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Spine procedures move to outpatient setting
Microscopes, special staff allow quick discharge
When Robert Bray, MD, was asked by a colleague opening a surgery center to move some of his spine procedures to his outpatient center eight years ago, Bray was willing to try a few simple procedures such as microdiscectomies. Because the outpatient trial for spine surgery was so successful and patient outcomes were so positive, Bray set up his own center dedicated to outpatient spine procedures.
"Technology that has enabled the growth of minimally invasive surgery in other specialties has had the same effect on spine surgery," says Bray, a Marina Del Ray, CA, neurosurgeon and founder of the Diagnostic and Interventional Spinal Care Center. "Because the procedures are less invasive, I saw inpatient stays drop from 5.2 days to 1.7 days," he says. Patients undergoing minimally invasive procedures often were ready to leave within 23 hours as long as they received the proper post-surgical care, he adds.
Setting up a center dedicated to outpatient spinal procedures is not without its challenges, points out Bray. The center's patients have a higher acuity and undergo more complex procedures than the typical outpatient center, so space requirements are between 150 and 250 square feet more than the typical 300- to 400-square-foot operating room, he says. The space is needed for the C-arm and microscope that are not normally available in an outpatient operating room, he explains. Because there were no existing centers for spine care, Bray had to create one.
"Our operating rooms are 560 square feet and contain top-of-the-line equipment," reports Bray. "We also have clean rooms with HEPA filters throughout the center's ventilation system and positive pressure operating rooms to minimize the chance of infection," he says. Because spine procedures are "cleaner" than procedures such as cholecystectomies or abdominal procedures, there is less risk of infection when the operating rooms don't have a wide range of procedures performed in them, he points out. Although Bray's center performs 50 procedures per month, there has not been any case of infection or other complications, nor has there been any transfers to the hospital, he says.
Specially trained nurses essential
They are licensed as a 23-hour stay facility, "so if I have a patient undergoing a more complicated procedure such as a two-level fusion, I will make arrangements for nursing coverage for the evening," says Bray. He does these arrangements prior to the day of surgery to make sure that he is not scrambling for nurses at the last moment.
The nursing staff required for outpatient spinal procedures is a more specialized staff, says Marcy Rogers, president and CEO of SpineMark, a health care consulting firm in San Diego that develops spine centers of excellence. "The nuances of postoperative care for the spine patient requires special training that enables the nurses to be proactive in their approach to patient care rather than reactive to symptoms," she says. "Nurses need to be ready to help patients ambulate early, and they need to be familiar with the food, fluids, and medication needs of the patients during recovery." Nurses should be able to follow patients from surgery through recovery to provide the best care, she adds. While neurosurgical or orthopedic experience is helpful, the most important facet of the nurses' training is to work exclusively with spine care patients on a daily basis, she adds.
In addition to having a well-trained nursing staff, it is important to have anesthesiologists who understand how to administer effective pain management throughout the procedure and into the recovery period, says Bray. "We use blocks prior to surgery and continue pain control in the recovery room so that the patient can begin moving around without pain soon after surgery," he says.
The move to more minimally invasive spine procedures will continue, but a successful surgical program is part of an integrated delivery system that includes psychiatrists, interventional pain medicine specialists, physical therapy, and holistic medicine specialists as well as others that might contribute to the care of a spine patient, says Rogers. There does not have to be a contractual agreement between providers, but it is helpful to have agreed-upon protocols to ensure continuity of care, she says. If all members of the group follow the same protocols for diagnosis and interventions prior to surgery and protocols for recovery after surgery, the patient's outcome will be better, she says.
Although Bray chose to build his center from scratch, it is possible for an outpatient surgery program manager who wants to see if outpatient spine surgery is a viable service to get started with existing space, he says. "Any surgery program with a qualified surgeon who is experienced in minimally invasive spine procedures can get started with one operating room dedicated to simple spine procedures such as microdiscectomy," he explains.
If there is a demand for more outpatient spine procedures, and the existing surgery center has the capability to expand, an operating room designed to handle more complex surgeries and related equipment can be built, says Bray. "Surgeons who are well versed in minimally invasive surgery and accustomed to using a microscope are most likely to be attracted to outpatient procedures," he says. When reviewing applications for outpatient spine procedure privileges, be sure to look for surgeons who have finished fellowship training in recent years but have a couple of years of a proven track record, he says.
Spine procedures are profitable
Reimbursement for spine procedures is positive, says Bray.
"I have a broad out-of-network payer base that pays a high enough reimbursement level along with technical add-ons to make the service profitable," he says.
Now that Bray has data on patient outcomes, infection and complication rates, and a track record for his surgery center, he plans to approach payers about contracting with his center. "Payers are interested in outpatient spine procedures because the cost is less than the cost of hospital stays for inpatient surgery," he points out. "Workers' compensation insurance is another opportunity for new patients."
Medicare is one payer that may not cover the costs of outpatient spine surgery but Medicare-aged patients are not typically good candidates for the outpatient spine procedures, points out Bray. "Older patients often have other health problems or conditions that increase the risk of developing complications, so it is not wise to perform their procedures on an outpatient basis," he says.
Before starting an outpatient spine program, be sure to check with payers in your area to see how they will reimburse outpatient procedures, suggests Rogers. Negotiate with payers individually to make sure that supplies, implants, and technology costs are covered, she says. "While going out of network is one way to enter the market, it is not a successful strategy in the long term," she says. "As more surgery programs offer more outpatient spine procedures, the competition for contracts increases." If you wait too long before approaching payers, you may lose the edge you have as the "first" in your area, she adds.
The competition will increase, admits Bray. "Most spine surgeons perform about 5%-10% of their procedures on an outpatient basis," he says. "I perform 60% to 80% of my procedures in the outpatient setting, and I predict that in the next eight to 10 years, more surgeons will approach the same level of outpatient surgery as I currently have."
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