10 Establishing an Ambulatory Spine Surgery Center

Over the past 20 years, an increasing number of spinal surgeries have transitioned from inpatient to outpatient. This is due to multiple factors including the evolution of minimally invasive spine surgery (MIS), improved anesthetic regimens, lower infections and higher patient satisfaction in outpatient facilities than in hospitals, and market forces. The new era of health care reform allows opportunities for small, market-responsive outpatient spine surgery centers to capture segments of the market by providing high-quality care in a narrowly defined, specific area. Outpatient spine centers are essentially boutiques that deliver world-class care in a highly focused niche, i.e., Regina Herzlinger’s “focused factories.”¹ The Shouldice Hospital model for hernia surgery in Canada was the original focused factory. The Shouldice model proved that when a limited number of procedures are done in high volume by the same providers and staff, the outcomes are better, the costs are lower, and the patients are more satisfied.

Outpatient spine surgery allows the spine surgeon to maintain tight control of cost and quality, responding to the needs of not only the surgeon and the patient, but also insurance companies. The cost for outpatient spine surgery is 50 to 70% lower than for the same procedure performed in a hospital. MIS spine procedures are 30 to 60% less costly than traditional surgery. Besides the lower cost, MIS also offers the significant advantages of shorter recovery times and decreased rates of recurrence. In this era of cost containment, particularly given the increased demands by baby boomers for healthy spines, outpatient and MIS spine surgery will continue to increase in frequency.

Presently, the range of spinal procedures that are frequently performed in an outpatient setting includes the following procedures:

• Anterior cervical discectomies with fusions (one, two, and three level).

• Cervical disc arthroplasties (one and two level).

• Cervical foraminotomies and posterior discectomies.

• Lumbar microdiscectomies.

• Lumbar laminoforaminotomies.

• Lumbar laminectomies.

• MIS lumbar fusions including XLIFs, TLIFs, and interspinous process fusions.

Cervical arthroplasties, or total disc replacements (TDRs), are an excellent example of a fairly new and very successful addition to the world of outpatient spine surgery. Based on the proven safety, cost effectiveness, clinical outcomes, and patient satisfaction with anterior cervical discectomy and fusion (ACDF), it was a natural next step to perform outpatient arthroplasties. Arthroplasties offer quicker recovery than ACDF, preserved motion of the neck, and less chance of developing adjacent disc degeneration which might require further surgery. The 5-year disc replacement data compared with fusion have demonstrated that patients who underwent TDR had 97.1% probability of no secondary procedures, compared with 85.5% for ACDF patients.² No reoperations were due to implant breakage or device failure. In total, 2.9% of TDR patients had reoperations within 5 years of the initial surgery, compared with 14.5% of ACDF patients. I have recently reported a consecutive series of 132 outpatient cervical arthroplasties from 2009 through April 2013 with 92% improved symptoms, an average operative time of 60 minutes for one level and 80 minutes for two levels, and an average time to discharge of 3 hours. There was no significant morbidity and no mortality. There were no transfers to a hospital, no postoperative ER visits, and no late hospitalizations. The cost for outpatient cervical arthroplasty is lower than the cost for ACDF, and is less than 50% of the cost of the same procedure in a hospital.

My prediction is that we will see an increasing percentage of spine surgeries transition to outpatient surgery centers. It is therefore critical for spine surgeons to understand how to establish an outpatient spine surgery center.

10.2 Ambulatory Spine Centers

The new era of health care and managed care introduced in the mid-1990s created an opportunity for market-responsive organizations and outpatient surgery centers to capture new market segments by providing high-quality specialty care. Outpatient surgery centers have now become the standard practice in many communities across the United States. These boutique health care providers are designed as “Centers of Excellence” to deliver world-class care in highly focused medical or surgical niches. Herzlinger,¹ of the Harvard Business School, called them “focused factories” in her book titled Market Driven Health Care.

Clearly, the trend toward same-day, or ambulatory, surgery is not just a fad. Rather, it is a major change in the practice of surgery and here to stay. According to the U.S. National Health Statistics,³ 48.3 million surgical procedures and nonsurgical procedures were performed during 28.6 million ambulatory surgery visits in 2010. Around 22.5 million of those visits occurred in ASCs.

The number of ambulatory procedures performed in the United States based on the National Health Statistics Report revision is based on 2010 numbers published in February 2017 ( Table 10.1).³

Minimally invasive surgery is less costly than traditional surgery. A 2012 study published in Risk Management and Healthcare Policy journal⁴ found minimally invasive posterior lumbar interbody fusion cost $2,825 less on average than the traditional open technique at the hospital. When the procedure is performed in an outpatient surgery center, the cost savings is estimated at 30 to 60% of the cost of comparable inpatient hospital procedures.

