Ortho ASC Growth Continues to Accelerate


Surgery centers are managing skyrocketing demand for joint repairs and replacements that shows no signs of slowing down.

Denise Kesler, RN, retired from her role as the director of the Athens (Ga.) Orthopedic Clinic ASC last month. She’s seen the surgery center evolve from a fledging facility to a high-volume center of advanced care. She began working at the ASC in 2006, when six surgeon-owners performed sports medicine procedures in two ORs. A steady growth in case volume forced the facility to convert a procedure room used primarily for placing regional blocks into a fully functioning surgical suite in 2008.

Today, 15 surgeons keep the facility buzzing by performing a wide range of procedures, from pain management injections and ACL repairs to total joint replacements and minimally invasive spine surgeries. Last year, 5,230 patients passed through the facility’s three ORs. It was a high volume of cases that amazed the surveyor who recently renewed the center’s accredited status because its streamlined workflows focus as much on safety as they do on speed — infection rates are near zero and complications are nearly nonexistent. 

Ms. Kesler, who had to manage the steady increase in surgical volume over the years, understands how to balance an evolving case mix with a constant focus on capturing as many procedures as possible to boost the bottom line. When surgeons outperformed their block times, she relied on creative juggling of the surgical schedule to maintain the facility’s capacity.

Last fall, the ASC took two Thursday mornings a month away from the block time of a high-volume sports medicine surgeon in order to add another total joint specialist to the team. “We ended up losing 150 of his cases to the local hospital and looked for ways to get them back,” says Ms. Kesler. “I shifted the joint specialist’s procedures to a single Thursday each month, instead of scheduling his cases over two days, and he was still able to perform 10 more replacements than he did the previous year. That freed up one of the mornings for the sports medicine physician, so we were able to recapture about 60% of the cases we had lost.”

The vast majority of orthopedic cases can be done safely and successfully in ASCs.
— Michael Shuler, MD

The clinic’s surgeons are beginning to perform increasing numbers of hip and knee replacements on Medicare patients since CMS added the procedures to the ASC-approved list in 2020 and 2021, respectively. Ms. Kesler had to tap into her savvy negotiating skills with vendors to slash the cost of pricey implants, which ate into most of the reimbursement CMS pays for joint replacements, to make the cases financially viable. 

Ms. Kesler points to the importance of orthopedic ASCs incorporating a chronic pain management program into the case mix, primarily to treat what can be debilitating discomfort for patients. She also notes that pain management patients might eventually need surgery to treat their condition or recommend the facility’s practice based on the quality of care they receive — two ways a surgery center can capture new cases.

The steady influx of orthopedic cases to surgery centers is only going to increase, according to Michael Shuler, MD, a hand and upper-extremity specialist and part owner of the Athens Orthopedic Clinic since 2008. “Surgeons prefer to operate in surgery centers, where they benefit from dedicated surgical teams that learn their preferred routines, unparalleled efficiencies, and control over the supplies and equipment they use and the quality of care delivered — factors that contribute to optimal outcomes,” he says. “There are certainly still orthopedic procedures that need to be performed in hospitals, but the vast majority can be done safely and successfully in ASCs.”

Orthopedic cases performed in the outpatient setting will continue to increase as total joint replacements and spinal procedures become more common within ASCs, according to a study Dr. Shuler co-authored in the March 2021 issue of Annals of Medicine and Surgery. The study, which explores ebbs and flows of surgical volume in ASCs throughout a calendar year, notes all surgical specialties experienced an overall increase in case volume from 2016 to 2019. The percentage increase was greater for orthopedic ASCs (76.9%) than for all ASCs combined (64.5%), according to the study, which notes an increasing yearly demand for orthopedic surgery and says the average surgical volume within the ASC setting should continue to rise each year.

“The cost of care in ASCs, which is significantly less than in hospitals, also drives more cases to surgery centers,” says Dr. Shuler. “This highlights the benefits of the outpatient model — and it’s surprising that one of the biggest factors preventing more cases from being performed in ASCs is the payment policies of insurers.” He points out that CMS doesn’t carve out separate payments for implants, but says that policy is beginning to change for joint replacements, which will hopefully lead to implants being approved for other procedures.

Ultimately, says Dr. Shuler, planning for case volume growth requires finding a balance between performing surgeries as efficiently as possible and controlling expenses in order to turn a profit. “Adding procedures must make sense from a cost-analysis standpoint,” he says. “You need to determine if increased efficiencies would cut down on the costs of adding more cases.” OSM

Note: This three-part article series is supported by Zimmer Biomet.

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