize payers, large healthcare systems or hospitals as their good will and participation are paramount to establishing true value-based care. One of the first steps, and what I believe is the most important, is to establish trust amongst all parties involved, including patients, providers, medical staff, payers, healthcare systems and hospitals. I believe compromise would soon follow. Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Value-based care is a healthcare delivery model under which all providers are contracted and reimbursed on the health outcomes of their patients and services rendered. Under some value-based contracts, there is shared financial risk and potential incentives for providing high-quality, efficient care. While quality care can be provided under both a VBC and Traditional Model, the aggregate management in VBC's management/paid and theoretically saved healthcare dollars streamline the process. In my opinion, the failure of this system is lack of participation by all physicians especially in the for-profit, physician-owned surgical system where metrics are neither collated nor applied. e over-lengthened pandemic and its financially disastrous effects to the entire healthcare system are more semblant as reimbursements from federal, state and private insurers have diminished, resulting in capital project and purchase curtailment has waned. e foreboding trends of unrealizable VBC are being redefined as prohibitive and withholding of care, especially in regard to the underserved and the complicated/chronic disease affected. Fine tuning of healthcare delivery is no longer the objective but rather a resource management issue for all physicians, fraught with delays and added scrutiny. n

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