February 16, 2022

Adding these complex surgeries demands careful planning and execution.

The ability to provide high-quality, accessible outpatient spine care requires specialized equipment and instrumentation, a safety-first focus and a keen awareness of the needs of your community.

Those have been the guiding principles throughout the development of The Surgery Center at Shrewsbury (Mass.) since 2018. The 35,000-square-foot multispecialty center recently added spine to its existing mix of orthopedics and sports medicine surgeries. "From day one of planning and designing our facility, we focused on how to grow those service lines, while also assessing the potential for growth into other specialties and services in the future — especially spine," says Prashanth Bala, MS, MHA, vice president of ASC operations at Shields Health Care Group and acting administrator at the center.

Surgeons have performed about five spine surgeries per month at the center since the first procedure last fall, with plans to slowly increase the number and types of spine cases performed at the facility over time. Here's what Mr. Bala says is necessary to create a successful outpatient spine line:

Physical space. Spine ORs don't need to be super-sized. "At 520 square feet, each of our nine ORs were built to be specialty-agnostic," says Mr. Bala. "An important consideration for a spine OR is to provide the surgeon enough room for the numerous instrument trays they need for each case. Because we knew from the beginning we would eventually add spine, we proactively prepped for it by saving shelf space for everything we could possibly need when we did take that step."

Capital equipment. Mr. Bala says getting his spine surgeons aligned on equipment allowed him to avoid overinvestment based on any one surgeon's preferences. "We controlled costs by focusing first on purchasing equipment and supplies for specific procedures all our surgeons would use, and then strategically adding to our fleet as needed," he says. "Start slow and grow from there."

The two most important spine-specific types of equipment are procedural positioning frames and surgical microscopes. "To save both money and square footage, only buy the frames you absolutely need," says Mr. Bala, who adds that microscopes are important to some but not all surgeons. "Some prefer to use them because they can stand up and see vascular conditions in and around the different components of the spine without needing to hover over the surgical field," he says.

Implants and instrumentation. Spine procedures typically involve five to seven trays. "A key for us was narrowing down exactly how much instrumentation our surgeons would need for a given case," says Mr. Bala, who engaged his vendors and surgeons to reduce the number of trays to three to five. "We call them our spine sets, and all our surgeons have agreed on what they should include," he says. "Reducing the number of trays will help your sterile processing staff as well."

Staffing. Mr. Bala designated a nurse as his facility's full-time "complex care coordinator." The nurse works with surgeons to ensure proper expectations are set with patients and runs an education class for patients so they understand what to expect before surgery, the day of surgery and during recovery. "Once each surgery is scheduled, our complex care coordinator consults with the surgeon on areas of concern about the patient's condition, so we can ensure a safe surgery," says Mr. Bala.

Reimbursement. "Commercial payers have demonstrated enthusiasm for the value of spine cases performed in safe, proven outpatient environments," says Mr. Bala, who notes that CMS returned 14 spine procedures to the inpatient-only list this year. "We continue to work with our commercial payers to inform them of what else our surgeons can do successfully in outpatient spine, and how we can prove it to them."

Surgeons. Mr. Bala's facility isn't letting just any physician enter its ORs. "Our surgeons must have a proven track record of performing spine surgeries in hospitals before they bring cases to our outpatient facility," he says. "To attract top physicians, we have tailored an efficient, safe, standardized program that will make them feel comfortable and confident working here, while ensuring every patient receives the same high quality of care."

Mr. Bala reiterates that careful planning is the key to success. "Everything we've done with our spine line has been a ‘crawl before we walk, walk before we run' approach," he says. "We're slowly ramping up in an appropriate fashion."

An independent spine surgeon backs the benefits of 23-hour post-op stays.

Spine is generating a lot of buzz in outpatient circles, and for good reason. Advancing technologies, minimally invasive surgical techniques and surgeons who are willing to push the specialty forward are allowing patients to undergo complex procedures in the morning and head home later the same day.

