This is part of a series on the five ambulatory surgery center specialties to watch in 2012. The five specialties are gynecology, ophthalmology, orthopedics and spine, pain management and urology. These specialties have a favorable outlook in terms of case volume, revenue and new procedures moving into the ASC setting.
With the quick rate of technology advancement, more and more orthopedic and spine procedures are able to be done as outpatient procedures. This trend mimics the overall trend of surgery, but W. Harwood Runner, CEO of Kerlan-Jobe Orthopaedic Clinic, Los Angeles, thinks it's more pronounced in orthopedic and spine.
"Generally, the trend is toward more and more minimally invasive surgeries and that means a shift of surgical cases from the inpatient to the outpatient world," he says. "Neuro-musculoskeletal science will continue to expand pretty rapidly. The questions around implementing those emerging technologies are more a matter of physician training, adoption and investment in the surgical ecosystem. The most significant vein of new opportunity continues to be around spine and to a certain extent joint replacement."
Mr. Runner and T.K. Miller, MD, of Carilion Clinic Orthopaedics and Medical Director of the Roanoke Ambulatory Surgery Center, discuss five points on orthopedic and spine for 2012 and beyond.
1. Increased push by surgeons and patients to do procedures in an ASC. Dr. Miller says more surgeons and patients are pushing for procedures to move from the inpatient to outpatient setting.
"Almost any surgeon that we hire with fellowship training is going to look at what they can do in an ASC setting," says Dr. Miller.
One such procedure that has started to make the transition is single-level, limited exposure spinal surgeries.
"When we look, a single-level disc procedure with limited exposure has a low rate of perioperative complications," he says. "We've gone from patient comments of 'I can't believe you can do that in an outpatient setting' to 'Why do I have to stay in the hospital?'"
Demand by patients has altered the patient population felt to be acceptable for care in the ASC setting. Dr. Miller says. Last week, he performed a revision rotator cuff repair on a woman over the age of 70. In the past, he might not have considered doing that case in an ASC, but the woman expressed her desire to have surgery in an ASC rather than hospital setting. Dr. Miller reviewed the perioperative expectations with the patient and her family, consulted with her primary care physician to make sure she truly had minimal co-morbid health issues, and the surgery was performed successfully in the ASC. The issue of appropriate setting for surgery at an ASC is much more dependent on co-morbid medical issues than patient age or the technical aspects of a proposed surgical procedure.
2. Managing pain is often the reason procedures stay in the hospital. Dr. Miller says one of the biggest considerations for whether a procedure can be done in an ASC is post-operative pain management. In the Roanoke Ambulatory Surgery Center, with the assistance of pain management physicians, surgeons have increased their use of multimodal pain management and pre-emptive use of pain medications.
"Keeping patients in the hospital is not a good way to manage pain," he says. "Pain management in hospitals is usually reactive rather than pro-active. In a center, you can — and have to — plan. We rely on regional blocks, use of extended release analgesia and use of nonsteroidal medications combined with narcotic pain control. Just as important is the patients' understanding that we have a plan to manage their pain and they will have a role in this"
This plan also involved integrating pain management services with spine procedures.
"Pain management is part of the spine service," he says. "More aggressive pain management has become the norm. Pain management physicians have become involved much earlier than they used to."
3. Key change in fracture management. While surgery used to be done immediately for most fractures, in many cases, surgeons have recognized the advantages of semi-elective fracture care, Dr. Miller says. This has opened up the hospital operating room schedule by treating fractures in a more controlled manner, and allowed surgeons and patients to have more control over when surgery is performed. Ankle, wrist and elbow fracture repairs are almost all done as outpatient procedures now, he says. He has seen the volume of fracture management procedures increase at his center.
"As the technology gets better and better, fracture management really has the potential to explode," he says. "In theory, there are some hip fractures that we could fix on an outpatient basis."
The continued development of minimally invasive techniques will allow more fracture procedures to move to the ASC setting. Advancements include limited contact plating through small incisions with x-ray guidance to place screws.
4. Minimally invasive hip procedures are emerging. Dr. Miller says that minimally invasive hip procedures such as arthroscopic hip reconstructive procedures are transitioning to the ASC environment. This transition will continue over the next few years.
"Hips are where shoulders were 10 years ago," he says. We start with diagnostic capabilities, evolve to debridement and clean up and, as instrumentation evolves, are moving to consistently reliable reconstructive techniques."
As with most sports-based surgeons, Dr. Miller now does almost all of his shoulder reconstructions with arthroscopic techniques and says this trend will be seen with other joints. Hip is next on the list.
