Eight ASCs in the United States Embracing Medical Tourism

Written by Laura Miller | Becker's ASC Review | June 21, 2012

Here are eight ambulatory surgery centers that have embraced medical tourism in the United States and attract patients from other countries. 

Red Rock Surgery Center (Las Vegas). Red Rock Surgery Center reaches out to its Las Vegas community as well as patients from around the world with their medical tourism branch. The surgery center was founded more than 10 years ago and surgeons perform approximately 1,000 procedures there annually. The center includes three operating rooms and one minor laser procedure room, allowing surgeons to perform a multitude of cases at the ASC. Medical staff at the center includes ophthalmologists, plastic surgeons, pain management physicians, hand surgeons, general surgeons and podiatrists. Red Rock Surgery Center is accredited by the Accreditation Association for Ambulatory Health Care and owned by David Malitz, MD.

The Surgery Center at Doral (Doral, Fla.). The Surgery Center at Doral includes interventional pain management, urology, general surgery and hand and upper extremity surgery. Alejandro Badia, MD, founded Badia Hand to Shoulder Center which works with the International Orthopedic Group to serve inbound medical tourist patients, who have their surgeries at The Surgery Center at Doral. The surgery center has three operating rooms, arthroscopic equipment and family waiting room. After traveling for their surgery, patients are able to stay at a hotel located near the center for recovery, often accompanied by a recovery room nursing staff. The patients are able to have rehabilitation and follow up visits while staying for a few days in the area.

Legacy Neurosurgery Spine & Brain Specialists Outpatient Surgery Center (Little Rock, Ark.). Legacy Neurosurgery Spine & Brain Specialists has served patients who travel across the country to have their surgery performed at a lower cost than it would be at their local hospital. They often serve cash-pay or high deductible patients traveling long distances. Led by Scott Schlesinger, MD, the team of neurosurgeons performs minimally invasive spine surgery as well as non-operative pain management procedures. The brain disorders they treat include brain tumors, aneurysms and arterial venous malformations. Additional services at the center include physical therapy.

Orthopedic Surgery Center of Orange County (Newport Beach, Calif.). The Orthopedic Surgery Center of Orange County is owned by the Orthopedic Specialists of Southern California and Hoag Hospital. It is a medical tourism facility associated with Patients Without Borders and has been an accredited ambulatory surgery center since 1999. Surgeons perform several procedures at the center, including ACL reconstruction, meniscus repair, shoulder surgery and spine surgery. The center is contracted with major insurance companies and will bill non-contracted payors. 

Surgery Center of Oklahoma (Oklahoma City). Surgery Center of Oklahoma is a 32,535-square-foot facility that is owned and operated by surgeons and anesthesiologists in central Oklahoma. The facility has been accredited by the Accreditation Association for Ambulatory Health Care since 1998 and includes prices for their services on the ASC website to attract patients of self-pay, self-insured or high-deductible plans. Surgeons at the ASC perform orthopedics, general surgery, ophthalmology, and ENT procedures. There are multiple lodging areas near the surgery center for patients to stay after their procedures. According to the ASC's website, they are able to offer lower prices since they don't have to process claims and there is no risk of non-payment.

Concord (N.H.) Ambulatory Surgery Center. Concord Ambulatory Surgery Center is accredited by the Accreditation Association for Ambulatory Health Care and provides ENT, orthopedics, plastic surgery, general surgery and pain management procedures. The facility has two operating rooms, four bed preparation areas and eight station recovery areas. Concord Ambulatory Surgery Center provides complete coordinated care to Canadian patients, which includes scheduling appointments, travel, accommodation and transportation to the facility. The procedures offered to medical tourism patients include knee arthroscopy, ACL reconstruction, liposuction, tonsillectomy and rotator cuff repair.

Loveland (Colo.) Surgery Center. Kenneth Pettine, MD, spine surgeon and co-owner of Loveland Surgery Center, noticed that patients were traveling to India and Germany to pay cash for procedures such as lumbar artificial disc replacement, which some insurance companies do not cover, although the technology is cleared by the FDA and surgeons in the United States can perform them. He felt he could provide these patients the same quality procedure at Loveland Surgery Center at a lower price if the patients were willing to pay cash. The cash price includes implant, surgeon, facility and anesthesia fees. Loveland Surgery Center is a Joint Commission-accredited facility.

Squaw Peak Surgery Center (Phoenix). Squaw Peak Surgery Center was founded in 1998 by Anthony Yeung, MD, and has two operating rooms. The surgeons perform endoscopic spine surgery and a dorsal endoscopic rhizotomy surgery invented and developed by Dr. Yeung. The surgery center can accommodate cash pay patients and Dr. Anthony's practice, Desert Institute for Spine Care, offers to coordinate care for medical tourists. The surgery center also has negotiated discounted rates at area hotels for their patients. The surgeons are team spine surgeons for several professional athletes, including the Arizona Diamondbacks, Colorado Rockies, Kansas City Royals, Seattle Mariners, Los Angeles Dodgers and Cincinnati Reds.