Table 10.1 The number of ambulatory procedures performed in the United States based on the National Health Statistics Report³

Even if raw costs are not compared, minimally invasive surgery holds huge advantages in areas such as quicker return to work, decreased recidivism rate, higher facility utilization, and increased physician productivity. An example of the benefits of minimally invasive or outpatient spine surgery is presented in Table 10.2.⁵

Many patients fear traditional invasive surgery and they “suffer in silence.” Such patients are more likely to accept minimally invasive surgery, which will improve their productivity and quality of life. Nationally recognized surgeons have begun to perform these procedures on an ambulatory basis with excellent outcomes, high patient satisfaction, and diminished costs for patients and insurers.

10.2.2 Furnishing a Minimally Invasive Spine Surgery Suite

The minimally invasive spine surgery suite has different equipment needs than the traditional operative arena, so the optimal operative suite is somewhat larger. Because the goal of these approaches is to minimize tissue dissection, surgeons frequently use fluoroscopy. At times, two fluoroscopy units are required, such as when surgeons perform vertebroplasty or kyphoplasty. Video imaging equipment is also required. Outpatient spine surgeons have found high-definition video monitors provide the best image quality and are oftentimes readily available. Endoscopes, cameras, and light sources play a critical role in video image quality. Outpatient spine surgeons have also found a three-chip camera provides the best image. The video image’s contrast and color can be adjusted to allow for adequate operative field visualization. Alternately, many of these procedures can be performed under loupe or microscope magnification, which provides the added benefit of three-dimensional visualization. However, the angulation of the endoscope allows one to “look beyond the confines of the tube,” and is particularly useful when performing contralateral decompression such as in endoscopic lumbar laminectomy.

Table 10.2 Cost examples for minimally invasive or outpatient surgery

Patients should be positioned on a radiolucent frame, particularly when anteroposterior fluoroscopic imaging is necessary, such as during percutaneous pedicle screw placement or vertebroplasty. The operating table’s base should allow for both anteroposterior and lateral fluoroscopic images. Therefore, an operating table with a large fixed center base is often not suitable, particularly when anteroposterior fluoroscopic images are required. The operating room setup should provide the surgeon with a clear field of view of both the video monitor and the fluoroscopic monitor ( Fig. 10.1). Two monitors are frequently used on either side of the patient: one opposite the surgeon and the other opposite the assistant. Properly position and secure cables to reduce clutter.

Instruments specifically made for minimally invasive procedures are required. These instruments are usually long, tapered, and bayoneted to reduce field-of-view obstruction and facilitate dissection ( Fig. 10.2). Precision instruments such as No. 1 and 2 Kerrison punches, micropituitary rongeurs, and fine 1- and 2-mm curettes help facilitate these procedures. In this regard, a long tapered smooth-running electric drill is used with a 1- or 2-mm bit. Foot pedal control frees hand movement, and the lack of a “kick” experience when using an electric drill improves safety when working near the neural elements. Suction retractors are also useful and permit one instrument to perform two functions, thus reducing the number of instruments in the operative field.

Fig. 10.1 Operating room setup with video monitor and C-arm in place.

Fig. 10.2 Frequently used operative equipment in operating theater for minimally invasive spine surgery. (a) Long tapered electric drill. (b) Bayoneted and microsurgical instruments. (c) Expandable tubular retractor.

At the outset, outpatient spine surgery centers should be developed in major urban areas in the United States. The number of spine surgeries performed in the United States in 2012 reached 600,000.⁶ Initially, each outpatient spine surgery facility should have two fully equipped operating theaters. Operating rooms should be designed for rapid and efficient patient turnover and to allow physicians to concentrate on the parts of the procedure that require their skills. Space for an additional two theaters should be available to accommodate future expansion as demand increases. An outpatient spine surgery facility with two to four operating rooms provides the scale to cover fixed costs, yet remains sufficiently small and responsive to patients. Additionally, this size will ensure a high facility utilization rate.

10.2.3 The Market for Outpatient Spine Surgery Services

Market Sizing

The national occurrence of a range of primary diagnosis that resulted in spinal discectomy procedures in 2011 gives a reported occurrence of more than 370,000 spinal discectomies. These data were reported by “The Burden of Musculoskeletal Diseases in the United States,”⁷ which is a joint project of the American Academy of Orthopaedic Surgeons, American Academy of Physical Medicine and Rehabilitation, American College of Rheumatology, American Society for Bone and Mineral Research, Arthritis Foundation, National University of Health Sciences, Orthopaedic Research Society, Scoliosis Research Society, and the United States Bone and Joint Initiative.