The limiting factor is capital investment because a center needs a special operating table, dedicated c-arm capability and hip specific arthroscopic equipment to perform the procedure. Unlike the evolution of arthroscopy from knee to ankle, elbow and shoulder, hip arthroscopy requires its own operative set up and equipment. With the right surgeon and referral network,it can be profitable for centers willing to invest in specialty hip equipment. Dr. Miller’s center does not perform these procedures, but expects they will.
5. Cost, not technology, will limit procedures done in an ASC. Orthopedic and spine surgeons will continue to feel the reimbursement squeeze that all specialties are feeling.
"We'll see continued downward pressure as the payor community continues to consolidate," Mr. Runner says, ”which is the long-term trend. Another thing I think we'll see emerge is an improved ability to discern quality in outcomes and that’s a data driven phenomenon. I hope to see that quality is rewarded."
In addition to shrinking reimbursements, the equipment that allows many procedures to be performed in the ASC is often cost-prohibitive.
"The one thing we always run into has to do with equipment and cost issues," Dr. Miller says. "That to me becomes the limiting factor. There are procedures that we could do, but [they are] cost-prohibitive to do."
Procedures at-risk for being cost-prohibitive include rotator cuff repair with acromioplasty and ACL repair with allograft. Dr. Miller says acromioplasty, which increases the space for the rotator cuff in the shoulder, is being bundled with the reimbursement code for rotator cuff surgery. So even though the procedure takes more time and equipment, the reimbursement is the same. In some ways, the additional reimbursement allowed a window for implant costs associated with the rotator cuff repair. Surgeons who use multi-anchor repair techniques may find they are too expensive for a center.
Allograft materials, where donor tendon or ligament is implanted during an ACL reconstruction are not always covered by payors. Dr. Millers says one insurer the center works with does not reimburse for this component of the procedure. Because of a lack of reimbursement, this "bread and butter" procedure can become unprofitable and has to be moved back to the hospital setting.
That said, Dr. Miller says the Roanoke center will take a loss of $300-400 on a procedure with an expensive implant or low reimbursement in order to keep that surgeon operating at the center all day.
"We'll accept the loss on that one procedure, but we can't function with an entire day where we use systems or implants at a loss," he says. In the end, it's about providing the best possible care while exercising fiscal responsibility."
Related Articles on Orthopedic and Spine:
8 Steps to Increase Orthopedic Case Volume at an ASC
Success in the Spine Market: 6 Spine Company Leaders Discuss the Future
7 Points About Personalized Partial Knee Replacements in Surgery Centers
With the quick rate of technology advancement, more and more orthopedic and spine procedures are able to be done as outpatient procedures. This trend mimics the overall trend of surgery, but W. Harwood Runner, CEO of Kerlan-Jobe Orthopaedic Clinic, Los Angeles, thinks it's more pronounced in orthopedic and spine.
"Generally, the trend is toward more and more minimally invasive surgeries and that means a shift of surgical cases from the inpatient to the outpatient world," he says. "Neuro-musculoskeletal science will continue to expand pretty rapidly. The questions around implementing those emerging technologies are more a matter of physician training, adoption and investment in the surgical ecosystem. The most significant vein of new opportunity continues to be around spine and to a certain extent joint replacement."
Mr. Runner and T.K. Miller, MD, of Carilion Clinic Orthopaedics and Medical Director of the Roanoke Ambulatory Surgery Center, discuss five points on orthopedic and spine for 2012 and beyond.
1. Increased push by surgeons and patients to do procedures in an ASC. Dr. Miller says more surgeons and patients are pushing for procedures to move from the inpatient to outpatient setting.
"Almost any surgeon that we hire with fellowship training is going to look at what they can do in an ASC setting," says Dr. Miller.
One such procedure that has started to make the transition is single-level, limited exposure spinal surgeries.
"When we look, a single-level disc procedure with limited exposure has a low rate of perioperative complications," he says. "We've gone from patient comments of 'I can't believe you can do that in an outpatient setting' to 'Why do I have to stay in the hospital?'"
Demand by patients has altered the patient population felt to be acceptable for care in the ASC setting. Dr. Miller says. Last week, he performed a revision rotator cuff repair on a woman over the age of 70. In the past, he might not have considered doing that case in an ASC, but the woman expressed her desire to have surgery in an ASC rather than hospital setting. Dr. Miller reviewed the perioperative expectations with the patient and her family, consulted with her primary care physician to make sure she truly had minimal co-morbid health issues, and the surgery was performed successfully in the ASC. The issue of appropriate setting for surgery at an ASC is much more dependent on co-morbid medical issues than patient age or the technical aspects of a proposed surgical procedure.
