The Society for Ambulatory Spine Surgery (SASS) was formed as a growing number of spine surgeons are electing to conduct surgeries in an ambulatory surgical environment using minimally invasive spine techniques. The mission of SASS is to help educate surgeons in the safety and efficacy of ambulatory spine surgery to enhance patients’ quality of life. Dr. Kube performs advanced spine techniques, including minimally invasive procedures and both operative and non-operative care. The SASS identified Dr. Kube as a leader in the ambulatory surgical center field and wanted to interview him about his experience.
Q: How much of your time is spent performing procedures in ambulatory surgery centers (ASC)?
Dr. Richard Kube: I would probably say at least two-thirds of my cases are at an ambulatory type of setting. It mainly just depends on insurance and what insurance is willing to cover. Otherwise I will do pretty much any kind of case other than maybe a deformity case in the outpatient setting. If I had a minimally invasive deformity case and I had three-day stay capability, I would probably considering doing some of those cases at ASCs as well.
Q: What spine procedures do you perform on an outpatient basis?
RK: I’ve done virtually any kind of neck procedures, whether it’s fusions, disc replacements or corpectomies. I’ve done all of those in the ambulatory setting. Patients can all go home the next morning pretty much first thing. I have done one- and two-level back fusions as well. Those cases are now mostly outpatient for me. I have been doing a lot of my fusion cases as outpatient for a year and a half.
We’re been continuing to hone our techniques in pre-op, post-op and intra-op to tie things down in the way you can in an ambulatory setting. You can really get things personalized so much better in that type of setting, and that’s what has assisted us to get to the point where we can deliver that kind of care to patients.
Q: How did you become comfortable performing spine procedures on an outpatient basis?
RK: Number one: You have to have an open mind. If you lock yourself into the concept that spine is so huge that it can’t be performed in these settings, you’ll never do anything. I think in general, I’m the type of doc that had great training, good confidence in anatomy and I know what I can and can’t do. We do tend to be early adaptors of things in general in my practice. You need that mentality to start with.
But it’s not like one day I woke up and decided I was going to try to start taking these cases to an outpatient facility and off we went. I always just honestly, from a standpoint of management of patients over time, thought it would be nice to not have all of these people laying around the hospital for several days. I thought that if I could get them out of the hospital, they would do a lot better and my workload would decrease because I wouldn’t spend my life rounding in the hospital. Between that and seeing that people don’t tend to do better laying around the hospital, in my practice I started looking at what can I do to get these people out sooner? What can I do to tweak my technique?
It was really a transition. I had spent a long time doing neck cases where we were regularly sending these patients home the next morning. So having overnight capability and not seeing many complications with those cases, it was a very easy transition for the necks to the outpatient setting. Whether I do it overnight in hospital or ASC, who cares? Usually I’m going to have much better nursing ratios in the ASC; I’m going to have one-to-one or one-to-two versus one-to-seven or one-to-eight in the hospital, so my patients will have better supervision in most ASCs. So necks were very simple, very logical first steps to take.
We were watching our back cases as well. When watching the backs, it was very clear that almost everyone went home post-op day two. When we realized that was when most of my patients were going, I thought that I could do these cases in the outpatient setting if I had three days to be able to keep them. That’s when we started to use a recovery care center, and I started to hone the technique more and more. Probably one-third of these patients are going home the next morning and two-thirds in two days.
Then we started adopting minimally invasive techniques, and that’s what really took us to a whole new level. Then almost everybody was going home the next morning or was an outpatient case. It’s just been a progressive situation where I can’t remember the last time I kept a one-level transforaminal lumbar interbody fusion (TLIF) overnight. It’s just been an evolution of a few years.
Q: What do you think are the benefits of performing spine on an outpatient basis and in an ASC?
RK: I think the benefits boil down to what I think are the benefits of the typical capitalistic system where you have a consumer and you have a provider of service. There are many levels of that in an ambulatory setting that have appositive impact on the surgeon as well as the patients. For example, you have the folks that run the ASC who provide the location and then you have the surgeons who are consumers, much more than the hospitals where they typically take a “we’re here sitting on our thrones and you shall come and kneel at our feet” kind of mentality. There’s an actual interest of having an interaction at most ambulatory settings where the ASC is interested in making your life better as a surgeon and making your life efficient. Where you might go to a hospital and spend eight hours in a hospital, only four of those are spent at the table operating. If you’re in an ASC and you spend eight hours there, you’re going to spend 6-7 hours of that time directly at the table operating. In these days when you have to perform more procedures to make the same revenue, it’s critical to be able to have that efficiency. Most hospitals in my experience just aren’t concerned with that.
Then you have the other portion of that model where you have the physician as the provider and the patient as consumer. What are the benefits there? Those are numerous as well. As a physician, I can have things tailored toward my spine patients so that they’re able to have very good outcomes. First thing is I’m getting the same nurses all of the time, I’m getting the same scrub techs all of the time. There’s consistency that provides comfort to me, that provides greater efficiency so I can deliver a better product to the patient.
Now that I own my facility, we’re able to do a lot more things for the patients. I have a fireplace in my overnight room. We don’t serve TV dinners. We have meals delivered by one of my favorite local restaurants. You order what you want off that menu and they bring it over to you.
