Becker's Spine Review

10 Spine Leadership There are other factors pushing spine cases out- patient as well; new pain management technol- ogy and spine innovation has made the transition possible, and payers are looking for high quality, low cost care settings. "Everyone is looking to decrease costs for spine procedures, and ASCs receive lower reimburse- ment than hospital outpatient procedures," says Stephen Hochschuler, MD, co-founder of Texas Back Institute in Plano. "With image intensifi- cation such as the O-arm and robotics, people are comfortable doing quality outpatient proce- dures because they are going to be more percu- taneous." Patients are also ahead of the curve when it comes to outpatient spine surgery. With the internet at their fingertips, patients are seeking out informa- tion about back pain and treatment to find the most beneficial care. People are asking for mini- mally invasive procedures and going to surgeons who perform them at outpatient centers. "My impression is with some of the new tech- nology, like robotics, outpatient spine surgery becomes much safer," says Dr. Hochschuler. "Additionally, the portable CT scan makes this a different world. Surgeons are getting used to it and it's becoming the paradigm of care. Years ago I decided to do myelograms outpatient and people thought I was crazy. Now everyone does them outpatient. Change is difficult to accept, but younger surgeons are accepting it more." In addition to the imaging and pain management technology, lateral procedures also make out- patient spine surgery attractive. The lateral ap- proach allows spine surgeons to avoid issues they face going through the abdomen or other tradi- tional approaches. Here are six key observations on where spine sur- gery and back pain treatment is headed: 1. Not all patients are a good fit for ASCs. "Start taking the healthy patients to the outpatient surgery center and then take older patients there as you feel more comfortable, if they're a good fit for outpatient surgery," says Dr. Hochschuler. "Be- gin with injections — nobody needs the hospital for injections. Then expand to laminectomies and discectomies. Whether they are percutaneous or open, that's a fail-safe procedure. Then go to fu- sions but make sure you have a good vascular sur- geon with you if they are anterior fusions." 2. The right expectations can make-or- break an outpatient case. "You have to be very conversant about what outpatient surgery means, what the benefits are and why you want to treat them in the outpatient setting," says Dr. Hochschuler. "Make sure patients are truly pre- pared with the right expectations." 3. Keep an eye on implant costs — they will be coming down. Implant costs are the bulk of overall cost per case, and for years smaller companies and distributors have been offering their specialized products for a discount. Now even the big companies are launching ASC-specific divi- sions including Johnson & Johnson's DePuy Syn- thes Select and Smith & Nephew's Syncera. Much like iTunes and Netflix disrupted traditional music and movie industries, device companies with lower cost structures and rep-less models are making a splash in healthcare today and forcing change. 4. Surgery centers run better than hospi- tals because of surgeon investment. "ASCs are one of the few opportunities surgeons still have to invest, and when surgeons own part of the facili- ty they demand it run better," says Dr. Hochschuler. "At our specialty hospital, which we still have own- ership in, we run outcomes tests and ask how pa- tients felt about their stay. The ownership also gives physicians an ancillary source of income." 5. Finding proper alignment will be the next focus in spine care. "Years ago, we weren't as concerned about proper anatomic alignment. We just stabilized the spine," says Dr. Hochschuler. "When you have proper alignment with the lumbar curve, all of a sudden the patient's balance comes back and they're able to do their therapy. These patients can recover more quickly and return home safely." There is also new technology such as AlignMed's patented NeuroBand Technology with the Pos- ture Shirt. The shirt is designed to relieve pain, improve balance, increase the range of motion, improve flexibility and increase recovery rate. The technology is working to improve core alignment and thermogenesis. 6. Non-operative solutions like core strengthening, conditioning and bracing will be crucial. "I think we're going to see the adoption of technology that is cheap, to prevent back problems and allow for better outcomes pre- operatively and postoperatively," says Dr. Hoch- schuler. "I have core strengthening and balance for my patients to go through and make sure they have the right posture. The American Heart Asso- ciation was extremely successful in their preven- tion campaign, and we should be the same way with back pain." n 6 Key Thoughts on Spinal Implants, Outpatient Surgery & Future Expectations (continued from cover) A study published in The Spine Journal examines the preoperative predictors of increased hospital costs for elective anterior cervical fusions. The study included 1,082 patients from a sin- gle institution. All patients underwent either one- or two-level anterior cervical fusions. Researchers analyzed the independent effects of preoperative planning characteristics on total hospital costs using multivariate linear regression models. The researchers found: 1. The patient's age, obesity and diabetes were all independently associated with increased average hospital costs. The higher costs include: • Age: $1,404 • Obesity: $681 • Diabetes: $1,877 2. The confidence interval for these costs were: • Age: $857 to $1,951 • Obesity: $285 to $1,076 • Diabetes: $726 to $3,072 3. The patient's age and diabetes were associated with longer length of stay and more complications. 4. Neither the patient's age nor whether they had diabetes had an impact on the operative time. 5. Obesity was not associated with increased length of stay, complications or operative time. n 5 Things to Know About Hospital Costs for Anterior Cervical Fusions By Laura Dyrda Dr. Stephen Hochschuler

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