Using an estimate to equate to an outpatient spine surgery center capturing a market share of 20% of the spine surgeries currently being treated with minimally invasive techniques, this results in 38,400 lumbar discectomies in an ASC and approximately 27,850 cervical discectomies nationwide (data obtained using SG2 Analytics).

Using the national occurrence numbers above, the estimated number of patients in King County, WA, in 2007, who had similar set of diagnosis that resulted in a lumbar discectomy was 1,187. Similarly, the estimated number of patients with a cervical disc diagnosis who underwent a cervical microdiscectomy was 860.⁸ The 2007 population of King County was approximately 1,861,300, according to the King County Annual Growth Report.⁸

A Trend toward Outpatient Surgery

Hospitals are concluding it is more profitable to have all types of outpatient procedures moved into ASCs. Existing ASCs are looking to add new and profitable services. Single-practice specialty groups reeling from lower reimbursements and higher overhead costs associated with new regulations have found ASC ownership is one of the last bastions of profitability in private practice medicine.

ASCs depend on physicians bringing their cases for survival, and the key to increasing case volume is pleasing surgeons with an efficient facility. Neurosurgeons will be able to directly influence patient flow into an outpatient spine surgery center using their ties in the medical community. The target patient customer is someone who requires “high-tech” minimally invasive procedures such as microscopic or microendoscopic discectomy. Among payors, the outpatient centers should target health care plans that will provide sufficient payment to ensure an adequate return; they should further target health plans that show a preference for an ASC and would be willing to develop an ongoing relationship. These health plans may even share in promotion, outcome studies, and Health Plan Employer Data and Information Set reporting.

Outpatient spine surgery center owners and operators must educate ASC administrators, surgeons, insurance companies, and patients that spine surgery and other related pain management and surgical procedures can be performed more cost-effectively and to the same level of quality as they could in an inpatient hospital setting in order to attract new business. At present, most neurosurgeons conduct 5% of their practices in an outpatient setting, yet this percentage could conceivably increase to 50% in an outpatient spine surgery center.⁹ The centers should select and hire anesthesiologists, nurses, and technicians with established reputations for the highest quality, most efficient outpatient surgical care. For surgeons, bringing cases to the ASC is attractive because of its geographic proximity to the office, speed of transportation to the facility, and short procedure time from start to finish.

Being able to schedule operations at a convenient time is also important to surgeons and patients. When surgeons use a facility frequently, block time is reserved for their sole use. The facility’s ability to respond to unusual requests, such as an additional case in the late afternoon, will also influence a surgeon’s perception of a surgical facility. The outpatient spine surgery center should be able to meet and exceed these needs.

10.2.4 Physician Benefits

Most surgeons have dedicated insurance staff to process claims and negotiate each claim individually with the payor. This approach is expensive and frustrating for the surgeon. In fact, interacting with insurance companies is often cited as one of the factors responsible for diminishing job satisfaction among surgeons.

To address this issue, the outpatient spine surgery center should offer “bundled” fees to the insurance companies, which would include the surgery center fee, the surgical fee, and the anesthesia fee. Such bundled fees are attractive to insurance companies, especially if the bundled total is significantly less than the sum of the component fees. Such an arrangement can be a “win-win” situation because the insurance company has a lower payment, the ASC is motivated to control costs even more tightly, and the patient may have a lower deductible fee.

A bundled fee will further allow the outpatient spine surgery center more room to negotiate reimbursement schedules with payors if necessary. To support cost containment, the outpatient centers should maintain a database for outcomes analysis, which is becoming a requirement for managed care contracting. Increased emphasis on accountability is anticipated in addition to cost containment going forward.

An additional need among surgeons is part-time office space. Some surgeons have two or three offices, each with its own overhead. A surgeon may want a presence in a certain geographic market but will not be able to use the office on a full-time basis. The outpatient spine surgery center should have available office space surgeons can rent on an hourly basis. The surgeon would be able to operate part of the day and see patients the rest of the day without traveling to a different office. The surgeon could thus maintain an additional office with less expense. This office space may be considered a virtual office and will be paperless, and staffed by a receptionist and nurse, with commensurate low overhead per surgeon as a result of time-sharing. Generate standardized preoperative ( Fig. 10.3) and postoperative ( Fig. 10.4) order forms for patients undergoing outpatient spinal procedures to further improve efficiency.

