Becker's Spine Review

29 OUTPATIENT SURGERY 17 Observations on Total Joint and Spine Procedures at ASCs By Laura Dyrda A SC owners and operators across the country are considering whether to add or expand total joint and spine programs at their centers. Orthopedics has been a desirable specialty for several years, and minimally invasive techniques as well as advanced pain management allow patients to return home within 24 hours of surgery. However, reimbursement and payer issues coupled with rising consolidation in the healthcare space have slowed growth in the field. At the Becker's ASC Review 24th Annual Meeting: e Business and Operations of ASCs, held in Chicago on Oct. 27, Medline hosted a roundtable discussion on total joint replacement and spine surgery in the ASC. Most of the 30-plus ASC owners and opera- tors participating in the roundtable were cau- tiously optimistic or enthusiastic about the potential for outpatient total joint and spine procedures in the future. Here are 17 key takeaways from their discus- sion. Primary drivers for adding total joints 1. Physicians find the ASC a more efficient setting for total joint replacements, according to the CEO of an orthopedics-focused ASC in Michigan. In ASCs where surgeons currently perform total joint procedures, they're able to perform a more predictable and reproducible procedure at a higher volume per day than in the hospital. 2. Physicians are more satisfied in the ASC set- ting. ey are familiar with the staff caring for the patients and know the center will provide a comfortable experience. If surgeons know their patients will be highly satisfied, they are more likely to perform cases in the ASC. 3. A Georgia-based ASC's administrator re- ported a bundled payment deal with Blue Cross Blue Shield that has brought in signif- icant case volume. e center performed be- tween 300 and 350 total joints in 2017. e ASC compiled and provided data on quality and cost savings compared to the local hospi- tal. e center's administrator sees the payer engaging in additional efforts to drive ap- propriate patients to the ASC in the coming years. Other centers represented in the room are work- ing on bundled payments, including the Michi- gan-based surgery center, which will implement a bundle with self-funded employers. Howev- er, the administrator noted difficulty working with these companies because they still want to funnel their insurance operations through third-party payers that do not have a system to adjudicate bundled payments by employer. 4. While the Georgia-based surgery center has had tremendous success bundling total joint replacements with Blue Cross Blue Shield, a Texas-based administrator expressed frustra- tion over even scheduling an appointment with BCBS of Texas. Despite quality and cost savings data presented, the payer has refused to negoti- ate with his ASC, a small player in the market. Roadblocks for adding total joints 5. Obtaining data from physicians can be tough. One administrator reported compet- itiveness and embarrassment among his sur- geons; none wanted to make their data trans- parent to their partners. In centers with data transparency, key physician leaders led the charge to gather and report the data publicly. 6. In some markets, hospital-based total joint surgeons have difficulty conceptualizing to- tal joint replacements in the ASC setting. Whereas sports medicine physicians have experience and confidence in the outpatient setting, total joint replacement surgeons are more familiar with the slower pace of pro- cedures and recovery at the hospital; they would need to revise their workflow and ex- pectations to perform total hip and knee re- placements in the ASC. 7. ere is a significant cost to launching a total joint replacement program at ASCs, and physician owners must approve the expens- es. An administrator from a Nebraska-based ASC expects to launch a total joint program in the near future, and while the owners ap- proved all expenses, they were still surprised by lower distribution checks. She expects the program to ramp up in six months and see a return on investment in around 12 months. Observations on adding or expanding spine 8. Two surgery centers represented on the roundtable launched spine surgery pro- grams five to six years ago, but were unable to make the programs successful. Specifical- ly, implants were too expensive, and filtering patient selection to only the outpatient-ap- propriate cases meant volume was lower than anticipated. As a result, both centers discon- tinued their spine programs. 9. Payers are more receptive to negotiating spine surgery contracts with ASCs than they were two to three years ago, in part because Medicare developed spine codes for the ASC. However, the Medicare payments are too low to sustain the procedure in most centers, and if commercial payers set rates too low, these procedures could migrate back into the hos- pital setting. 10. Pain control is a challenge for spine cases in the ASC, especially for patients who have a high opioid tolerance. If patients are taken off of pain medication too quickly, they may need to be transferred to the hospital. Anes- thesiologists can mitigate this risk by collab- orating with physicians on patient selection. 11. e Michigan-based ASC's administra- tor reported spending four years developing their current contract for spine procedures, beginning with low-acuity cases and even- tually adding spinal fusions. She sees payers wanting to drive spine cases to the ASC, but believes they'll attempt to lower reimburse- ment in the future. 12. Endoscopic spine surgery is possible in ASCs with appropriately selected patients. However, there are few U.S. physicians trained in the procedure, and the equipment expense could exceed reimbursement for low- and mid-volume centers. 13. Robotic technology is available for total joint and spine procedures, but the equipment is expensive. Younger surgeons train on robots during residency and want to bring them into the ASC setting, especially if the local hospi- tal will not purchase the technology. Older surgeons who have spent 10 to 20 years suc- cessfully performing procedures freehand are less likely to find benefit in robotic technology, which could lead to a clash between owners. ere was one ASC administrator present whose physician owners wanted to market their center as a "high-tech" center; they al- ready own robotic technology and are look-

• Cover