Orthopedics is one of the most popular and profitable specialties for surgery centers, and 2012 is expected to introduce more procedures into the ASC setting. Here three orthopedic surgeons — Ken Pettine, MD, an orthopedic surgeon in Loveland, Colo., T.K. Miller, MD, orthopedic surgeon with Roanoke (Va.) Ambulatory Surgery Center, and Douglas Garland, MD, medical director of MemorialCare Joint Replacement Center at Long Beach (Calif.) Memorial Medical Center — discuss seven opportunities and challenges facing outpatient orthopedic surgeons over the next year.
1. Larger volume of fracture management and spine care in the ASC setting. Dr. Miller believes surgery centers will see a larger volume of elective — and increasingly complex — fracture management. "As orthopedic technology and integrated perioperative pain control advances, there should be a continued shift from hospital-based short stay to pure outpatient care," he says. "Polytrauma care, complex spine and co-morbid medical issues will be the primary reason for hospital-based surgical intervention."
Dr. Miller believes that surgery centers may see a new group of orthopedic surgeons bringing procedures to their facilities, including trauma surgeons and joint reconstructive surgeons. He says he believes as outpatient spine procedures increase and integrated pain management associated with spine becomes more prevalent, ASC-based comprehensive spine care — which combines the work of a spine surgeon with pain management — should grow.
2. Shorter lengths of stay for joint replacement patients. According to Dr. Garland, joint replacement procedures are necessitating shorter lengths of stay in the hospital, with a movement toward more outpatient procedures. As outpatient total joint procedures become more common, physicians and payors are likely to become more comfortable with bringing the procedure to the surgery center and contracting for reimbursement.
"In 2011, I did a handful of outpatient total hips, and I expect that trend to increase substantially," Dr. Garland says. Surgeons say the most important issue now is to make sure that total joint patients in the ASC are screened for co-morbidities that would make the procedure inappropriate in an outpatient setting.
3. Expansion into stem cell procedures. Dr. Pettine believes surgery center orthopedic surgeons may be able to profit in 2012 by adding stem cell procedures to the ASC. Dr. Pettine has partnered with a stem cell research company to provide adult stem cell therapy for orthopedic and spine conditions resulting from injury or aging. He says the procedures can be performed in about 30 minutes, and the patient pays $4,500 in cash, eliminating the need to negotiate payor contracts.
Dr. Pettine says the procedure can be very profitable for surgery centers that take advantage of a partnership with a stem cell company. "We figure we're going to do about 20 of these procedures in January and February," he says.
4. Younger patients receiving total joint replacements. Dr. Garland says more young people and seniors are receiving total joint replacements — a boon for surgery centers on one end and a gain for hospitals on the other. Dr. Garland says when he trained for orthopedic surgery 30 years ago, few patients under age 60 underwent a total hip replacement because of the high chance of failure due to activity level or duration of use.
"Now about half of total joints are performed in those under 65, with younger individuals having total joint replacements thanks to advances in surgical techniques and improvements in artificial joint technology," he says. "[This results] in replacements lasting much longer than ever before — typically two decades or more." He says younger patients will provide increased volume for outpatient surgery centers, which are an appropriate setting for healthier patients who require shorter hospital stays. On the other hand, older, more fragile patients are more likely to remain in the hospital setting because of the need for a longer recovery period.
5. Opportunity to make more money from implants. Dr. Pettine says orthopedic surgeons and surgery centers have an opportunity to make more money on implants if they can increase the difference between the wholesale price and the retail price. He says there are companies that produce same-quality implants at a drastically reduced price — sometimes 80 percent less expensive than the brand name products.
"Off the top of my head, I bet we go through about $8 million a year in implants, so if you can cut your implant costs by just 10 percent, that's significant," Dr. Pettine says. He says the key is looking for implant companies that have largely eliminated their sales force. He says most surgeons do not need a sales representative in the operating room, and companies without a sales force have much more room to offer cost-savings.
6. Increasing failure of "all metal" or "metal-on-metal" hips. At their peak, "all metal" or "metal-on-metal" hip replacements accounted for one-third of hip replacements performed in the United States each year. In recent years, orthopedic surgeons have seen this devices start to fail, meaning orthopedic surgeons must monitor all metal patients for many years because of the potential for late failure.
This is a cause for concern for ASC physicians who have implanted all metal hips in the past or continue to do the procedure today. "Although they are not life-threatening issues, these atypical metal-on-metal reactions can be crippling, painful injuries," Dr. Garland says. "In addition to closely monitoring these individuals, we need to provide them with access to legitimate websites so they, too, can follow the latest developments." He says orthopedic surgeons may still be able to perform metal-on-metal hip replacements in young adult males, for whom the rewards may outweigh the risks.
7. Anesthesia developments for orthopedic patients. Dr. Garland says orthopedic surgeons increasingly understand that patients undergoing total joint replacements need different levels of sedation than other patients. "Those needing joint replacements will be up and moving shortly after leaving the recovery room and, therefore, [anesthesiologists] need to modify the amount and types of anesthesia drugs," he says. "This means less general anesthesia, less traditional drugs such as narcotics for pain and much more preemptive medication."
He says fewer narcotics can minimize and eliminate the side effects of nausea, constipation and other issues, and anesthesiologists are seeing excellent results with nerve blocks, local injections and non-traditional anesthetic drugs. For example, he says his OR team uses anti-inflammatory drugs and injects locally at the incision cite, interrupting three sites for pain control in addition to providing analgesic medications such as Tylenol. "Our goal is to interrupt the pain pathways at various sites and by different mechanisms, [requiring] less or no general anesthesia and traditional narcotics," he says.
