As the saying goes, “With great power comes great responsibility.” And with spine surgery on the menu of an increasing number of ambulatory surgery centers (ASCs), the chance for physicians to participate in this new wave is tempting.

But prudence is advised, says Reginald Davis, M.D., a neurosurgeon with The BioSpine Institute in Tampa, Florida, who has some experience with spine ASCs.

“It is undeniable that physicians have experienced a substantial downward drift in their ability to influence patient care,” says Dr. Davis, a former assistant professor of neurosurgery at Johns Hopkins in Baltimore. “While the nucleus of medicine used to be comprised of the physician and the patient, other parties have now moved in, and the voice of the physician has been crowded out.”

Which is one reason why surgeons might find a spine ASC alluring.

“There is a mounting interest in taking spine to the ASC,” states Dr. Davis, “and because this trend will likely continue, we must approach it in a measured, thoughtful manner.”

“The advantage of spine surgery in an ASC is that the patient benefits from a system that is very unique and highly focused on their problem. The experience is deeply personalized for individual patients, the outcomes can be superior, the recovery time is less, and many procedures cost less than in a hospital.”

But the major drawback is one that should give any surgeon pause.

Dr. Davis: “In the event that things go awry, you do not have the backup of hospital resources at your disposal. Unusual circumstances can occur…a certain instrument is needed or there is a complication. Things are particularly serious if the patient experiences a cardiac event or requires a transfer.”

Lesson #1:

And that is why, according to Dr. Davis, the key to success in a spine ASC is patient selection. “You want the healthiest patients with a specific pathology and no comorbidities. You are essentially cherry picking with your eye on the bullseye…and the further you stray from bullseye the closer you are to catastrophe.”

“Comorbidities such as cardiac, pulmonary, or renal issues can lead to anesthesia problems. Intraoperative cardiology issues in particular will result in the immediate cessation of surgery and transfer to a hospital. If you have an otherwise healthy patient who is a smoker with elevated blood pressure you are on a slippery slope. A higher body mass index (BMI) is notorious for creating anesthesia problems, and the more difficult the surgery the longer it takes and the more likely you are to have complications.”

“Let’s say at the preop weigh-in a patient’s BMI is 40.8, but on the day of surgery it has risen to 42. It may not represent a major issue—and things may go well—or not. It is important to deconstruct what goes into patient selection. Examine the medical comorbidities by sorting through every major system, which is an overwhelming algorithm. For the most part it is always best not to make your selection on a case-by-case basis. It is better to anticipate every variable and have a hard stop for each one. And forget about exceptions…the ones that didn’t go well were always the exceptions.”

Medicine…walking a tightrope.

“In any medical arena there is a pull and push between providing the highest level of care and delivering the most economical care. This warring can turn internal, in essence, and put the physician is a difficult situation. It may be tempting to cut corners and focus more on cost, but then the quality of care may be compromised. It is a balancing act that is replayed over and over in a surgeon’s day-to-day life.”

“Attempting to complete a procedure hastily or doing anything that would jeopardize the best outcomes can turn into a cascade of negative events. For example, if you are doing a lumbar fusion and you want good decompression then you must be on target with the alignment, stabilization, and fusion. But good decompression takes time. You have to prepare the bed, and use good bone or Infuse. If the thought, ‘I will use the cheapest demineralized bone matrix I have, ’ then think again.’

“Doctors are trained in traditional settings such as universities where you do whatever it takes—for as long as it takes—to reach the zenith of patient care. Frankly, that is how doctors are programmed. For the longest time we were the patient’s best advocates and compromising on quality was unheard of. Now that the difference comes out of the surgeon’s pocket, he or she is routinely placed in comprising positions as far as conflicts of interest. Performing spine surgeries in an ASC requires an ethical surgeon with strong integrity.”

“It’s easy to give lip service to being patient-centric, but if your hospital says, ‘You will use this screw, or you will not be allowed to operate here’ then the patient will pay out of pocket…and so will you.”

No standing still…

“We are all either headed toward evolution or extinction, meaning that our past successes are almost irrelevant. The failure to evolve or to have perspicacious situational awareness is detrimental to physician as the patient, industry, and hospital landscapes are always on the move.”

“There is no formal training for a surgeon who commences work at a spine ASC…it’s basically on-the-job training. Until we have a journal and/or meeting where the business, medical, and legislative aspects of spine ASCs can be addressed, then this remains an area where interested parties should make their decision after thorough vetting and careful consideration.”

The rise of High Deductible Health Plans is a big change in patient responsibility, with implications for Ambulatory Surgery Centers (ASCs).

With the ASC market expected to top $40 billion by 2020, how ASCs handle this sea change has implications for healthcare overall.

