It is well known that ambulatory surgery centers (ASCs) provide surgical services at costs lower than hospitals — due in large part because ASCs typically limit their procedures to simpler, lower-risk, ambulatory procedures. In a controversial leap forward, starting in 2015, the Centers for Medicare and Medicaid Services (CMS) approved several new spine surgery codes that neurosurgeons can perform at an ASC. These include:
- Cervical spine fusion
- Lumbar spine fusion
- Spine fusion extra segment
- Cervical spine disc surgery
- Laminectomy single lumbar
- Removal of spinal lamina
- Decompression spinal cord
The result is that many healthy, presumably younger, Medicare patients can opt to have their surgeries at a surgery center, rather than having to go to the hospital. Medicare’s approval of these cases opens the door for more commercial payers to reimburse for these procedures when they are performed at ASCs as well. Some payers in particular regions of the country have been reluctant to approve spine surgery in ASCs — even with available cost effectiveness and quality data — because they base reimbursement on Medicare’s payment policies.
Since 1994, pioneering neurosurgeons gathered and published data on outcomes and cost differentials for spine surgeries in the ASC and hospital, leading a radical change in how nearly all spine care is delivered. Just a few decades ago, the typical patient undergoing removal of a herniated disc (lumbar microdiscectomy) might remain on bed rest for several days and in the hospital for a week or longer. Today, the vast majority of these cases are done on an outpatient basis with a rapid return to normal activity. The recent CMS ruling now makes all the benefits of outpatient spine surgery available to Medicare beneficiaries.
With experience, we anticipate these changes will lead to further efficiencies and quality in neurosurgical interventions. Consider the following:
- Medicare patients will not be relegated to hospitals and thus will experience fewer surgical infections;
- The entire healthcare delivery system benefits due to lower cost of spine surgeries, which are increasingly necessary for aging baby-boomers — a demographic that wants to remain active; and
- Medicare patients can be operated on in the ASC, without taking up space in the hospital operating room, which blocks access for patients who require a hospital setting for surgery.
As more patients are treated in ASCs, here are a few key trends worth watching in the short and long term:
- Increased overnight stays at the ASC;
- Increased need for outpatient rehabilitation or recovery care;
- More stringent contingency plans for Medicare patients that end up needing a higher-level of care in the hospital; and
- Further expansion of spine surgery in ASCs.
CMS has finally recognized the safety, improved patient satisfaction, and cost-effectiveness of the ASC setting for spine surgery, which many neurosurgeons have recognize for years.
1. Wohns, RNW: Safety and Cost-Effectiveness of Outpatient Cervical Disc Arthroplasty. Surgical Neurology International, www.surgicalneurologyint.com/content/1/1/77, 2010