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As a spine surgeon, I’ve watched the specialty become one of the fastest growing in the ambulatory surgery center (ASC) setting, and I’m looking forward to a bright future for patients, surgeons and the healthcare system.
The shift began in the late 1990s and early 2000s when the development of minimally invasive spine surgery paved the way for surgeries to move out of inpatient settings and into outpatient settings. A significant breakthrough came in 2015 when CMS began to allow certain spine procedures, such as laminectomy and discectomy, to be performed in ASCs. Ten years later, as we near 2025, the following spine procedures are performed in ASCs:
• microlumbar discectomy
• lumbar laminectomy
• vertebroplasty
• kyphoplasty
• anterior cervical discectomy and fusion (ACDF)
• posterior cervical foraminotomy
• cervical disc arthroplasty (1 or 2 level)
• lumbar fusions
• posterior cervical fusion
Surgery Advancements Drive Case Migration
According to Sg2’s 2024 Impact of Change report, ASC case volumes across all specialties are projected to increase by 21% in the next decade. Outpatient orthopedic and spine services are expected to see 11% growth. More than 200 ASCs across the U.S. already offer spine surgery, and the number is rising as reimbursement catches up with technical advancements and more surgeons become ASC partners.
With the continued migration of spine cases from hospital inpatient settings to hospital outpatient departments (HOPDs) and ASCs, it’s critical for surgeons, health system leaders, healthcare professionals and the spine companies that serve them to understand the factors behind this trend. Being proactive will ensure that we’re positioned to provide the highest quality care in these evolving environments.
Case migration from inpatient hospitals to outpatient settings would not be possible without recent technical advancements that make spine surgeries more feasible for ASCs.
Minimally Invasive Spine Surgery (MISS). Lateral positions for spine surgery typically involve smaller incisions compared to posterior approaches, which means that muscles and tendons are less disrupted. The reduced blood loss, shorter recovery times, minimized postoperative pain and lower risk of complications make spine surgeries that deploy lateral approaches ideal for ASCs.
Endoscopic spine procedures involve tiny incisions, less tissue damage, less pain, quicker recovery and lower risk of complications, meaning that for many patients these surgeries are well-suited for ASCs.
CT-guided navigation and robotics have improved spine surgery feasibility, accuracy and efficiency. Many ASCs are investing in advanced, specialized equipment, often surpassing equipment available in HOPDs.
Regional Anesthesia Advancements. Using regional blocks instead of general anesthesia is another move that makes spine surgeries more suitable for ASC settings because “awake spine surgery” requires shorter recovery times. Regional anesthesia minimizes the need to use narcotics to control postoperative pain, making ambulatory spine surgery more feasible.
Improved Patient Experience. Because spine ASCs have highly specialized surgical staff, they can offer focused pre-op and post-op care, which boosts recovery and outcomes. Many ASCs are investing in software platforms that take patients through prehab exercises to strengthen their bodies before surgery, as well as coaching to help them recover optimally at home.
A New Option for Hemostasis. Advancements in surgical bleeding control should make spine surgeries even more feasible for ASCs in the future. For example, LifeGel recently became the first and only hemostatic agent to receive a Breakthrough Designation from FDA.
Once LifeGel receives FDA approval, it would allow spine surgeons to control surgical bleeding without swelling, which would help mitigate the risks of complications when operating within the spine’s confined spaces. This could make more ASC spine surgeries possible for more patients. The product is also clear, which allows for more visibility. LifeGel does not require thrombin, making it cost-effective, easy to store and ready for immediate use — factors that make it ideal for ASCs.
Cost-effective Care
Payors are key drivers of case migration to ASCs because they understand that they pay much more for spine procedures performed in HOPDs than they do for equivalent procedures performed in ASCs. Surgeons receive the same reimbursement in both types of facilities but the average facility fee is up to 60% less in an ASC.