From a consumer standpoint, we also understand that surgery is a stressful time. The ability to come into an environment where I have a nurse taking care of me and only me, who is there — available to me as a patient — so I don’t have to wait 20 minutes for my pain medicine if I have a problem is important. We provide a nice, comfortable environment. We allow families to stay in the patients’ room with them. We have pullout Tempur-Pedic beds so family can stay if they desire. We have people who travel a long ways for these procedures, sometimes from out of state. They save hotel costs since they’re able to stay overnight with us instead.
There are a lot of things that we can do to improve a situation, so it really boils down to this value equation and providing value. I think that’s the thing that really, at the end of the day, gives ambulatory surgery facilities an advantage. If you’re looking to really drive down the cost of healthcare, I think you need to have people competing on value. At the end of the day, if I’m able to provide an environment that’s much cleaner, much more comfortable, relaxing, one that eliminates anxiety for the patient and family, and I’m able to provide that service where we have fewer infections, fewer complications, very high satisfaction rates and I’m able to do it at a cost much less than at a hospital, why wouldn’t consumers want that? You’re getting the best product at best price, and that’s what I think most consumers are looking for when going for procedures.
Q: What are some of efforts you are presently undertaking to further grow spine surgery in the ASC setting?
RK: One of the things we’re looking to start doing here soon is bring adult harvested autologous stem cells. That’s something there’s very early literature on. It’s something there is no code, so to speak, for that type of procedure. If patients wanted to have their stem cells harvested and implanted into a disc, that would be impossible to do in a hospital setting. This is something you would have to pay cash for, and it’s cost prohibitive in a hospital. We can do it for a quarter of the cost in our ASC.
I’m currently collecting data on all of our one- and two-level disc replacements on workers’ comp patients. I’m hoping to put something out on that as well. We have a couple dozen patients that we’re trying to get 1-2 year follow up on and put something out there on that data.
We are also presently involved in a study on minimally invasive SI joint fusion.
Q: What do you think is the value of having an organization like the Society for Ambulatory Spine Surgery support the migration of spine to the ASC setting?
RK: It’s all about advocacy and having a unified voice to advocate for spine in ASCs. In this day in age, I think, unfortunately, that we’re looking at a medical system where the people in charge of the dollars aren’t the consumer, which is the first problem. The second problem is you have people who feel that it is an end-sum economic equation, that there is only X number of dollars available for medicine and their answer for that is rationing. They think that if we provide fewer services or make fewer services available to our patients, then we will have to pay fewer claims and therefore the cost can be contained. I think that’s taking healthcare backwards and contrary to what most of us probably subscribe to in basic economics in that you want to try to promote efficiency and promote value. If you do those things, then your costs are going to go down.
What would a 65-inch LED TV have cost 10 years ago? If it had even existed, it would have cost $20-30,000. Now it costs $2,000. Think about farming. What would it cost to farm 2,000 acres right now if you didn’t have a combine or tractor and you had to put people out there doing it by hand? In healthcare, as we add efficiencies to systems, and we’re able to produce more through ingenuity and provide more value, that’s what allows us to drive costs down. We use new technology, and as the new technology becomes more widely accepted, it allows us to drop costs because our outcomes are going to be improved. New technologies will be able to save costs because the implants last longer. Look at hip and knee replacements: These devices now have decades of longevity whereas before, we were all concerned about revising those in 5-10 years. Thanks to the improvements of those implants, the revision rate has plummeted. The ASC has the ability to cut costs because we don’t have intervening bureaucracies, we are very efficient and everything is based about care for the patient.
You have direct interaction between the provider and consumer, and that’s where the value is able to be driven because if the consumer is empowered to make their own decisions and if the consumer is holding the checkbook, then the consumer is going to search for where the best value is for the money they are spending. That will drive down cost through competition because people will be looking for that value, and the hospitals can’t compete on the same playing field we can.
Q: What do you believe needs to happen for a majority of spine procedures to be performed on an outpatient basis?
RK: I think there are two things that need to happen. Number one: Insurers need to be educated about the ability to save money by shifting these procedures this direction. If their true motivation is immediate cost savings, then it should be a no-brainer.
The second thing that really needs to happen, in my opinion, is to allow for competition — to truly allow for competition. You have lots of states out there — mine included — that require certificates of need; that judge need and weigh need for services. That need should be determined by the public. If I open a hamburger stand on the corner down the street, and if there’s no need for that hamburger stand, it’s going to close and go out of business. But if there’s a very large desire by the population for hamburgers on that street corner, then that business will grow and thrive and create more jobs and so forth.
I think the same thing is true for ASCs. There should be the ability to open these facilities and directly compete. I think competition is a good thing. I know the hospitals will not like that, and I know there are a lot of arguments they have about all of the larger services and emergency services they provide, but at the end of the day, our society will be better equipped to pay for some of those large, invasive and costly life-saving and end-of-life issues if we aren’t spending so much money on a lot of the bread and butter cases out there. We have the ability to save enormous amounts of money through competition if we were able to perform these kinds of procedures in an ASC setting. If the average spine surgeon is doing 250 cases a year and shifts 150 cases to the ASC setting and you’re saving maybe $10,000/case — and I would argue that it’s more than that in savings — that’s at least a million dollars saved. How many spine surgeons are out there? And that’s just one specialty. There could be millions upon millions upon millions of dollars saved.
Learn more about the Society for Ambulatory Spine Surgery, click here.