Spine surgery's soaring demand and seismic shift to the outpatient setting have combined to create an amazing growth opportunity for surgeons and ambulatory facilities alike. What's driving the demand for spine services? An aging, overweight and sedentary population suffering from back and neck pain, which causes more disability worldwide than any other disease or disorder.

A combination of factors has accelerated spine's recent conversion to outpatient surgery. Among them are advances in minimally invasive techniques that require much less muscle dissection or retraction, studies touting the safety and efficacy of outpatient spine surgery, high satisfaction rates among patients and, of course, lower costs that will be better suited for soon-to-arrive bundled payment models for spine, which will reward providers that deliver high-quality, low-cost episodes of care. Given all of this, it should come as no surprise that it's estimated that more than 50% of all spine surgeries can be safely performed outpatient.

You could say that we were ahead of the spine curve. Way ahead. We opened our first spine surgery center 11 years ago. We've since built a second spine ASC. We've performed more than 9,000 surgeries at both facilities — with a 99% patient-satisfaction rate and only 2 hospital transfers (for unrelated medical conditions). We've never had a death, never had a heart attack, never needed a transfusion and never had a surgical infection. If you're considering adding spine, we suggest you take advantage of all that we've learned.

1 Quality comes first
First, and most importantly, always emphasize quality over cost. Spine is expensive, but more than half of the money spent on it in the U.S. is spent dealing with problems — readmissions, infections, chronic pain, failed surgeries and so on. If you tackle quality first, and make sure you don't have those issues, cost will take care of itself.

In building our center, we used that philosophy for every component. We worked extensively with sterile processing and we went to great lengths to educate nurses and staff. We've tackled pain management, mobilization, bladder management, patient education and family education. We even built the facility with 100% HEPA filtration, 100% UV filtration and high-flow exhaust.

Quality is a never-ending pursuit. We typically have 4 or 5 quality studies going at any given time, and one result is that we consistently beat every national benchmark by a wide margin.

2 Build slowly
If you have an existing center or hospital outpatient department, and you're thinking of adding spine, it makes sense to start with the simpler stuff — microdiscectomies and microdecompressions, for example. Just make sure you understand your environment, your doctors, where cases will come from and the payer mix.

If, on the other hand, you're thinking about opening a center that does everything we do, know that it's a big undertaking with a lot of moving pieces. It's doable, but in addition to needing a surgeon champion to run it, you'll need a tenacious administrator, some very significant capital and someone with a lot of expertise in negotiating contracts. In fact, partnering with an experienced management company is probably your best bet.

Current ambulatory spine procedures include spine injections, lumbar decompression surgery, posterior cervical decompression, anterior cervical decompression and fusion vs. artificial disc, and lumbar fusions. We started with relatively minor procedures and developed incrementally. Now we have 9 spine surgeons and we've progressed from microdiscs to anterior cervical discectomies, to complex lumbar fusions, to super-complex front and back interventions, to removing intradural tumors. The only procedure we don't do is multi-level scoliosis, primarily because these patients require a longer hospital stay for pain management.

For more complex cases, you need to have access to spinal cord monitoring capability and all the experience and skills needed to run a complex environment. We have every piece of spine-related equipment hospitals have, and then some. The nice part about being in charge is you don't have to jump through all the budget-related hoops you face at most hospitals.

We operate in California, which is a 23-hour, 59-minute outpatient state. Some of what we do wouldn't be possible otherwise. Take anterior lumbar interbody fusions, for example. It's much easier to do these cases with a 23-hour option. A vascular surgeon collaborates with the spine surgeon to gain access to the spine and to move the vessels, if necessary, so we can do the procedure with a higher level of safety. Surgery centers in every state have the potential to operate with extended hours Anyone can schedule fairly complicated cases early in the morning and keep patients until 8 or 9 p.m., if necessary. That opens up a lot of possibilities.

3 Patients have to get it
For outpatient spine to work, patients have to clearly understand that you're not running a hospital — that from the moment patients arrive for surgery, the emphasis is on moving them through the process safely, efficiently and quickly. Patients need to know they're an active participant and they're going to be out of recovery quickly, and walking and sitting up in a chair a short time later. We reassure them, of course. It's a big surgery, we say, and this is how we're going to keep you comfortable and control your pain. And we never promise they're going to be pain-free.

Educating family members is essential, too. When you have a patient who's on board, you can't have her husband saying, "Don't move. Don't get out of bed. Oh my gosh, you need more medicine. I can't take her home like this."