Related Articles on Orthopedic and Spine-Driven ASCs:
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Dr. James Macon Spine Surgical Innovation Featured in Boston Globe Article
Lake Surgery Center in Michigan 1st ASC to Buy Robotic Spinal Surgery System
1. Larger volume of fracture management and spine care in the ASC setting. Dr. Miller believes surgery centers will see a larger volume of elective — and increasingly complex — fracture management. "As orthopedic technology and integrated perioperative pain control advances, there should be a continued shift from hospital-based short stay to pure outpatient care," he says. "Polytrauma care, complex spine and co-morbid medical issues will be the primary reason for hospital-based surgical intervention."
Dr. Miller believes that surgery centers may see a new group of orthopedic surgeons bringing procedures to their facilities, including trauma surgeons and joint reconstructive surgeons. He says he believes as outpatient spine procedures increase and integrated pain management associated with spine becomes more prevalent, ASC-based comprehensive spine care — which combines the work of a spine surgeon with pain management — should grow.
2. Shorter lengths of stay for joint replacement patients. According to Dr. Garland, joint replacement procedures are necessitating shorter lengths of stay in the hospital, with a movement toward more outpatient procedures. As outpatient total joint procedures become more common, physicians and payors are likely to become more comfortable with bringing the procedure to the surgery center and contracting for reimbursement.
"In 2011, I did a handful of outpatient total hips, and I expect that trend to increase substantially," Dr. Garland says. Surgeons say the most important issue now is to make sure that total joint patients in the ASC are screened for co-morbidities that would make the procedure inappropriate in an outpatient setting.
3. Expansion into stem cell procedures. Dr. Pettine believes surgery center orthopedic surgeons may be able to profit in 2012 by adding stem cell procedures to the ASC. Dr. Pettine has partnered with a stem cell research company to provide adult stem cell therapy for orthopedic and spine conditions resulting from injury or aging. He says the procedures can be performed in about 30 minutes, and the patient pays $4,500 in cash, eliminating the need to negotiate payor contracts.
Dr. Pettine says the procedure can be very profitable for surgery centers that take advantage of a partnership with a stem cell company. "We figure we're going to do about 20 of these procedures in January and February," he says.
4. Younger patients receiving total joint replacements. Dr. Garland says more young people and seniors are receiving total joint replacements — a boon for surgery centers on one end and a gain for hospitals on the other. Dr. Garland says when he trained for orthopedic surgery 30 years ago, few patients under age 60 underwent a total hip replacement because of the high chance of failure due to activity level or duration of use.
"Now about half of total joints are performed in those under 65, with younger individuals having total joint replacements thanks to advances in surgical techniques and improvements in artificial joint technology," he says. "[This results] in replacements lasting much longer than ever before — typically two decades or more." He says younger patients will provide increased volume for outpatient surgery centers, which are an appropriate setting for healthier patients who require shorter hospital stays. On the other hand, older, more fragile patients are more likely to remain in the hospital setting because of the need for a longer recovery period.
5. Opportunity to make more money from implants. Dr. Pettine says orthopedic surgeons and surgery centers have an opportunity to make more money on implants if they can increase the difference between the wholesale price and the retail price. He says there are companies that produce same-quality implants at a drastically reduced price — sometimes 80 percent less expensive than the brand name products.
"Off the top of my head, I bet we go through about $8 million a year in implants, so if you can cut your implant costs by just 10 percent, that's significant," Dr. Pettine says. He says the key is looking for implant companies that have largely eliminated their sales force. He says most surgeons do not need a sales representative in the operating room, and companies without a sales force have much more room to offer cost-savings.
6. Increasing failure of "all metal" or "metal-on-metal" hips. At their peak, "all metal" or "metal-on-metal" hip replacements accounted for one-third of hip replacements performed in the United States each year. In recent years, orthopedic surgeons have seen this devices start to fail, meaning orthopedic surgeons must monitor all metal patients for many years because of the potential for late failure.
This is a cause for concern for ASC physicians who have implanted all metal hips in the past or continue to do the procedure today. "Although they are not life-threatening issues, these atypical metal-on-metal reactions can be crippling, painful injuries," Dr. Garland says. "In addition to closely monitoring these individuals, we need to provide them with access to legitimate websites so they, too, can follow the latest developments." He says orthopedic surgeons may still be able to perform metal-on-metal hip replacements in young adult males, for whom the rewards may outweigh the risks.
7. Anesthesia developments for orthopedic patients. Dr. Garland says orthopedic surgeons increasingly understand that patients undergoing total joint replacements need different levels of sedation than other patients. "Those needing joint replacements will be up and moving shortly after leaving the recovery room and, therefore, [anesthesiologists] need to modify the amount and types of anesthesia drugs," he says. "This means less general anesthesia, less traditional drugs such as narcotics for pain and much more preemptive medication."
He says fewer narcotics can minimize and eliminate the side effects of nausea, constipation and other issues, and anesthesiologists are seeing excellent results with nerve blocks, local injections and non-traditional anesthetic drugs. For example, he says his OR team uses anti-inflammatory drugs and injects locally at the incision cite, interrupting three sites for pain control in addition to providing analgesic medications such as Tylenol. "Our goal is to interrupt the pain pathways at various sites and by different mechanisms, [requiring] less or no general anesthesia and traditional narcotics," he says.
Related Articles on Orthopedic and Spine-Driven ASCs:
Dr. Maury Harwood Performs Tibia Surgery on Yamaha Racer at California Surgery Center
Dr. James Macon Spine Surgical Innovation Featured in Boston Globe Article
Lake Surgery Center in Michigan 1st ASC to Buy Robotic Spinal Surgery System