Researchers who extracted publicly available Medicare data for 21 individual spine surgery CPT codes concluded that “performing spine surgeries in ASCs is associated with cost savings compared with HOPDs,” according to a Journal of Neurosurgery article published last year. For example, total cost for decompression procedures is much less in ASCs ($4,183 ± $411.07) than in HOPDs ($7,583.67 ± $410.89), mostly because facility fees are dramatically lower ($2,998 ± $0 vs. $6,397 ± $0). Fusion and instrumentation procedures also had much lower facility fees when performed in ASCs ($10,436.6 ± $2,347.51 vs. $14,161 ± $2,147.07).
Because of lower facility fees and lower out-of-pocket payments for patients, commercial payors are often willing to negotiate favorable spine surgery rates for ASCs. It makes economic sense for ASCs to add spine procedures as they develop and grow their case mix.
Many patients also understand that they pay much less out-of-pocket when they have surgeries performed in an ASC. The rise of price transparency and the availability of cost comparison sites like Sidecar healthcare Calculator and Medicare.gov’s Procedure Price Lookup are making the cost advantages of ASCs very clear to patients.
And those cost advantages are substantive. For example, Medicare beneficiaries pay much less for decompression procedures performed in ASCs ($835.58 ± $82.13) than in HOPDs ($1,515.58 ± $82.13), according to the Journal of Neurosurgery study mentioned above.
Convenience and Patient Comfort
COVID changed everything, including sites of service for surgeries. During the worst days of the pandemic, many hospitals were not able to accommodate outpatient surgeries, which meant that ASCs were the only option. COVID’s accidental proving ground taught patients and the larger healthcare community that many surgeries work very well in ASCs.
Even after HOPDs were up and running again, patients leery of COVID exposure were eager to explore their ASC options. Patients continue to seek out ASC options because they don’t want to stay overnight in a hospital, they want to avoid hospital-acquired infections or they simply feel more comfortable recovering at home. They crave the added convenience that many ASCs offer them, such as shorter travel times and simpler navigation of facilities. While HOPDs sometimes bump less acute patients for more critical cases, ASCs have much more predictable surgery times.
Benefits to Patient Care
In most cases, outpatient spine procedures are just as safe as inpatient procedures. For example, there are no significant differences in postoperative complications between outpatient and inpatient single- or multiple-level cervical disc replacement for cervical radiculopathy, according to a recently published Spine study. The risk of post-surgical infections is also lower in ASCs.
Spine surgeries performed in ASCs benefit not only ASC patients, but also hospital patients. Moving less acute spine surgery cases to ASCs frees up hospital operating rooms for more acute cases.
Spine Surgeons Embrace ASCs
Many physicians crave opportunities to lead the facilities where they provide patient care. ASCs offer spine surgeons opportunities to do just that. Physicians have sole or part ownership in 90% of ASCs, Donnelle Jageman, Director of Intelligence – Orthopedics at Sg2 told ORTHOWORLD earlier this year.
ASCs can also offer spine surgeons specialized equipment and surgical teams that focus exclusively on just a few procedures — an appealing work environment indeed.
Because ASCs handle only less acute procedures, spine surgeons in a well-managed ASC can perform more procedures in a day than they can in an HOPD, which means more revenue for their practice. Surgeons’ schedules are more predictable on ASC days because, unlike in hospitals, less acute cases don’t get bumped for more acute cases.
The Future of ASC Spine Surgery
Spine case migration to ASCs is good for patients, surgeons and healthcare systems. While each regional service area will see differences depending on comorbidities in the population, certificate of need regulations, availability of larger, newer ASCs that can accommodate the cost and size of specialized equipment and other factors, there’s good reason to look forward to the future of ambulatory spine surgery.
As a spine surgeon, I’ve watched the specialty become one of the fastest growing in the ambulatory surgery center (ASC) setting, and I’m looking forward to a bright future for patients, surgeons and the healthcare system.
The shift began in the late 1990s and early 2000s when the development of minimally invasive spine surgery paved...