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Key Challenges, Opportunities for Growth in Spine Surgery

Written by Bob Spoerl | Becker's ASC Review | June 18, 2012

At the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago on June 15, Kenneth Pettine, MD, a spine surgeon at the Loveland (Colo.) Surgery Center; Larry Teuber, MD, a spine surgeon and president of Medical Facilities in Rapid City, S.D.; and Timothy T. Davis, MD, DABNM, DABPMR, DABPM, a spine surgeon and director of interventional pain and electrodiagnostics at The Spine Institute in Los Angeles, discussed trends in spine surgery and ideas for improving profitability and outcomes of spine programs. Scott Becker, JD, CPA, partner at McGuireWoods, moderated the session. 

Mr. Becker kicked off the discussion by asking the spine surgeons some of the top spine surgery trends on their minds.

Dr. Davis said he sees a growing trend of spine centers and surgeons needing to meet certain criteria to get surgeries covered. He compared the trend to what he said has happened to cardiology.

"I think it's going to come down to really having to follow a strict algorithm of spine care, he said. "We already have to do this in the worker's compensation environment."

Electronic medical records will become increasingly important for spine surgeons to ensure every procedure has been tried and standards are being followed,  which is critical for reimbursement.

Dr. Pettine said he's seeing a trend in payors denying spine procedures, what he called a "dramatic change" in spine surgeons' ability to get surgeries authorized. He suggested all orthopedic surgeons study insurance plans' guideline packets, which state the requirements needed to get procedures authorized.

"If you don't understand the rules, you can't play the game," he said. 

He predicted the total number of spine procedures performed could drop by as much as 30 percent in the next year because of payor denials. 

Dr. Teuber echoed the notion by saying the backlog of pre-authorizations for spine surgeries is huge.

Later in the conversation, Mr. Becker asked the panel about some of the most exciting developments they're seeing.

"Biologics are far and away the next frontier of spine," Dr. Davis said. He was referring to the use of biologics both in surgery and prior to it. He said it's the "biggest single improvement in spine care."

Dr. Teuber agreed and added "implants will always be a growth area too.”

Dr. Pettine discussed the future in terms of where spine procedures happen. "Spine care in an ASC setting is absolutely the future," he said. It's the place where "all of the modern minimally invasive techniques for spine" can be utilized.

"The hospitals absolutely cannot compete with an ASC," he added. "We can provide this care [for] significantly less."

In order to be profitable over the next five years performing spine surgery, Dr. Pettine said spine centers should seriously look at case rates. There's an opportunity for ASCs to pick up potential spillover patients from other surgeons who sign with hospitals but lack the time to perform as many surgeries, he said.

"As far as hospitals purchasing doctors, I think that's great. The minute the hospital purchases several neurosurgeons, then he's no longer competition," he said.

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Dr. Kenneth Pettine: Four Points on Performing Spine Surgery in ASCs

Written by Laura Miller | Becker's ASC Review | June 18, 2012

At the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago on June 15, Founder of The Spine Institute and Loveland (Colo.) Surgery Center Kenneth A. Pettine, MD, gave a presentation titled "Everything You Need to Know to Successfully Perform Spine Surgery in an ASC." In his presentation, Dr. Pettine touched on several factors that will make it easier to bring spine procedures into an ambulatory surgery center in the future. 

"My goal is to move 50 percent of inpatient hospital spine surgeries in the United States to an ASC," Dr. Pettine said. "I would encourage everyone to be involved in the Society for Ambulatory Spine Surgery. We need to change current Medicare ASC guidelines, which will allow us to perform more cases in the ASC. We've seen this trend with arthroscopies."

1. Negotiate down implant costs. It's important to negotiate down implant prices to retail prices, if they aren't already there. "It's not difficult to negotiate 40 to 60 percent discounts on implants," said Dr. Pettine. "Share that discount with spine surgeons."

Also consider implant cost when negotiating for payor contracts. "Don't leave implant money on the table," said Dr. Pettine. "Have appropriate contracts to perform spine surgery at the ASC."

2. Give surgeons the numbers. If surgeons in your community are dragging their feet about bringing cases into the surgery center, give them data to show them the impact it could make on their practice. "Surgeons are rather reticent to change their practice patterns," said Dr. Pettine. "They do the same procedures they did 10 to 20 years ago. One of the ways you can convince them to change is with data. With numbers is power."

