LET'S SEE SOME SPINE Minimally invasive spine procedures offer stability and relief with less trauma and shorter recoveries.

The arrival of a new neurosurgeon at our surgery center a few years ago opened our doors to outpatient spine surgery. If you've considered the specialty, you know the advantages that minimally invasive pain management and spine stabilization cases hold over open procedures and hospital settings. But you probably also recognize the challenges you'll face in adding them. I'm here to tell you that minimally invasive pain relief is within your reach.

Which cases should we consider?
As the outpatient migration of certain spine procedures trends nationwide and is eagerly discussed by your provider peers at the latest conferences, it's easy to ask yourself, "Should we be offering these at our surgery center?" Identifying which cases present ideal opportunities comes down to throughput. Procedures that don't take long and that can be turned over quickly make for an efficient, service-oriented schedule. That's not to say that patients are just products on an assembly line. They like speedy surgeries and discharges as much as physicians do. So choose for patient convenience and experience as well.

Keep in mind, though, that you're bringing the procedures on board as a new revenue stream, so it's important to assess the costs in light of their reimbursement rates (see "Can We Profit From Outpatient Spine?" on page 69). Just as you don't want to see physicians waiting to start their cases, you don't want case costs to swamp your profits before a procedure even begins.

Pain management procedures are a great place to start. Spinal injections and pain stimulator placements — for both trial and permanent implants — are relatively simple operations and can build a base for your service line. These cases are patient-satisfiers, not to mention lucrative business.

Minimally invasive spine surgery is the next step up, and includes kyphoplasty, microdiscectomy and laminotomy, which are easily performed in outpatient settings and which pay pretty well. Anterior cervical discectomy and fusion also fall into this category, as do transforaminal and posterior lumbar interbody fusions. For the lumbar fusions, however, your center must prepare for the possibility of overnight stays. While some patients may be safely discharged, others may require extended recoveries due to pain or airway issues. So you'll need a plan, which first means consulting your state regulations on whether 23-hour stays are allowable where you are.

Surgeons on board?
It's more than likely that your physicians will be the ones leading the way toward minimally invasive spine. If hosting the cases is the administration's idea, however, one of the biggest challenges you might encounter is recruiting and convincing surgeons to take on outpatient spine.

Orthopedic spine surgeons and neurosurgeons cover the same anatomical territory. Even though neuro docs seem about 10 times more conservative in their techniques and treatment, the regimentation of both specialties may affect their practitioners' comfort with same-day discharges.

STRIKE A NERVE Pain stimulator placements are easy to add, patient-satisfying and lucrative business, as long as you reach a favorable deal with your insurers.

The first step toward adding the procedures is determining the level of physicians' discomfort. In one-on-one conversations, discuss the achievability of expanding patient care and developing a new revenue stream. Does their discomfort stem from the procedure itself, or from the ambulatory environment? Are their objections based on personal philosophy ("This procedure should not be done outpatient."), clinical trends ("We should wait until Medicare covers this, and everyone else is doing it.") or safety ("I've had a bad experience with this, so I'm cautious.")? Every surgeon is human — though they don't much like to admit it — and as administrators, it's our job to address what's really bothering them.

One practical way of doing that is creating a plan of action for adoption. Beginning with simple pain and spine procedures can build your surgeons' confidence, as will careful patient selection. You might even suggest that they trial the procedures by booking them as outpatient cases at the hospitals where they hold privileges. Then they'll have the support of the hospital's resources as they determine how do-able the surgeries are. If they don't feel as though they are rushing patients out the door, they'll be more willing to perform them at your ASC.

Once they bring the cases to your ORs, take advantage of teamwork. Staff their cases with the anesthesia providers, nurses and scrub techs they know. Set up the room with the equipment they're used to. This familiarity will boost both confidence and efficiency. Don't neglect a safety net. Have a backup plan in place in the event that emergency care becomes necessary. This should include a transfer agreement with a nearby hospital and a contract with a local ambulance service.

A job done right
Pain management and minimally invasive spine are unique specialties in terms of patient satisfaction. Even if we do the job right and deliver good outcomes, we may be seeing those patients again when they return for another round of injections or a potential surgical solution. Provide every patient with a quality experience, and once you've overcome the challenges of starting an outpatient spine program, you'll keep it healthy over the long term.

STARTING POINT Delivering pain management injections is a simple and profitable base on which to build outpatient spine procedures.

CRUNCHING THE NUMBERS
Can We Profit From Outpatient Spine?

Adding pain management and minimally invasive spine to your facility's lineup may require a moderate initial investment in equipment and instruments, if other specialties haven't already brought the components on site. A full-size C-arm is a must, and can cost $120,000 new or substantially less if you opt for a refurbished model. A refurbished neurosurgical microscope costs $50,000 to $70,000, although leasing arrangements may be available.

A set of minimally invasive tubal retractors for lumbar access ranges from $39,000 to $55,000, and a stylus power drill goes for $14,000 to $18,000. Some physicians swear by headlamps to light the way; those can cost about $6,000 to $7,000. Ask your distributors if they're affiliated with a medical equipment supplier or scout out dealers online for the best deals.

Your biggest budget concern, though, is likely to be the continuing costs of implants and disposables. While pain management is as inexpensive as it is quick — $50 to $75 for epidural steroid injection kits that take 10 to 15 minutes to use — incisions add up the costs. Consider the following. Trial leads for pain stimulators cost $850 to $2,000. On average, Medicare reimburses the implantation of trial pain stimulators at $3,837. The permanent leads range from $18,000 to $29,000, while permanent implantation is reimbursed at $20,807. The biologics, cages, rods and screws needed for cervical fusion can cost $2,200 to $5,000. Medicare pays $7,842 for the procedure. For lumbar fusion, compare the $6,000 to $9,000 for implants with a reimbursement of about $12,922.

Clearly you'll want to keep a close eye on your implant deals. The key here is to remember that your surgeons and your center are on the same team. This is a conversation you have to hold in order to stay profitable. Sometimes you'll see hospitals cutting implant deals with specific vendors, or vendors reaching out to surgeons directly. That runs counter to your business's interests. Discuss implant preferences with your surgeons and present a unified front when you negotiate with your implant vendors. They should provide a service and a product, and they should work for your business.

— Laurie LaPenotiere, MSN, RN