TLIF in ASC: Impact of CMS "Hospital Without Walls" Program

In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This initiative granted hospitals regulatory flexibility to offer services and procedures in non-traditional locations, including Ambulatory Surgery Centers (ASCs), while still receiving Medicare payments. This unprecedented situation provided a unique opportunity to evaluate the safety and effectiveness of minimally invasive transforaminal lumbar interbody fusion (TLIF) in ASCs for Medicare beneficiaries.

Surgeon Perceptions of Performing Transforaminal Lumbar Interbody Fusion in an Ambulatory Surgical Center vs Hospital Setting in the Elderly Population: Results of a Surgeon Survey

Advantages and Challenges of TLIF in ASCs

Minimally invasive TLIF procedures have shown comparable two-year clinical outcomes to open TLIF surgeries and offer superior cost-effectiveness. However, despite these benefits, the implementation of TLIF in ASCs has faced several hurdles. The advantages of minimally invasive spine surgery, such as reduced blood loss, decreased post-operative pain, lower infection risk, and faster return to daily activities, align well with the benefits of performing the operation in ASCs. Patients generally tend to have higher satisfaction rates in ASCs due to streamlined workflows, reduced waiting times, and perceived cost advantages. ASCs provide outpatient care with a more personalized and patient-centered approach, allowing patients to undergo TLIF surgery and return home on the same day.

Surgeon Perspectives on TLIF in ASCs

A survey study aimed to understand surgeons' perspectives as the ultimate decision-makers in determining where to perform TLIF on elderly patients—whether in an ASC or a hospital setting. The study explored factors that drive surgeons' decisions, including reimbursement adequacy, regulatory and legal considerations, and medical reasons. By examining these factors, the study sought to provide insights into the decision-making process surrounding TLIF procedures in the elderly population in an ASC versus hospital setting.

Survey Findings

The survey, distributed to 235 spine surgeons, revealed that most surgeons (78%) believed TLIF could be safely performed in ASCs when appropriate patient selection criteria were met. Surgeons cited streamlined workflow, lower infection rates, and cost-effectiveness as the main attractions of ASCs. However, concerns about reimbursement adequacy and staffing issues were significant hurdles. Many surgeons felt that ASCs were reimbursed at a lower rate than hospitals, and a lack of trained support staff was a common issue.

Discussion

Before the implementation of the HWW program, fusion procedures like minimally invasive TLIF in ASCs were limited to non-Medicare patients. The HWW initiative facilitated the comparison of intraoperative variables and short-term safety outcomes between Medicare-age patients treated in ASCs and those treated in hospitals. The study showed similar patient characteristics, procedural efficacy, and safety, supporting ASCs as appropriate sites for treating select Medicare beneficiaries.

The survey highlighted that medical comorbidities were the most relevant factor when deciding whether to book a patient for TLIF in an ASC or a hospital. Surgeons were less concerned about handling complications in ASCs, emphasizing the importance of appropriate patient selection. The most significant implementation hurdle was insufficient reimbursement, followed by a lack of trained staff.

Summary

Advancements in techniques, technologies, and efficiencies have enabled complex spinal procedures like TLIF to be performed safely in ASCs. However, the surgical intensity and risks remain, requiring well-trained staff and appropriate financial remuneration. Establishing site-neutral payments for outpatient procedures, regardless of whether performed in ASCs or hospital outpatient departments, with augmented Medicare physician payment, is crucial to ensure accessible, high-quality healthcare. The current HWW reimbursement model incentivizes hospitals at the expense of physicians, potentially affecting professional autonomy and procedural diversity in spine surgery. Survey data indicate that surgeons' perceptions of CMS rules and regulations may hinder the transition of spine surgeries into the ASC setting due to concerns about low reimbursement and high regulatory burdens.

Authors:

K. U. Lewandrowski, A. Alhammoud, S. M. Schlesinger, B. R. Gelber, M. B. Gerber and M. Lorio

Reference:

Surgeon Perceptions of Performing Transforaminal Lumbar Interbody Fusion in an Ambulatory Surgical Center vs Hospital Setting in the Elderly Population: Results of a Surgeon Survey. Int J Spine Surg 2024 Vol. 18 Issue 2 Pages 199-206. DOI: 10.14444/8596.