The outpatient spine surgery centers should simplify and streamline record keeping with a major focus on easing the surgeons’ paperwork burden. At the completion of an operation, the surgeon usually dictates a detailed record of what was done and sends a letter to the referring physician. Dictation can simplify this process. Where possible, a dictation template should be used for a particular operation as performed by a particular surgeon. The surgeon would then fill in the necessary blanks to complete the dictation, and a letter would be generated to the referring physician. Surgeons will find this approach attractive as it will free them up to spend more time performing surgery, and satisfied surgeons generate positive word-of-mouth recommendations in the local surgical community.

Another benefit of the outpatient spine surgery center is a reduction in paperwork for the staff. In most hospitals, the circulating nurse in the operating room spends much of his or her time filling out paperwork. At the outpatient spine surgery center, this paperwork will be completed electronically with considerable time savings for the nurse.

10.2.5 Patient Benefits

The patient’s most important need is to have a successful outcome of surgery with the least possible disruption of daily living and normal routine.

The nature of the facility is not usually an expressed need of the patient, beyond certain minimal expectations. If all goes well, however, the facility and its function become important. Patients will favorably receive a pleasant, punctual, comfortable facility that provides amenities for both patients and their families. Patient education including clear preoperative ( Fig. 10.5) and discharge ( Fig. 10.6) instructions helps to eliminate confusion and improves patient care.

Fig. 10.3 Standard preoperative order form.

Although most practitioners have personally defined a broad philosophy for patient care, few actually articulate their patient care philosophies to their staff and those around them in a formal manner. According to the Institute of Medicine,¹⁰ the following principles apply:

• Safe: avoiding injuries to patients from the care that is intended to help them.

• Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

• Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.

• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.

• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

The role of leaders is to define and communicate the purpose of the organization clearly and establish the work of practice teams as being of highest strategic importance. Leaders must be responsible for creating and articulating the organization’s vision and goals; listening to the needs and aspirations of those working on the front lines; providing direction; creating incentives for change; aligning and integrating improvement efforts; and creating a supportive environment and a culture of continuous improvement that encourages and enables success.¹⁰

Leadership is imperative to create and maintain effective health care teams. Physicians play a key role (whether formal or informal) in determining the direction of their organizations. The health care team’s philosophy of care, mission, objectives, and goals should be thoughtfully defined and articulated to all team members. Although it is a common occurrence for these types of documents to be enthusiastically developed and then filed away, never to be seen again, highly effective teams will incorporate these blueprints into their everyday decisions for personnel selection, performance evaluations, quality improvement processes, outcomes evaluation, and program development. Whether the team is a solo physician practice or a large physician organization, the philosophy of care should drive all decisions for the team ( Fig. 10.7).

Fig. 10.4 Standard postoperative order form.

Fig. 10.5 Preoperative instructions.

Fig. 10.6 Discharge instructions.

Fig. 10.7 Philosophy of care algorithm.

10.3.3 Ambulatory Surgical Center Staff

Key responsibilities at the corporate level include management and oversight of clinic operations; payor, hospital, patient, and physician relationship management; and management of the information generated by operational activities at the clinic level. The outpatient spine surgery center should have a core team of dedicated surgical and administrative staff as well as a select group of participating neurosurgeons from the surrounding geographic area. As the patient volume grows at a given location, additional surgical theaters should be brought online and additional nursing staff added. Table 10.3 shows the typical staffing of both associated professionals and full-time employees at a representative outpatient spine surgery center.

The health care team may be comprised of any number of caregiver types depending on the size of the organization, types of patients cared for, acuity level of the patients, and number of physicians. The clinical team may consist of a variety of caregivers.

Physician Assistants

The typical physician assistant (PA) program is 24 to 25 months long and requires at least 2 years of college and some health care experience before admittance. More than half of the programs award a master’s degree.¹¹ Physician assistants are trained within the medical model and are seen as an extension of the physician rather than a different type of practitioner. Physician assistants are certified (PA-C) through the National Commission on Certification of Physician Assistants. To maintain certification, physician assistants must log 100 hours of continuing medical education every 2 years and take the recertification examination every 6 years. Physician assistants may obtain medical histories, perform physical examinations, assist in surgery, and perform certain procedures. They may prescribe medication in all 50 states.¹² Physician assistants must be supervised by a physician in order to practice. In 2015, the average annual salary for physician assistants was $99,270 per year, or $47.73 per hour; however, this salary varies depending on the specialty, years of experience, and geographic location.¹¹

