Brian R. Gantwerker, MD, of The Craniospinal Center of Los Angeles, discusses the quality and cost benefits of performing spine surgery in ambulatory surgery centers and what it will take for Medicare to reimburse for these procedures in the future.
Q: When will Medicare approve reimbursements for spine surgery in ambulatory surgery centers?
Dr. Brian Gantwerker: I think it will be necessary for Medicare to start covering outpatient spine surgery in terms of a viable business model for healthcare. Surgery centers can perform minor spine operations, such as a minor spinal decompression and cervical procedures, safely and more cost effectively than in hospitals. If Medicare is serious about cost savings, they probably need to move some of these smaller procedures in carefully selected patients to an outpatient setting. It cost almost a tenth of the amount to do a lumbar microdiscectomy in a surgery center than a hospital; this is a real cost savings.
Q: Covering spinal surgeries in outpatient ASCs seems intuitive from a cost and quality standpoint. Why are there still barriers for Medicare coverage? Will surgeons be able to overcome these roadblocks in the future?
BG: Unfortunately, there may be various reasons why it will be difficult to gain Medicare coverage for spinal surgery in ASCs. There is a lot of pressure for hospitals to create accountable care organizations to keep physicians in an organized, managed fashion. The hospitals probably stand to lose considerable business if Medicare moves spine to an outpatient setting.
Q: Medicare patients often have higher comorbidities and other special considerations. Will surgery centers be able to accommodate for this population if Medicare does reimburse for them?
BG: I think surgery centers could support them. It would behoove Congress to look at supporting the surgery center model to maintain the viability of the entire Medicare system. Obviously, patients need to be very carefully selected for. Not just in spine, but spine is a great place to start.
Upper endoscopies, angiograms, and kyphoplasty are already done in an outpatient setting. It may be that doing a single level microdiscectomy or minimally invasive decompression would allow these patients to get their care, in a safe setting, and show real cost savings to the federal program.
Another aspect, is that hospitals can and have done joint ventures with physician-owned surgery centers. Essentially, everyone wins in this model. The hospital can get the services done and get their facility fees, Medicare gets their patients taken care of at a lower cost and the physician has the satisfaction of a job well done in a an outpatient setting.
Q: What will prompt this change? Is there anything spine surgeons or surgery centers can do to promote this change more quickly?
BG: We have to go to Congress and show them the numbers. I don't think there is any other way they are going to understand it unless they see what it really costs to have a patient treated in the outpatient setting. I think it's mandatory that we have to show them these costs and establish a relationship with Congress.
By working within our professional organizations, such as North American Spine Society and the American Association of Neurological Surgeons, and create a lobby for outpatient spine. We need to show them the cost savings and help them realize the impact of performing carefully selected spinal cases in surgery centers.
Q: Are physicians ready to perform these types of procedures in the surgery center? In the immediate future, will they be able to advocate for Medicare reimbursement?
BG: Maybe all it takes is a conversation; it just takes a group of individuals who could present a brief and codified statement that says outpatient spine surgeries are just as safe and effective as in the hospital and realize the cost savings. There may be obvious hesitations and concerns about patient safety, but there are higher morbidity procedures being performed in the outpatient setting. The obvious caveat is the patients — how old? Is there a cutoff? What is an acceptable risk? How do we stratify these patients?
It's going to require a very strong group of individuals who will go to Congress and present hard data on cost savings.
As a whole, a lot of surgery centers are able to access what their fee schedules are for certain procedures and provide that to Medicare with a cost analysis. Compare the procedure in both settings, including anesthesia, and I think it would demonstrate a tremendous cost savings. There is a lot of motivation to return patients home comfortably and provide very good care for them.
As physicians all want Medicare to work; nobody wants the system to fail. We want patients to be able to afford their healthcare and have a certain level of confidence in their physicians and system they paid into for the past 50 years. Physicians are willing to make this work but we need partners in Congress and surgery centers to show it is a viable option to have spine surgery in the outpatient setting when it is safe, appropriate and most importantly, when it's in the patient's best interest.