Most of the time, anyway. Richard Kube, MD, owner of Prairie Spine & Pain Institute in Peoria, Ill., prefers to keep some of his patients for extended observation out of an abundance of caution. He built a room adjacent to the pre- and post-op bays in his surgical center where patients can remain for up to 23 hours, in accordance with Illinois state laws. "They receive one-to-one care, which they couldn't get at the local hospital," says Dr. Kube.

Incorporating an overnight observation room into the facility's design allows Dr. Kube to assess patients multiple times before they're discharged. He checks on patients between cases, before he leaves at the end of the day, and first thing the next morning before they're discharged. "I see them three or four times before they go home," he says. "I'm able to get a strong sense of how they're recovering, and they're getting access to their surgeon that they might not get elsewhere."

Dr. Kube describes the extended stay room as on par with a suite at a high-end hotel. The bed is a standard hospital model, but it's surrounded by luxurious amenities: a cushy reclining chair (the same one Dr. Kube has in his own living room), a pullout Tempur-Pedic bed for loved ones of patients who want to spend the night and a high-quality set of table and chairs. Patients can relax by the room's fireplace and watch a full lineup of cable channels on a 65-inch ultra-high-def TV. A private bathroom features a granite-topped vanity, high-end fixtures and a walk-in shower with a 15-inch rainfall shower head.

The stylish space makes quite an impression. "I wouldn't say it's the Ritz Carlton, but it's pretty darn close," says Dr. Kube. "Anything I can do to make the surgical experience feel less institutional is a plus for patient care and is satisfying for me as a provider."

He also points to marketing benefits that are more difficult to quantify but no less important. "You can't put a price on the value of patients who post on social media about their experience and share a picture of themselves eating a filet in front of a roaring fire," says Dr. Kube. "Is that worth the extra investment? I definitely think so."

This physician offers important considerations and valuable advice for developing a solid spine procedure service line at your ASC.

In the ever-changing world of ASCs, one trend that is taking hold as stakeholders take a closer look at the possibilities is the migration of spine surgeries to the outpatient setting. This may not be a totally new story and in some communities there already is history, but today more movement of spine procedures into the ASC space is happening as healthcare professionals and industry partners work together with new strategies, innovations and technologies. We spoke to Paul E. Kraemer of the Indiana Spine Group to learn more about how this ASC has evolved and what to keep in mind as orthopedic spine surgeons consider moving cases to an outpatient setting.

Q: Tell us a little about your background and the history of your ASC.

North Meridian Surgery Center is a spine only ASC founded in the 90's but in modern form since 2011. It started with a general ortho focus, with a few other cases, but has been spine only for over 10 years. We changed locations in 2011 and consolidated other practice partners with other ASCs to one location. We now have about 20 spine surgeons and 8 pain physicians under one roof.

Q: As more spine procedures migrate to the ASC, what would you say are the top three things to keep in mind for an orthopedic spine surgeon who wants to begin moving cases to the outpatient setting?

"Practice" outpatient cases in an inpatient setting. If your ASC doesn't have it, then don't use it. If you need it, buy it, but you'll be surprised at how lean you get. When "practicing" outpatient cases in an inpatient setting, send patients home like you would in an ASC. Pick the right cases for an ASC, and then expand from there. Choose thin, motivated patients with straightforward pathology to test the system, then go from there. Troubleshoot, repeat.

Look around to what others are doing outside of your area. The best way to find out what can be done as an outpatient case is to announce what can't be done, and then someone will tell you they did exactly that yesterday and it went fine. Even though they may be 1,000 miles away –it's ok to contact a center you think is doing something interesting and go for a visit.

Think outside the box and partner with others who will do the same. There is a lot to learn from joint surgeons, other spine surgeons, vascular, even OB/Gyn and Urology (where I learned about TAP blocks). "This is the way I have always done it" gets you nowhere. A partner that is invested in making it work will help you find a way.