The most important data to highlight includes:

•    Turnover times, which should be around 10 minutes in the ASC compared to 45 minutes in the hospital
•    Implant income with percentage over cost
•    Infection control data

3. Build a convalescence center. A convalescence center allows patients who need extra recovery time to stay 23-plus hours in the facility after outpatient spine surgery. If constructing a convalescence center isn't possible, consider partnering with other facilities for discharging patients who aren't quite ready to return home.

"You can accomplish the same thing as a convalescence center with a rehabilitation facility or nursing home," said Dr. Pettine. "There are ways to accomplish this same type of facility in states where surgery centers can't get a convalescence license." 

4. Procedures performed in a surgery center. Right now, typical procedures performed in the surgery center include anterior lumbar interbody fusions, posterior lumbar fusions, artificial disc replacements and sacroiliac joint fusions. "Currently, these are not controversial procedures to perform in an ASC because we have gathered effectiveness data," said Dr. Pettine. "We've done about 1,700 non-instrumented cases in the ASC and because of published data they aren't controversial."

Dr. Pettine also participates in clinical trials using biologics during spine surgery. "There are approximately 20 different types of adult stem cells in your body," said Dr. Pettine. "In orthopedics, we use mesenchymal stem cells. The goal is to harness the natural healing potential of stem cells. I am unaware of any adverse effects of using the patient's own stem cells."

After harvesting the stem cells, they are processed and then implanted back in the patient to promote fusion. The FDA considers the procedure the same as blood transfusion. "Results of the study are extremely promising," said Dr. Pettine. "The more you learn about this technology, the more optimistic you become."


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Five Trends in Orthopedic and Spine Devices and Implants

Written by Taryn Tawoda | Becker's ASC Review | June 18, 2012

In a session titled "New Developments in Orthopedic and Spine Devices and Implants" at the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago, Chris Zorn, vice president of sales at Spine Surgical Innovation, and Kenneth A. Pettine, MD, founder of the Spine Institute and Loveland Surgery Center, discussed trends and developments in orthopedic and spine implants. 

1. The focus is on developments that inspire innovation. Mr. Zorn said he has seen devices developed with an emphasis on making the healthcare system more efficient and less costly, particularly since reimbursement is under tremendous pressure. "What can we do to help make the procedures less traumatic for patients, easier for the surgeons and less expensive for the healthcare systems paying for all of this?" he said. "Delivering surgery in an ASC is obviously different from surgery in a hospital. You have to keep an eye on what you're doing and look for incremental changes that can help you or your patient in the OR, and changes that you can get paid for."

2. Innovative spine implants in the U.S. are hindered by a complicated regulatory process. A lengthy FDA approval process can delay many innovative implants in the U.S., said Dr. Pettine. "I am extremely optimistic about the future of spine surgery in ambulatory surgery centers, but I'm very pessimistic about the future of really innovative spine implants in the U.S.," he said, adding that the U.S. is behind in implant developments compared to other parts of the world. "Europe is at least three to five years ahead of us in terms of spinal implant technology. In the U.S., a study will take at least one year, then there is a two year wait for data, and then the FDA may sit on data for five years."

3. Venture capital money is declining. According to Dr. Pettine, venture capital money for new devices is draining, and the lengthy FDA device approval process is largely to blame. "When people invest in something, they're expecting a minimum five-year turnaround with that money," he said. "But in the U.S., we’re looking at seven to 10 years before a device gets approval, so this venture capital money is going elsewhere."

4. Reimbursements for disposables are low. Disposable supplies are not reimbursed well, said Dr. Pettine. "You can get reimbursed for an implant, but not disposables, in an ASC setting," he said. "So if a technique is associated with a lot of disposables, may not work for you at your surgery center."

5. Using more disposables can save money long-term. "Some countries want you to do everything disposable," said Mr. Zorn. "Since the pressure is on everybody to deliver more for less, switching your capital investment into a disposable method makes a lot of sense. The problem is that disposables are still outrageously priced in the U.S."


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Spine Leader to Know: Dr. Kenneth Pettine of The Spine Institute

Written by  Bob Spoerl | April 17, 2012 | Becker's Spine Review

Kenneth Pettine, MD, is co-founder of Rocky Mountain Associates in Orthopedic Medicine and The Spine Institute in Loveland, Colo. In addition, he co-invented and co-designed the Maverick Artificial Disk as well as the Prestige Cervical Artificial Disc.

Throughout his career, Dr. Pettine has focused on innovation and was among the first spine surgeons to perform a minimally invasive lumbar disc procedure using the Mesoblast Limited technology. The procedure was performed in a Phase 2 clinical trial of the adult Mesenchymal Precursor Cell product for treating patients with low back pain and degenerative disc disease.

He performs outpatient spine surgery in a surgery center and has predicted that over the next several years, 50 percent of spine procedures could move into the outpatient setting. He also provides cash pay for spine surgery at his center.