As a spine surgeon, I’ve watched the specialty become one of the fastest growing in the ambulatory surgery center (ASC) setting, and I’m looking forward to a bright future for patients, surgeons and the healthcare system.
The shift began in the late 1990s and early 2000s when the development of minimally invasive spine surgery paved the way for surgeries to move out of inpatient settings and into outpatient settings. A significant breakthrough came in 2015 when CMS began to allow certain spine procedures, such as laminectomy and discectomy, to be performed in ASCs. Ten years later, as we near 2025, the following spine procedures are performed in ASCs:
• microlumbar discectomy
• lumbar laminectomy
• vertebroplasty
• kyphoplasty
• anterior cervical discectomy and fusion (ACDF)
• posterior cervical foraminotomy
• cervical disc arthroplasty (1 or 2 level)
• lumbar fusions
• posterior cervical fusion
Surgery Advancements Drive Case Migration
According to Sg2’s 2024 Impact of Change report, ASC case volumes across all specialties are projected to increase by 21% in the next decade. Outpatient orthopedic and spine services are expected to see 11% growth. More than 200 ASCs across the U.S. already offer spine surgery, and the number is rising as reimbursement catches up with technical advancements and more surgeons become ASC partners.
With the continued migration of spine cases from hospital inpatient settings to hospital outpatient departments (HOPDs) and ASCs, it’s critical for surgeons, health system leaders, healthcare professionals and the spine companies that serve them to understand the factors behind this trend. Being proactive will ensure that we’re positioned to provide the highest quality care in these evolving environments.
Case migration from inpatient hospitals to outpatient settings would not be possible without recent technical advancements that make spine surgeries more feasible for ASCs.
Minimally Invasive Spine Surgery (MISS). Lateral positions for spine surgery typically involve smaller incisions compared to posterior approaches, which means that muscles and tendons are less disrupted. The reduced blood loss, shorter recovery times, minimized postoperative pain and lower risk of complications make spine surgeries that deploy lateral approaches ideal for ASCs.
Endoscopic spine procedures involve tiny incisions, less tissue damage, less pain, quicker recovery and lower risk of complications, meaning that for many patients these surgeries are well-suited for ASCs.
CT-guided navigation and robotics have improved spine surgery feasibility, accuracy and efficiency. Many ASCs are investing in advanced, specialized equipment, often surpassing equipment available in HOPDs.
Regional Anesthesia Advancements. Using regional blocks instead of general anesthesia is another move that makes spine surgeries more suitable for ASC settings because “awake spine surgery” requires shorter recovery times. Regional anesthesia minimizes the need to use narcotics to control postoperative pain, making ambulatory spine surgery more feasible.
Improved Patient Experience. Because spine ASCs have highly specialized surgical staff, they can offer focused pre-op and post-op care, which boosts recovery and outcomes. Many ASCs are investing in software platforms that take patients through prehab exercises to strengthen their bodies before surgery, as well as coaching to help them recover optimally at home.
A New Option for Hemostasis. Advancements in surgical bleeding control should make spine surgeries even more feasible for ASCs in the future. For example, LifeGel recently became the first and only hemostatic agent to receive a Breakthrough Designation from FDA.
Once LifeGel receives FDA approval, it would allow spine surgeons to control surgical bleeding without swelling, which would help mitigate the risks of complications when operating within the spine’s confined spaces. This could make more ASC spine surgeries possible for more patients. The product is also clear, which allows for more visibility. LifeGel does not require thrombin, making it cost-effective, easy to store and ready for immediate use — factors that make it ideal for ASCs.
Cost-effective Care
Payors are key drivers of case migration to ASCs because they understand that they pay much more for spine procedures performed in HOPDs than they do for equivalent procedures performed in ASCs. Surgeons receive the same reimbursement in both types of facilities but the average facility fee is up to 60% less in an ASC.