From increased patient education efforts to best billing practices, ASCs—with their usual speed—must adapt to the shifting payer/provider landscape.

How Did We Get Here?

Acting on the assumption that HDHPs would stem a rumored over-utilization of healthcare spending, many employers embraced them for the first time in 2006.

RELATED: Health savings accounts and high deductible plans maintain steady enrollment growth

In 2007, 85% of adults with employment-based health coverage were enrolled in a traditional plan, with an average deductible of $379 (adjusted for inflation) for single coverage. Today, only 56.6% have a traditional plan, with 43.4% enrolled in a HDHP. The average HDHP deductible stands at $1,350 today, or more than triple the 2006 figure for a traditional plan.

When patients access healthcare, it’s not likely they have the funds to meet even the lowest deductible before doing some major financial juggling. Wage growth hasn’t followed the increase in insurance premiums, as a study by the Los Angeles Times and Kaiser Family Foundation discovered. Complicating matters, federal data shows that while 61% of adults could cover an unexpected $400 expense, 39% would have to borrow, money, sell something or simply not be able to cover it at all.

The bottom-line impact on ASCs quickly becomes apparent when you examine the patient pay mix. Medicare and Medicaid are growing, but commercial pay still accounts for the majority of ASC payments. The mean percent of gross charges for ASCs, as measured in VMG Health’s 2018 Multi-Specialty ASC Benchmarking Study., breaks down as follows:

  • Commercial 61%
  • Medicare: 20%
  • Worker’s comp: 10%
  • Other: 10%
  • Medicaid: 7%
  • Self-pay: 6%

If the 43.4% figure above is applied to the commercial pay percentage from the VMG study, 26% of the average ASC’s commercial payer mix relies on HDHPs. Physicians may have been worried about how they would be paid by the uninsured; now it’s the patient responsibility portion of any HDHP policyholder that’s keeping them up at night.

Here are three areas where ASCs should be making changes to accommodate HDHPs.

Patient Communication and Information

Patients need a solid understanding of their role in paying for their care. But unlike any other consumer purchase process, it’s hard for patients to get a clear picture of what they owe at the time of payment. ASCs—36% never discuss a patient’s ability to pay before delivering services—need to take a greater role in patient education. Proactive communication about co-pays, deductibles and coinsurance well before a patient’s procedure is critical.

Some have moved ahead of the game by directly addressing HDHPs with patients as part of their insurance and billing patient education. They provide clear direction on how patients can work with their insurer to determine current deductible status and related out-of-pocket responsibility.


Many with HDHPs may elect to schedule their surgery early in the year to quickly meet their deductible. Some centers may have already encountered this, but others should prepare for higher than usual patient volumes in the early months of the year.

Best billing practices for HDHPs

HDHPs are intricate cost-sharing agreements that can tax the skills of even the savviest revenue cycle management pro. Some policyholders have Health Savings Accounts—flexible healthcare spending dollars available to patients who set aside a pre-tax portion of their earnings—which can be used towards paying their deductible.

Others don’t.

RELATED: Study: High-deductible health plans aren’t making members better healthcare consumers

Still, flexibility is the watchword to successfully navigate billing and payments with HDHPs. Payment plans or flexible financial solutions, like the short-term payment plans offered by one center, are increasingly being used. A tiered campaign of letters and phone calls in the days and weeks leading up to a surgery to collect co-pays and deductibles also smooths the payment process.

HDHPs also up the ante for accurate coding. Now is the time to review billing and coding processes to avoid common coding mishaps that add to time and cost pressures.

HDHPs may be a wrench thrown into the dynamic surgery center environment, but given the “get-it-done” culture of most ASCs, HDHPs aren’t anything they can’t handle.

David Howerton is the CEO of Tennessee-based Simplify ASC, a software development company that provides a fully integrated clinical and business management platform to the ASC industry. 

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Meeting in Bogota between Spineway’s management teams and those of its new partner, National Clinics Colombia (NCC): Laying the foundation for the joining of Spineway and NCC (Colombia)

With respect to strengthening the Group’s positions in the Americas, Spineway’s management teams and those of its new partner, National Clinics Colombia (NCC), met in Bogota at the end of May to work on developing the distributor network. Spineway already generates 3.4 million euros in revenue in Latin America and implementing synergies with NCC should allow it to increase this number significantly.
Due to an emerging middle class, an improved hospital network and the development of access to medical care, the healthcare market on this continent has been growing rapidly over the last 10 years, with the number of spinal surgeries increasing constantly.
A development plan is being prepared for the expansion of the distribution network and will focus on certain countries where NCC has a strong presence. This structural rapprochement will provide Spineway with new opportunities for growth on territory that is known and understood by NCC.