Orthopedic cases continue to move into surgery centers as CMS updates its list of approved procedures, and anesthesia techniques develop. Here T.K. Miller, MD, an orthopedic surgeon with Carilion Clinic Orthopedics and medical director of the Roanoke (Va.) Ambulatory Surgery Center, discusses several orthopedic procedures that have moved into his ASC recently and the driving forces behind the change.
1. CMS changes are moving kyphoplasties and vertebroplasties in the ASC space. Dr. Miller says his surgery center has started performing more kyphoplasties and vertebroplasties in the last year, since CMS added the procedures to their list of approved procedures for the ASC space. He says as a rule, kyphoplasties and vertebroplasties require general anesthesia, meaning it can be difficult to slot the patients into an environment where the main ORs are already filled. "They may become add-on cases, so it's a difficult population to add to a surgical schedule," he says. "They're not the patients you want waiting all day."
He says the patient population presents some issues for surgery centers, which generally handle patients of a lower ASA class than hospitals. "It's an older patient population, so I view them as the same risk stratification group as rotator cuff patients," he says. He recommends that ASCs perform ASA I and II-class patients and look critically at ASA III-class patients to evaluate whether they are appropriate. "ASA III requires a formal anesthesia consult at our facility," he says. "When we drafted our initial policies, we decided not to do ASA IVs."
He says because his surgery center is located in a CON state, leadership has to look critically at OR use because the ability to expand the surgery center is limited. The surgery center has a dedicated pain management room that can be used for conscious sedation for locally-based procedures. The surgery center only specializes in ENT and orthopedics, so the allocation of the pain management room left several ORs and anesthesia-capable rooms that were not always being used consistently. With the change that allowed ASCs to perform vertebroplasties and kyphoplasties, Dr. Miller says the ASC has the option of letting the pain management physicians perform local and sedation procedures in the non-anesthesia-based room, allowing the ASC to use the ORs for other specialties.
2. Some surgeries are still insurer-based. Dr. Miller says both spine surgeons and pain management physicians in his ASC perform vertebroplasties and kyphoplasties. "Those are two directions where we see patients fed to us," he says. He says single-level spine surgery is still in a transitional period that's based very much on the insurer. "With the right insurer and permission, we can do single-level spine, but that's not as large a population," he says.
The ASC has spoken to its spine surgeons and decided to give them "dedicated days" to perform spine surgery, allowing the surgeons to have a more efficient day at the ASC. "It's much easier if they don't have to move somewhere else," he says. "And it means we can take procedures we couldn’t do before."
3. Fracture management is moving into the outpatient setting — as long as costs are feasible. Dr. Miller says his surgery center's affiliated hospital is moving towards staged fracture management, meaning that some patients are better-suited to initial stabilization and elective treatment for their fracture, rather than undergoing surgery immediately. "If you've got the staff and they're used to doing it, fracture service can move to staged elective management for a much larger volume of fractures than we did in the past," he says.
He says as with single-level spine surgery, his ASC has allocated a dedicated day for fracture management procedures. According to Dr. Miller, the feasibility of the procedure often comes down to the cost of the implant system. "I can tell you if one of our fracture physicians fixes an ankle fracture, I know the implant system that we use, and I know our insurer spread," he says. "That procedure is going to be cash-flow positive."
He says the surgery center depends on its primary vendor to reduce costs in exchange for capturing a larger percentage of the market. "They're going to get the volume, and we're going to choose their system every time a certain procedure comes up," he says. He says his surgery center physicians are very cognizant of implant prices: "When a new system comes out, the first question is how much it costs," he says.
4. Complex fracture management is becoming more feasible, while simple fracture management is becoming run-of-the-mill. Dr. Miller says straight-forward fractures — fractures of the ankle, patella, wrist or elbow, for example — are "nothing new and amazing" for his ASC at this point. He says the real breakthrough is with more complex fractures, such as tibial plateau fractures. "Some fractures that might have been considered as a 23-hour stay or overnight stay in the hospital are now appropriate for the ASC," he says.