Researchers who extracted publicly available Medicare data for 21 individual spine surgery CPT codes concluded that “performing spine surgeries in ASCs is associated with cost savings compared with HOPDs,” according to a Journal of Neurosurgery article published last year. For example, total cost for decompression procedures is much less in ASCs ($4,183 ± $411.07) than in HOPDs ($7,583.67 ± $410.89), mostly because facility fees are dramatically lower ($2,998 ± $0 vs. $6,397 ± $0). Fusion and instrumentation procedures also had much lower facility fees when performed in ASCs ($10,436.6 ± $2,347.51 vs. $14,161 ± $2,147.07).
Because of lower facility fees and lower out-of-pocket payments for patients, commercial payors are often willing to negotiate favorable spine surgery rates for ASCs. It makes economic sense for ASCs to add spine procedures as they develop and grow their case mix.
Many patients also understand that they pay much less out-of-pocket when they have surgeries performed in an ASC. The rise of price transparency and the availability of cost comparison sites like Sidecar healthcare Calculator and Medicare.gov’s Procedure Price Lookup are making the cost advantages of ASCs very clear to patients.
And those cost advantages are substantive. For example, Medicare beneficiaries pay much less for decompression procedures performed in ASCs ($835.58 ± $82.13) than in HOPDs ($1,515.58 ± $82.13), according to the Journal of Neurosurgery study mentioned above.
Convenience and Patient Comfort
COVID changed everything, including sites of service for surgeries. During the worst days of the pandemic, many hospitals were not able to accommodate outpatient surgeries, which meant that ASCs were the only option. COVID’s accidental proving ground taught patients and the larger healthcare community that many surgeries work very well in ASCs.
Even after HOPDs were up and running again, patients leery of COVID exposure were eager to explore their ASC options. Patients continue to seek out ASC options because they don’t want to stay overnight in a hospital, they want to avoid hospital-acquired infections or they simply feel more comfortable recovering at home. They crave the added convenience that many ASCs offer them, such as shorter travel times and simpler navigation of facilities. While HOPDs sometimes bump less acute patients for more critical cases, ASCs have much more predictable surgery times.
Benefits to Patient Care
In most cases, outpatient spine procedures are just as safe as inpatient procedures. For example, there are no significant differences in postoperative complications between outpatient and inpatient single- or multiple-level cervical disc replacement for cervical radiculopathy, according to a recently published Spine study. The risk of post-surgical infections is also lower in ASCs.
Spine surgeries performed in ASCs benefit not only ASC patients, but also hospital patients. Moving less acute spine surgery cases to ASCs frees up hospital operating rooms for more acute cases.
Spine Surgeons Embrace ASCs
Many physicians crave opportunities to lead the facilities where they provide patient care. ASCs offer spine surgeons opportunities to do just that. Physicians have sole or part ownership in 90% of ASCs, Donnelle Jageman, Director of Intelligence – Orthopedics at Sg2 told ORTHOWORLD earlier this year.
ASCs can also offer spine surgeons specialized equipment and surgical teams that focus exclusively on just a few procedures — an appealing work environment indeed.
Because ASCs handle only less acute procedures, spine surgeons in a well-managed ASC can perform more procedures in a day than they can in an HOPD, which means more revenue for their practice. Surgeons’ schedules are more predictable on ASC days because, unlike in hospitals, less acute cases don’t get bumped for more acute cases.
The Future of ASC Spine Surgery
Spine case migration to ASCs is good for patients, surgeons and healthcare systems. While each regional service area will see differences depending on comorbidities in the population, certificate of need regulations, availability of larger, newer ASCs that can accommodate the cost and size of specialized equipment and other factors, there’s good reason to look forward to the future of ambulatory spine surgery.
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Dr. Jun Kim is a fellowship-trained spine surgeon in Manhattan. An expert in minimally invasive spine surgery, Dr. Kim treats patients with a variety of spinal conditions, including herniated discs, spinal stenosis and scoliosis. Dr. Kim is also a researcher and has published several papers on new techniques for spine surgery.