More Articles on Surgery Centers:
7 Signs the Time is Right for Surgery Center Expansion
5 Tips for Collecting in Full From Out-of-Network Payors
The ABCs of an Effective ASC
Q: When will Medicare approve reimbursements for spine surgery in ambulatory surgery centers?Dr. Brian Gantwerker: I think it will be necessary for Medicare to start covering outpatient spine surgery in terms of a viable business model for healthcare. Surgery centers can perform minor spine operations, such as a minor spinal decompression and cervical procedures, safely and more cost effectively than in hospitals. If Medicare is serious about cost savings, they probably need to move some of these smaller procedures in carefully selected patients to an outpatient setting. It cost almost a tenth of the amount to do a lumbar microdiscectomy in a surgery center than a hospital; this is a real cost savings.
Q: Covering spinal surgeries in outpatient ASCs seems intuitive from a cost and quality standpoint. Why are there still barriers for Medicare coverage? Will surgeons be able to overcome these roadblocks in the future?
BG: Unfortunately, there may be various reasons why it will be difficult to gain Medicare coverage for spinal surgery in ASCs. There is a lot of pressure for hospitals to create accountable care organizations to keep physicians in an organized, managed fashion. The hospitals probably stand to lose considerable business if Medicare moves spine to an outpatient setting.
Q: Medicare patients often have higher comorbidities and other special considerations. Will surgery centers be able to accommodate for this population if Medicare does reimburse for them?
BG: I think surgery centers could support them. It would behoove Congress to look at supporting the surgery center model to maintain the viability of the entire Medicare system. Obviously, patients need to be very carefully selected for. Not just in spine, but spine is a great place to start.
Upper endoscopies, angiograms, and kyphoplasty are already done in an outpatient setting. It may be that doing a single level microdiscectomy or minimally invasive decompression would allow these patients to get their care, in a safe setting, and show real cost savings to the federal program.
Another aspect, is that hospitals can and have done joint ventures with physician-owned surgery centers. Essentially, everyone wins in this model. The hospital can get the services done and get their facility fees, Medicare gets their patients taken care of at a lower cost and the physician has the satisfaction of a job well done in a an outpatient setting.
Q: What will prompt this change? Is there anything spine surgeons or surgery centers can do to promote this change more quickly?
BG: We have to go to Congress and show them the numbers. I don't think there is any other way they are going to understand it unless they see what it really costs to have a patient treated in the outpatient setting. I think it's mandatory that we have to show them these costs and establish a relationship with Congress.
By working within our professional organizations, such as North American Spine Society and the American Association of Neurological Surgeons, and create a lobby for outpatient spine. We need to show them the cost savings and help them realize the impact of performing carefully selected spinal cases in surgery centers.
Q: Are physicians ready to perform these types of procedures in the surgery center? In the immediate future, will they be able to advocate for Medicare reimbursement?
BG: Maybe all it takes is a conversation; it just takes a group of individuals who could present a brief and codified statement that says outpatient spine surgeries are just as safe and effective as in the hospital and realize the cost savings. There may be obvious hesitations and concerns about patient safety, but there are higher morbidity procedures being performed in the outpatient setting. The obvious caveat is the patients — how old? Is there a cutoff? What is an acceptable risk? How do we stratify these patients?
It's going to require a very strong group of individuals who will go to Congress and present hard data on cost savings.
As a whole, a lot of surgery centers are able to access what their fee schedules are for certain procedures and provide that to Medicare with a cost analysis. Compare the procedure in both settings, including anesthesia, and I think it would demonstrate a tremendous cost savings. There is a lot of motivation to return patients home comfortably and provide very good care for them.
As physicians all want Medicare to work; nobody wants the system to fail. We want patients to be able to afford their healthcare and have a certain level of confidence in their physicians and system they paid into for the past 50 years. Physicians are willing to make this work but we need partners in Congress and surgery centers to show it is a viable option to have spine surgery in the outpatient setting when it is safe, appropriate and most importantly, when it's in the patient's best interest.
More Articles on Surgery Centers:
7 Signs the Time is Right for Surgery Center Expansion
5 Tips for Collecting in Full From Out-of-Network Payors
The ABCs of an Effective ASC