Q: Spine procedures require specialty specific equipment and consumables. What considerations should factor into decisions about equipment purchases and vendor relationships for new service lines?

This is where focus and economies of scale can help substantially. Having a critical mass of surgeons who will use a table, a microscope or special retractors makes justifying infrastructure more palatable. I think radical transparency about what everything costs, what is being used, and who pockets what is a great way to run a business shared by smart professionals. It's the best way to remind everyone that you are spending your own real money, and that while purchases aren't bad, only buy what you need and nothing more. That applies to capital as well as implants, even support staff. Everything affects the bottom line.

Q: What do you look for in a partner when it comes to equipment, implants and disposables for your ASC?

It varies based on where you are in the lifecycle of the ASC. Early on, or when you're looking at a substantial expansion, capital concerns are likely predominant. At mid-life of the ASC, those capital concerns might be less common, and implant costs are paramount, especially when you start doing more ACDFs and lateral/ oblique fusions that are implant and biologic heavy. Earn out or value-added arrangements can be helpful. Either way, there will be something unexpected that comes up, and having someone to rely on in a tight situation is a great asset.

Q: Where do you see outpatient spine in the next five years?

More. The arthroplasty surgeons are doing things that would have been unfathomable just a few years ago. Once you know what can be done there is no going back. We have done up to 3 level anterior necks for 2 decades, without trouble but with a fairly strict protocol. We have been doing anterior and oblique Lumbar fusions for about 7 years with great success. Many of our challenges are regulatory rather than medical. As this flips from a brake to an accelerant, we will continue to do more. The combination of specific blocks, better anesthesia, better retractors and setting patient expectations will combine to make ASCs a default option for many operations very soon.

Q: How is your ASC benefitting your local community?

We provide many great employment opportunities and unlike the nominally not-for-profit hospital conglomerates, we pay property taxes and income taxes. Our medical education lab provides many learning opportunities, including cost-free programs for motivated high school students interested in health care. We have a true charity scoliosis program that has been implemented at our sister hospital, which is also physician-owned. Most importantly, we take great care of our friends and neighbors, now including much of the state.

Q: What advice would you give to someone before they decide to begin operating in an ASC or purchasing ownership in an ASC?

The future is very bright for spine in the ASC. I think the most important thing, being in spine, is to recognize your value. Spine is well reimbursed, and nearly always a profit center if you get all the above details right. Being a high performing outpatient surgeon is extremely valuable. An ASC should be the best investment you ever make, but it's like having a child, not an IRA. It takes constant attention and focus. The best time to do it has already passed, but the second-best time is now.

Note: Dr. Paul E. Kraemer is a consultant of Stryker. The opinions expressed by Dr. Kraemer are those of Dr. Kraemer and not necessarily those of Stryker.

Paul E. Kraemer, MD, was educated at Cornell University in New York, The University of Iowa Medical School and the University of Wisconsin Hospitals and Clinics Orthopaedic Surgery residency program. He spent an additional year at Seattle's Harborview Medical Center/ the University of Washington in a combined orthopedic and neurosurgical Spine Surgery fellowship. Dr. Kraemer has a special interest in scoliosis, revision surgery and minimally invasive techniques. He is actively involved in research, resident education and cross-specialty education of practicing physicians and has presented research and taught courses nationally at the American Academy of Orthopaedic Surgeons, the American Association of Neurological Surgeons and the North American Spine Society, as well as speaking locally on complex spine and diagnostic challenges to the IU departments of medicine, orthopedics and neurosurgery.

Note: Whether you're building a new ASC or adding a spine sub-specialty to your ASC, Stryker's ASC business can help you build and grow strategically. By giving you access to our world-class portfolio of wall-to-wall capital, head-to-toe implants, ASC specialists who understand your unique challenges and ongoing support, we deliver everything your ASC needs to win today – and tomorrow. To learn more about Stryker's ASC business visit https://www.stryker.com/us/en/care-settings/asc.html