Five spine surgery experts provide five best practices ambulatory surgery centers should consider when adding spine. Note: Included with the best practices are links to the articles where the advice originally appeared, providing you with more practical guidance. Best practices are listed in alphabetical order of leader's last name.
1. Understand spine to recruit effectively. Surgeons practicing specialties traditionally found today in ASCs have most likely been recruited by multiple facilities during their career, which makes it difficult to formulate an enticing recruiting strategy for them. "What you're doing is hoping to find, for example, young ENTs who are new to the market or potentially an ENT practice that is backing out from a center they are not happy in," says Chris Bishop, partner and senior vice president of acquisitions for Blue Chip Surgical Center Partners. This does not hold true for spine. "An advantage to recruiting spine is most spine surgeons still are not involved or haven't yet invested in ASCs."
There are several important things Mr. Bishop says ASCs should know about spine surgeons, which encompasses both orthopedic spine as well as neurosurgical spine surgeons. "They have slightly different training programs but what happening is there's now quite a bit of overlap," he says. "It used to be that an orthopedic surgeon would train to be an orthopedist and then specialize in spine, which meant that when he started his spine practice, he would potentially still do some orthopedics. Neurosurgeons began by really focusing a lot on the brain and the upper part of the spine but have now shifted down. So you have neurosurgeons with a brain-down approach and orthopedists have become a bottom-up approach."
While these two groups of surgeons have sometimes struggled to work together, Mr. Bishop says a melding between them is occurring in ASCs as they begin to understand the benefits of collaborating as investment partners. The groups are finding that their techniques are more similar than they realize and they've become more comfortable agreeing upon the same equipment needs, he says, which further enhances the appeal of working together in an ASC.
Spine and pain can also make a solid pairing, Mr. Bishop says. Since spine surgeons see many patients who need epidural injections, unless their practices have associated physiatrists or pain fellowship-trained anesthesiologists that can perform these injections, the spine surgeons will refer these procedures outside of their practice. An ASC has the opportunity to potentially capture these cases.
"When you're successful recruiting spine surgeons, you often will also have some success recruiting pain physicians to join your group as well because it's a nice logical fit," he says. "Because of kickback laws, you have to have a good healthcare attorney counseling you before proceeding [with these arrangements], but our experience has been those two specialties do a lot of cross-referring and it's a logical fit for them to invest in an ASC together."
One more important thing to know about spine surgeons is the number of cases they will typically perform in an ASC. Mr. Bishop says it is not uncommon to hear expectations of 150-200 cases annually from a single surgeon, but he says experience has shown that number is more like 75-80 outpatient cases a year from a good, busy surgeon. "It's obviously beneficial to recruit a neurosurgical group with four doctors in it or an orthopedic spine group with a few doctors in it," he says.
Even if your ASC is already performing orthopedics, and has a C-arm and some of the basic hand instruments, you can still expect to invest a few hundred thousand dollars to add spine. Therefore, it is critical to determine if you can add enough surgeons and generate the case volume needed to support such an investment. From: 5 Steps to Profitable Spine in Surgery Centers
2. Enlist surgeons to reduce implant costs. Involve the surgeons in your efforts to reduce implant costs. Make them aware of the cost associated with each device and vendor and compare the costs. "Your surgeons work closely with company reps, so it is easier for them to ask for lower prices for implants," says Lynn S. Feldman, RN, MBA, administrative manager of Eastwind Surgical, a spine center in Westerville, Ohio. "They have more leverage with the companies than an administrator could have." Many surgeons simply don't want to talk about prices, but those who do are invaluable in keeping costs down. From: 8 Reimbursement and Business Concepts for Spine
3. Properly train staff. Spine surgery is a different type of procedure than most procedures performed in the ASC, and surgeons must make sure the staff members are experienced and prepared to work with them. Even after you begin bringing spine cases to the ASC, you must train your staff on each new type of procedure before performing the case. Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco, holds an in-service day at his ASC before bringing a new procedure to the facility so the staff will understand the different components of the surgery.
"It's common to have an in-service and ask the device company to bring in the equipment for the procedure so you can do a dry run and make sure everyone understands what will happen when the patient arrives," he says. "When a new procedure starts in the ASC, you might be missing something and that could mean the case might not go smoothly. Have a checklist for the procedure and make sure the components can adapt to the ASC. Once you start ahead of time, you can find the kinks and it isn't an issue; but if problems occur during the actual surgery, it could be a major complication."
For example, if a wrong-sized cannula is pulled for the case and the surgical team doesn't realize it until the surgery has begun, finding the appropriately sized cannula will take time and the patient will most likely need admittance to the hospital. From: 7 Tips for Success With Spine Surgery in ASCs
4. Develop the right case mix. Focus on neck operations and lower back, says Joan F. O'Shea, MD, neurosurgeon and orthopedic spine surgeon at the Spine Institute of Southern New Jersey in Marlton, N.J. In an ASC, spine surgeons should be able to handle up to three levels for anterior cervical discs, lumbar discectomy, spinal cord and lumbar fusions. Cases that are generally not good for ASCs involve comoribidities, redo operations and complex scoliosis surgeries, such as kyphoplasty, which are usually performed on the elderly. "We don't want high-risk patients in the ASC," Dr. O'Shea says. Another example would be overweight patients over ASA grade 2. From: 7 Ways to Achieve Great Results for Spine Surgery in an ASC
5. Embrace simplicity. "The latest and greatest technology often comes with higher expense and extensive and long learning curves," says Chris Zorn, vice president of sales for Spine Surgical Innovation and executive director of Minimal Incision-Maximum Sight (MIMS) Institute. "Stick to what is proven, accepted and think about how much trial and experimentation with the newest technology really costs you, not only in the cost of the devicess but the most important fact, your and your OR team's time." From: 6 Ways to Increase Spine Surgery Productivity in Surgery Centers