SPREAD THE WORD Marion R. McMillan, MD, founder of the Synergy Spine Center, treats a patient with spinal stenosis. "Making patients and physicians aware of minimally invasive outpatient spinal surgery is one of the challenges."

The margins are narrow and the need for efficiency is paramount, but outpatient spine, with its considerable growth potential, can be a lucrative service line for surgery centers that understand and embrace the required components.

One of the first challenges, say those who've succeeded, is getting the word out — getting potential patients to understand that conservative and minimally invasive approaches exist, and don't necessarily require overnight stays. You need to "make patients and referring physicians aware of the availability and advantages of minimally invasive outpatient spinal surgery as an alternative to traditional hospital based spinal surgical care," says Marion R. McMillan, MD, medical director and founder of Synergy Spine Center in Seneca, S.C.

The Orthopaedic Spine Center of the Rockies, in Fort Collins, Colo., has come up with several innovative ways to make its presence known, including sponsoring high school and middle school sporting events. "We visit the training rooms and work with coaches, trainers and athletes, offering advice and injury-prevention tips," says Barb Hardes, RN, MSMHCA, BSN, CNOR, administrator and chief operating officer. It also conducts an annual "orthopedic symposium" — a series of lectures by its physicians for other healthcare professionals in the community and region.

The right surgeons
The outreach to other professionals is extremely important, say decision-makers, because centers need to find surgeons who have both the needed skills and the demeanor to flourish in an intensely cost-conscious environment.

Finding the right surgeons "is a very lengthy and selective process," says Ms. Hardes. "Cost containment requires physicians to be fully engaged."

Physician leadership is a must, says Mark Hood, CEO of Spine Team Texas, which operates several centers in the Dallas-Fort Worth area. "Physicians who are already part of the project can be essential in recruiting other physicians who understand the need to balance having the right equipment and meeting a budget."

Dr. McMillan suggests controlling costs by taking an incremental approach to adding services and making sure established procedures are well supported before introducing anything new. "For example," he says, "first introduce and support lumbar decompression surgery for herniated discs and uncomplicated spinal stenosis before you introduce more complicated — and costly — lumbar spinal fusion procedures."

You can also leverage vendors who are looking to take advantage of the growing spine market. Many are willing to provide introductory trials for both equipment and instruments, says Dr. McMillan. Ask for a 60-day trial period before committing to a purchase. And when manufacturers push higher-profit single-use items? Push back. "Physicians need to be willing to use high-quality reusable instruments and surgical supplies."

Additionally, he says, since downtime can be devastating, look for vendors that offer service agreements and loaner instruments, and that have U.S.-based repair facilities.

SKILL SET Along with having specialized skills, outpatient spine surgeons need to embrace an intensely cost-conscious environment.

Getting paid
Reimbursement is challenging when you're working with payers who are unfamiliar with outpatient spine, so you have to be proactive, says Jenny Mishler, revenue manager at the Orthopaedic Spine Center of the Rockies. Payers may have different guidelines regarding treatments and implants. If, for example, conservative treatments are either required — or contraindicated — you need to carefully document everything.

"Authorization is the primary hurdle," says Ms. Mishler. "The secret to successful reimbursement is to be proactive at the point of prior authorization."

Dr. McMillan recommends having a contingency plan in place as well. "All planned procedures must be preauthorized with claim reference numbers provided," he says. But, he notes, insurers like to point out that preauthorization doesn't guarantee payment, so it's also important to have legally enforceable patient guarantees when claims are denied. The guarantees, he says, must specify that the patient knows exactly what the charges and the insurance contractual write-off are, and patients must authorize an alternate source of payment.

Patient selection
Of course, not every patient with back pain is a candidate for surgery. "Patient selection is tremendously important, especially in the start-up phase," says Mr. Hood. "Be conservative, have established selection criteria and stick to them." A holistic approach that includes pain management and the option to provide conservative treatment before, after, and sometimes instead of, surgery, is an integral part of the bigger picture.

"Our philosophy is to be conservative, offering surgery as a last resort," says David Rothbart, MD, the medical director and founder of Spine Team Texas. The multi-disciplinary team at Spine Team Texas includes rehabilitation physicians who specialize in non-surgical spine care, anesthesiologists who specialize in chronic spine pain and spine-focused physical therapists, as well as surgeons.

Smaller facilities can benefit from partnering with office-based pain-management physicians, says Dr. McMillan, as patients transition from appropriate non-surgical or conservative management to minimally invasive outpatient care and back to pain management, if necessary.

Infection prevention
Aggressive infection prevention protocols are a must with spine procedures, which are especially prone to surgical site infections.

Theresa Johnson, RN, formerly the orthopedic coordinator at the Texas Children's Hospital in Houston, helped develop a protocol that reduced the hospital's spine SSI rate from 6.3% to 1.5%. The key elements included scrubbing the surgical site first with Betadine, then with ChloraPrep, and letting it dry for at least 3 minutes. With a goal of standardizing prophylactic dosing time, Ms. Johnson determined that the ideal time to begin administering antibiotics was when the patient was flipped into the prone position. "It worked out well," says Ms. Johnson, now the pediatric coordinator at the Woman's Hospital of Texas in Houston, "because the time between the flip and the first incision was typically between 30 and 45 minutes." Limiting traffic in and out of the room during surgery was also a priority, helped by signs on the door that said "Spine in progress." The final steps were irrigating the surgical site, first with saline, then with a 50% dilution of Betadine for 3 minutes, and sprinkling 2 grams of vancomycin powder onto the soft tissue.