Article Figures & Data
Figures
- Figure 1
Two hundred thirty-five spine surgeons accessed the online survey; 41 submitted a valid survey at a completion rate of 25.8%.
- Figure 2
Respondents indicated that the most common surgical indication for transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASC) was spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Unilateral cages (72.5%) with bilateral (4) pedicle screws (67.5%) were preferred by most surgeons. Only 12.5% of surgeons placed 2 (bilateral) TLIF cages, and another 12.5% stabilized the spine with a unilateral pedicle screw construct. The mini-open approach was used by 45% of surgeons, followed by tubular retractor (35%), open TLIF (25%), and other minimally invasive retractor-based (20%) surgeries. Most surgeons (78%) believed TLIF could be done safely in an ASC in appropriately selected patients, and 58.5% indicated that ASC is attractive because of streamlined workflow, lower infection rates, and cost. Only 19% of surgeons were worried about having complications in an ASC. When booking a patient for TLIF in an ASC vs hospital, 75.8% of surgeons indicated the patient’s medical history being the most relevant factor, followed by ASC resources and capabilities (61%) and surgeon preference (61%).], higher efficiencies at an ASC (14.6%), contractural issues (9.8%), or ownership issues (7.3%).
- Figure 3
Most respondents (65.9%) believed that ambulatory surgical centers (ASCs) were reimbursed at a lower rate, and 48.8% thought hospitals get paid at a higher rate for transforaminal lumbar interbody fusion (TLIF). More than half of surgeons (53.7%) thought that ASC could provide surgical services at a lower cost because of lower overhead (43.9%). Hospitals were believed to have higher costs because they must provide additional services. When asked about TLIF implementation hurdles in an ASC, 43.9% of surgeons believed the reimbursement was too low, 24.4% needed more trained support staff, 22% were uncomfortable performing TLIF in an ASC, and 22% considered the ASC staffing inadequate. Only 17.1% of responding surgeons thought that their TLIF patients were not a good fit for the ASC environment because of the complexity of their underlying medical problems.
- Figure 4
Among the survey respondents, 36.6% of respondents did not think that Centers for Medicare and Medicaid Services (CMS) reimbursement was adequate to perform transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs) even with careful cost management; 34.1% opined that the CMS-mandated staffing and equipment requirements were creating cost-overruns. A smaller group of surgeons (26.8%) reported that their local CMS administrator does not cover TLIF in ASC, and another 19.5% indicated that the credentialing cost through the Joint Commission or the Accreditation Association for Ambulatory Health Care was too high.
- Figure 5
Compliance with Stark Law and Anti-Kickback statutes was a lesser concern to responding spine surgeons. The majority (53.7%) indicated that their ambulatory surgical center complies with strict Stark requirements because it discloses ownership interests of the physician owners to patients and provides notice to the government. Self-referrals under the “In-Office Ancillary Services Exception” were reported by 22% of surgeons. However, the same percentage of surgeons indicated that under the Stark law, they were prohibited from referring patients to entities they were interested in. Another 19.5% were worried about potential Stark violations and the potential for significant penalties and fines.
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