Patients who understand and trust the process are engaged and motivated. But they also need coaches. When they're sore, they need someone to say: You're doing great. Let's get you out of bed and into the shower. Patients aren't just happier; they're also less vulnerable to infections. Fear and anxiety lead to immobility and pain. You can dramatically reduce that with education.

4 Educate your surgeons, too
When new surgeons join the practice, they, too, need to be educated. They can't use the same orders they're used to using in the hospital. The emphasis has to be on discharge from the moment the patient arrives, as well as on quality, safety and satisfaction. It works out great for them because it cuts down on phone calls to their offices. Happy patients lead to happy surgeons — surgeons who want to bring their patients to your facility. That's how you begin to see growth.

5 Less medication more often
To be guided through the process, patients need to be alert and responsive after surgery. To manage pain, we use a multimodal protocol, but we administer a little less medication a little more frequently. Patients are engaged and cooperative instead of being out cold. Again, we stress to them that they're active participants in their recovery, which they appreciate. For more complex cases, our pre-op cocktail also includes Flomax to prevent urinary retention. We use a bladder scanner in post-op and don't discharge patients until their bladders function normally.

6 Safe at home
For some of our most complex cases, we also send a nurse to the patient's home to help manage them for 8 to 24 hours. It's more about reassurance than it is about true nursing, but patients really appreciate it. It eases the fear that they're going to be sent home with no one to adequately look after them. We do it at our own expense, but it's a good investment, because it lets us do more complex cases, and it improves patient satisfaction. Some facilities use post-discharge recovery units or make arrangements with hotels. We don't, but those are also worth considering.

7 Improving reimbursements
The reimbursement climate for spine has improved dramatically and continues to improve. Because we were pioneers at doing complex cases in the outpatient environment, we were completely out of network when we started, and our surgeons had to do a lot of peer-to-peer consultations to get cases approved. But payers are increasingly seeing that we can efficiently achieve the triple aim of being safer, better and cheaper, and more and more are coming to the table. Happier patients, an amazing safety track record and efficiency go a long way. We are now mostly in network for our spine cases.

In the last couple of years, Medicare has also stuck a toe in the door. The margins are tight for spine, but there's hope that eventually we'll see some sort of reward for the quality and cost savings we offer. We're also looking at options with major groups that carry Medicare Advantage. We may even consider risk-sharing or bundled payments at some point.

8 Capital equipment costs
What equipment is required for minimally invasive spine? You'll need a table and frame (Jackson or Jackson-type table and a Wilson frame), microscope, MIS equipment and imaging options (C-arm, navigation or robotics). A 2014 study in the Journal of Neurosurgery found that three-dimensional fluoroscopic image guidance systems demonstrated significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.

Most minimally invasive spine surgery is performed with microscopic visualization. Microscopes cost a quarter of a million dollars, and as spine complexity increases, prices also increase dramatically. In addition to equipment, there are implants, biologics and a hard-working, but expensive, staff. You can't hire just anybody and get the quality and efficiency you want. So we're constantly working with vendors to contain costs without compromising any of our goals.

9 Large range of patients
Our patients come from all walks of life. We have uninsured hardship cases, and patients who fly in on private jets. Everyone gets the same surgery, the same care and the same course. With most, it's normal aging or wear and tear on the spine. However, we also have a large number of younger, more athletic types with ruptured discs or injuries from motor vehicle accidents.

The largest group of patients is made up of people who are frustrated by their limitations. They used to play tennis and golf, but find they can't anymore. They used to take trips or visit their kids, but now, if they drive long distances, they spend the whole weekend in bed because their backs hurt so badly. Comorbidities are the one significant inhibiting factor, but as long as our team is confident that we can manage and educate a given patient, we can handle a broad range. We've had patients in their 90s who've been highly motivated and who've done very well.

Of course, surgery isn't the first option. Our surgical patients are people who've tried anti-inflammatories, or other approaches, like chiropractics or acupuncture. It's when those things fail that we'll look at X-rays and MRIs and discuss findings and options. Keep in mind, however, that payers are steering volume to high-value programs and requiring conservative management before surgical consultation for low back pain.

A patient may have an epidural, may have physical therapy or may go straight to surgery. It depends on the pathology. Once they've had surgery, it's usually about 6 weeks before they can start physical therapy, but they're usually back at work very quickly. It's amazing how much spine surgery has progressed in the last 20 years. Incisions are smaller, and with microscopes and very fine instruments, tissue disruption is minimal and recovery is fast. Most importantly, it's giving people back the lifestyles they want. OSM