The difference, he says, is advances in regional anesthesia. He says when the ASC started transitioning to ACLs, rotator cuffs and fracture management, they started looking more closely at how to make patients comfortable. "It meant expanding the use of regional blocks and pre-emptive analgesia," he says. "We found that once you start doing those things, there's no safety issue with doing them as outpatient procedures, and it's pretty hard to justify doing them in the hospital setting."
He says for most anesthesiologists, frequent regional blocks will require the use of an ultrasound machine — a significant investment for an ASC. But some of his older anesthesiologists are skilled at regional management without using an ultrasound, so there may be potential for ASCs to add fracture management even without the investment. "The patient has to know the pain will be well-controlled," he says. "We talk to patients beforehand and explain, 'You will have a femoral nerve block, and here is your schedule of pain medication post-operatively.'"
5. Moving fracture cases to the ASC can benefit a hospital partner too. Dr. Miller says because his partnered hospital does not own 100 percent of the surgery center, they could view the movement of cases into the ASC as competition. "They can view it as a competitor or as the best way to manage these patients," he says. "It actually ends up freeing up their hospital-based OR time for the patients that really need to be done in the hospital." He says from a cost standpoint, moving the cases is beneficial to the hospital, because it reduces their add-on list and improves patient satisfaction by decreasing wait times for surgery.
6. Scheduling more complex cases earlier in the day helps with efficiency. Dr. Miller says his surgery center has a two-hour limit on any case done in the facility, which helps the center keep on schedule. "It also, by definition, screens some of the patients, because some are not appropriate for the two-hour limit," he says. The surgery center performs its most complex cases earlier in the day, anticipating that those patients will require longer recovery room times. However, he says that once anesthesia providers have mastered regional blocks, recovery room times will decrease significantly.
Dr. Miller says it can help to benchmark recovery room times. "We don't want to pick on any one person, but if you have a provider whose patients are in recovery for a disproportionately long period of time, we want to know why," he says. "Is it the patient population, is it the medication mix?"
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1. CMS changes are moving kyphoplasties and vertebroplasties in the ASC space. Dr. Miller says his surgery center has started performing more kyphoplasties and vertebroplasties in the last year, since CMS added the procedures to their list of approved procedures for the ASC space. He says as a rule, kyphoplasties and vertebroplasties require general anesthesia, meaning it can be difficult to slot the patients into an environment where the main ORs are already filled. "They may become add-on cases, so it's a difficult population to add to a surgical schedule," he says. "They're not the patients you want waiting all day."
He says the patient population presents some issues for surgery centers, which generally handle patients of a lower ASA class than hospitals. "It's an older patient population, so I view them as the same risk stratification group as rotator cuff patients," he says. He recommends that ASCs perform ASA I and II-class patients and look critically at ASA III-class patients to evaluate whether they are appropriate. "ASA III requires a formal anesthesia consult at our facility," he says. "When we drafted our initial policies, we decided not to do ASA IVs."
He says because his surgery center is located in a CON state, leadership has to look critically at OR use because the ability to expand the surgery center is limited. The surgery center has a dedicated pain management room that can be used for conscious sedation for locally-based procedures. The surgery center only specializes in ENT and orthopedics, so the allocation of the pain management room left several ORs and anesthesia-capable rooms that were not always being used consistently. With the change that allowed ASCs to perform vertebroplasties and kyphoplasties, Dr. Miller says the ASC has the option of letting the pain management physicians perform local and sedation procedures in the non-anesthesia-based room, allowing the ASC to use the ORs for other specialties.
2. Some surgeries are still insurer-based. Dr. Miller says both spine surgeons and pain management physicians in his ASC perform vertebroplasties and kyphoplasties. "Those are two directions where we see patients fed to us," he says. He says single-level spine surgery is still in a transitional period that's based very much on the insurer. "With the right insurer and permission, we can do single-level spine, but that's not as large a population," he says.