2. Managing pain is often the reason procedures stay in the hospital. Dr. Miller says one of the biggest considerations for whether a procedure can be done in an ASC is post-operative pain management. In the Roanoke Ambulatory Surgery Center, with the assistance of pain management physicians, surgeons have increased their use of multimodal pain management and pre-emptive use of pain medications.
"Keeping patients in the hospital is not a good way to manage pain," he says. "Pain management in hospitals is usually reactive rather than pro-active. In a center, you can — and have to — plan. We rely on regional blocks, use of extended release analgesia and use of nonsteroidal medications combined with narcotic pain control. Just as important is the patients' understanding that we have a plan to manage their pain and they will have a role in this"
This plan also involved integrating pain management services with spine procedures.
"Pain management is part of the spine service," he says. "More aggressive pain management has become the norm. Pain management physicians have become involved much earlier than they used to."
3. Key change in fracture management. While surgery used to be done immediately for most fractures, in many cases, surgeons have recognized the advantages of semi-elective fracture care, Dr. Miller says. This has opened up the hospital operating room schedule by treating fractures in a more controlled manner, and allowed surgeons and patients to have more control over when surgery is performed. Ankle, wrist and elbow fracture repairs are almost all done as outpatient procedures now, he says. He has seen the volume of fracture management procedures increase at his center.
"As the technology gets better and better, fracture management really has the potential to explode," he says. "In theory, there are some hip fractures that we could fix on an outpatient basis."
The continued development of minimally invasive techniques will allow more fracture procedures to move to the ASC setting. Advancements include limited contact plating through small incisions with x-ray guidance to place screws.
4. Minimally invasive hip procedures are emerging. Dr. Miller says that minimally invasive hip procedures such as arthroscopic hip reconstructive procedures are transitioning to the ASC environment. This transition will continue over the next few years.
"Hips are where shoulders were 10 years ago," he says. We start with diagnostic capabilities, evolve to debridement and clean up and, as instrumentation evolves, are moving to consistently reliable reconstructive techniques."
As with most sports-based surgeons, Dr. Miller now does almost all of his shoulder reconstructions with arthroscopic techniques and says this trend will be seen with other joints. Hip is next on the list.
The limiting factor is capital investment because a center needs a special operating table, dedicated c-arm capability and hip specific arthroscopic equipment to perform the procedure. Unlike the evolution of arthroscopy from knee to ankle, elbow and shoulder, hip arthroscopy requires its own operative set up and equipment. With the right surgeon and referral network,it can be profitable for centers willing to invest in specialty hip equipment. Dr. Miller’s center does not perform these procedures, but expects they will.
5. Cost, not technology, will limit procedures done in an ASC. Orthopedic and spine surgeons will continue to feel the reimbursement squeeze that all specialties are feeling.
"We'll see continued downward pressure as the payor community continues to consolidate," Mr. Runner says, ”which is the long-term trend. Another thing I think we'll see emerge is an improved ability to discern quality in outcomes and that’s a data driven phenomenon. I hope to see that quality is rewarded."
In addition to shrinking reimbursements, the equipment that allows many procedures to be performed in the ASC is often cost-prohibitive.
"The one thing we always run into has to do with equipment and cost issues," Dr. Miller says. "That to me becomes the limiting factor. There are procedures that we could do, but [they are] cost-prohibitive to do."
Procedures at-risk for being cost-prohibitive include rotator cuff repair with acromioplasty and ACL repair with allograft. Dr. Miller says acromioplasty, which increases the space for the rotator cuff in the shoulder, is being bundled with the reimbursement code for rotator cuff surgery. So even though the procedure takes more time and equipment, the reimbursement is the same. In some ways, the additional reimbursement allowed a window for implant costs associated with the rotator cuff repair. Surgeons who use multi-anchor repair techniques may find they are too expensive for a center.
Allograft materials, where donor tendon or ligament is implanted during an ACL reconstruction are not always covered by payors. Dr. Millers says one insurer the center works with does not reimburse for this component of the procedure. Because of a lack of reimbursement, this "bread and butter" procedure can become unprofitable and has to be moved back to the hospital setting.
That said, Dr. Miller says the Roanoke center will take a loss of $300-400 on a procedure with an expensive implant or low reimbursement in order to keep that surgeon operating at the center all day.
"We'll accept the loss on that one procedure, but we can't function with an entire day where we use systems or implants at a loss," he says. In the end, it's about providing the best possible care while exercising fiscal responsibility."
Related Articles on Orthopedic and Spine:
8 Steps to Increase Orthopedic Case Volume at an ASC
Success in the Spine Market: 6 Spine Company Leaders Discuss the Future
7 Points About Personalized Partial Knee Replacements in Surgery Centers