Nurse Practitioners

A nurse practitioner is a registered nurse who has advanced education (usually a master’s degree in nursing) and clinical training in a health care specialty area. Most nurse practitioners have practiced as registered nurses for several years before obtaining a master’s degree in advanced nursing practice. The Masters/Nurse Practitioner degree usually takes 2 to 3 years to complete and most nurse practitioners are certified within their specialty. In the neurosciences, persons achieve Certified Neuroscience Registered Nurse status after passing a written examination, and continuing education units are required to maintain the certification. Nurse practitioners practice under the state’s Nurse Practice Act. Nurse practitioners may obtain medical histories, perform physical examinations, diagnose and treat health problems, order and interpret diagnostic tests, assist in surgery, perform some procedures, and prescribe medications using their own DEA (Drug Enforcement Administration) number. They focus on prevention, wellness, and patient education as well as patients’ medical conditions. Most nurse practitioners practice within a collaborative relationship with a physician or group of physicians. However, in more than half of the states they are allowed to practice independently without a physician’s supervision. This is especially common in rural areas where physicians may not be available. The median annual salary for nurse practitioners in 2015 was $101,260, or $48.68 per hour; however, there is wide variability related to years of experience and practice setting.¹³

Registered Nurses

There are three paths to becoming a registered nurse: (1) a 2-year associate’s, degree; (2) a 3-year diploma; or (3) a 4-year bachelor’s degree. Graduates of all three programs take the same licensing examination, the NCLEX-RN. Some have advocated that the bachelor’s degree program be the minimum requirement for entrance into the nursing profession. However, with a critical nursing shortage, it may be impractical to mandate that all registered nurses hold a bachelor’s degree. The registered nurse coordinates patient care, assesses patients, assists with procedures, provides patient education, and “triages” telephone calls. Registered nurses may not prescribe medication or medical treatment. Registered nurses may obtain certification in their specialty, for example, Certified Neuroscience Registered Nurse. The median annual salary for registered nurses working in physician offices in the year 2015 was $65,350 per year, $31.42 per hour.¹¹

Table 10.3 Typical staffing for an outpatient spine surgery center

Licensed Practical Nurses

Licensed practical nurses complete a 1-year training program and pass a state licensing examination. Licensed practical nurses provide basic patient care such as taking vital signs or assisting with procedures. Some states allow them to administer prescribed medications and intravenous fluids. The median annual income for licensed practical nurses in the year 2015 was $43,170 per year, or $20.76 per hour.¹¹

Medical and Nursing Assistants

Although formal training is not required for medical or nursing assistants, most complete a 1-year certificate program offered in vocational-technical high schools or postsecondary vocational schools. Courses include anatomy and physiology, medical terminology, and record keeping, as well as laboratory techniques and some clinical and diagnostic procedures, such as performing electrocardiograms. Clinical duties vary by state law but may include taking medical histories and vital signs, telephoning prescriptions to a pharmacy, removing sutures, and changing dressings. Median annual earnings for medical assistants in 2015 were $30,590 per year, or $14.71 per hour.¹³

The outpatient spine surgery center should provide a “surgeon-friendly” environment. Although a core staff of 10 full-time nursing and administrative personnel, 10 affiliated neurosurgeons, and 2 anesthesiologists is optimal, small practices may employ only a nurse or medical assistant to assist with escorting patients to and from the examining room, telephoning prescriptions to a pharmacy, and assisting with minor procedures. Larger practices often include at least one nurse practitioner and/or physician assistant, registered nurses in the clinic, and medical or nursing assistants.

Although nurse practitioners and physician assistants may be more expensive than registered nurses and medical/nursing assistants, they have a wider variety of skills and are often reimbursed by insurance companies for assisting in surgery as well as performing physical examinations. In addition, some studies have reported increases ranging from 20 to 90% in productivity for practices after adding a nurse practitioner.¹⁴

Performance Management

Office staff attrition not only is expensive but also often results in low morale and decreased productivity. It is estimated that one full-time registered nurse replacement (which includes recruitment and orientation) can cost up to $15,000. This figure does not take into account productivity loss and decreased staff morale. Although it cannot be avoided entirely, careful applicant screening and a thorough orientation process are imperative for reducing staff turnover. Personnel should be selected and trained for competence, ability to function as a member of a team, reliability, responsiveness, and ability to communicate with others. It is recommended that physicians take an active role in the interview and screening process for key positions within their practice. The philosophy of care, mission, and objectives of the practice should determine what questions are asked during the interview. Follow-up questions should further probe the applicant’s responses. For example, the interview might proceed as shown in the following:

Related posts:

Establishing Ancillary Services and Health Care Regulatory Implications Pathophysiology of Back Pain Operating Room Setup Anterior Thoracoscopic Sympathectomy Transforaminal Lumbar Interbody Fusion Anatomy of the Spine: An Overview

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