The ASC has spoken to its spine surgeons and decided to give them "dedicated days" to perform spine surgery, allowing the surgeons to have a more efficient day at the ASC. "It's much easier if they don't have to move somewhere else," he says. "And it means we can take procedures we couldn’t do before."
3. Fracture management is moving into the outpatient setting — as long as costs are feasible. Dr. Miller says his surgery center's affiliated hospital is moving towards staged fracture management, meaning that some patients are better-suited to initial stabilization and elective treatment for their fracture, rather than undergoing surgery immediately. "If you've got the staff and they're used to doing it, fracture service can move to staged elective management for a much larger volume of fractures than we did in the past," he says.
He says as with single-level spine surgery, his ASC has allocated a dedicated day for fracture management procedures. According to Dr. Miller, the feasibility of the procedure often comes down to the cost of the implant system. "I can tell you if one of our fracture physicians fixes an ankle fracture, I know the implant system that we use, and I know our insurer spread," he says. "That procedure is going to be cash-flow positive."
He says the surgery center depends on its primary vendor to reduce costs in exchange for capturing a larger percentage of the market. "They're going to get the volume, and we're going to choose their system every time a certain procedure comes up," he says. He says his surgery center physicians are very cognizant of implant prices: "When a new system comes out, the first question is how much it costs," he says.
4. Complex fracture management is becoming more feasible, while simple fracture management is becoming run-of-the-mill. Dr. Miller says straight-forward fractures — fractures of the ankle, patella, wrist or elbow, for example — are "nothing new and amazing" for his ASC at this point. He says the real breakthrough is with more complex fractures, such as tibial plateau fractures. "Some fractures that might have been considered as a 23-hour stay or overnight stay in the hospital are now appropriate for the ASC," he says.
The difference, he says, is advances in regional anesthesia. He says when the ASC started transitioning to ACLs, rotator cuffs and fracture management, they started looking more closely at how to make patients comfortable. "It meant expanding the use of regional blocks and pre-emptive analgesia," he says. "We found that once you start doing those things, there's no safety issue with doing them as outpatient procedures, and it's pretty hard to justify doing them in the hospital setting."
He says for most anesthesiologists, frequent regional blocks will require the use of an ultrasound machine — a significant investment for an ASC. But some of his older anesthesiologists are skilled at regional management without using an ultrasound, so there may be potential for ASCs to add fracture management even without the investment. "The patient has to know the pain will be well-controlled," he says. "We talk to patients beforehand and explain, 'You will have a femoral nerve block, and here is your schedule of pain medication post-operatively.'"
5. Moving fracture cases to the ASC can benefit a hospital partner too. Dr. Miller says because his partnered hospital does not own 100 percent of the surgery center, they could view the movement of cases into the ASC as competition. "They can view it as a competitor or as the best way to manage these patients," he says. "It actually ends up freeing up their hospital-based OR time for the patients that really need to be done in the hospital." He says from a cost standpoint, moving the cases is beneficial to the hospital, because it reduces their add-on list and improves patient satisfaction by decreasing wait times for surgery.
6. Scheduling more complex cases earlier in the day helps with efficiency. Dr. Miller says his surgery center has a two-hour limit on any case done in the facility, which helps the center keep on schedule. "It also, by definition, screens some of the patients, because some are not appropriate for the two-hour limit," he says. The surgery center performs its most complex cases earlier in the day, anticipating that those patients will require longer recovery room times. However, he says that once anesthesia providers have mastered regional blocks, recovery room times will decrease significantly.
Dr. Miller says it can help to benchmark recovery room times. "We don't want to pick on any one person, but if you have a provider whose patients are in recovery for a disproportionately long period of time, we want to know why," he says. "Is it the patient population, is it the medication mix?"
Related Articles on Orthopedic-Driven ASCs:
Iconacy Orthopedic Implants Receives FDA Clearance for Total Hip Replacement System
Moving Spine Procedures to ASCs: Key Business and Clinical Issues
Iconacy Orthopedic Implants Receives FDA Clearance for Total Hip Replacement System