"We were noticing many patients were considering going to Germany or India where they could pay cash for an ADR," Dr. Pettine says. "We felt we could offer these patients a cash price similar to what they would pay overseas but allow them to have their surgery close to home by a surgeon they know and trust. Follow up is easier and more efficacious."

Dr. Pettine's background is in spinal surgery, research and rehabilitation. His spine fellowship was at the Institute for Low Back Care in Minneapolis, and he complete residency and a master's degree in orthopedic surgery at the Mayo Clinic in Rochester, Minn. He earned a medical degree from the University of Colorado School of Medicine.

Dr. Pettine holds 14 awards from medical school and residency, has been published 22 times and presented at 45 events and conferences around the world. He recently founded the Society for Ambulatory Spine Surgery, which he launched last November with Access MediQuip. He is a member of the American Academy of Orthopaedic Surgeons, North American Spine Society and Arthroscopy Association of North America.

For Back, Neck Pain, Artificial Disc Replacement Has Cost, Outcome Advantages Over Fusion Surgery

ScienceDaily (Mar. 22, 2011) —

When physical therapy and drugs fail to relieve back or neck pain, patients often turn to spinal fusion surgery as a last resort, but two new studies show that in certain situations, especially when several discs are involved, artificial disc replacement may give better long-term results at lower cost.

Hospital costs for artificial disc replacement were 49 percent lower, and four years out from surgery, artificial disc patients were four times less likely to need additional surgery than those who had fusion operations, according to two recently published studies.

"Back pain is the fifth leading cause of hospital admission and the third most common reason for surgery," said orthopaedic surgeon Rick B. Delamarter, M.D., co-director of the Cedars-Sinai Spine Center. "Estimates vary and are probably understated, but health care expenditures for back pain top $91 billion a year, not including indirect and societal costs such as time lost from work and worker's compensation.It is crucial that we develop surgical procedures that are cost effective without sacrificing high-quality results."

Delamarter is a lead author of the two studies, which were published recently in the SAS Journal of the International Society for the Advancement of Spine Surgery and the Society for Minimally Invasive Spine Surgery.

Both studies compared disc replacement surgery with the more common fusion operation to treat degenerative disc disease -- deterioration caused by aging and wear and tear. One study looked at 209 patients with damaged neck discs who received either minimally invasive disc replacement or the more complex spinal fusion surgery. These patients were followed at regular intervals for four years. A separate group of 136 who received an artificial disc two years after the first group also were part of the study. All patients were assessed on their satisfaction with the results of the procedure. The other study focused on 53 patients suffering from three-level, lower back disc disease and looked at cost comparisons for length of hospital stay, resources used and other factors

Discs act as cushions between the bones (vertebrae) of the spine. When healthy, the discs have enough "give" to allow the back to be flexible but are firm enough to provide stability. With age or injury, they lose their pliability and density. Nerves may become pinched between the bones, causing pain not just in the spine but in other parts of the body.

Fusion surgery seeks to relieve symptoms of the degenerative disease by removing the damaged disc and replacing it with bone. Studies show this procedure often can be effective but there can be drawbacks: in some cases, fused spinal sections can lose flexibility, impeding normal movement and stressing adjacent discs, often leading later to more fusion surgery. Artificial disc replacement, which has been performed in the United States since 2000, tends to cause less tissue injury than fusion surgery, and the discs are designed to maintain natural spine movement and reduce need for follow-up surgery.

In their study of patients suffering neck (cervical) disc disease, Delamarter and his colleagues found both disc replacement and fusion surgery acceptable options providing good long-term outcomes. But four years out from surgery, fusion patients were four times more likely to need more surgery. Half of these secondary operations were needed to treat new disc problems occurring adjacent to fused sections.

Patients in the study had imaging scans to measure before-and-after flexibility and range of motion; were evaluated for physical and neurological improvement; and completed self-assessment questionnaires on neck disability, neck and arm pain intensity. Improvements were seen in all categories, regardless of the surgical procedure, but results tended to be at least slightly better in patients with disc replacements.

An important area, according to Delamarter, was patient satisfaction with the procedure. Four years after surgery, nearly 88 percent of disc replacement patients reported that they were very to completely satisfied, compared with 76 percent of fusion patients. When asked if they would undergo the same surgery again, 89 percent of disc replacement patients and 81 percent of fusion patients said yes.

"While the results of this 13-center study are preliminary, it appears that artificial disc replacement surgery compares favorably as an effective procedure, is preferred by patients and slows the rate of adjacent-level disease," Delamarter said.

Spinal fusion has been recognized as one of the more expensive surgical procedures. The second study looked at costs and is believed to be the first to compare those of three-level disc replacement with three-level fusion. It evaluated itemized billing records of 53 patients undergoing surgery for three consecutive discs of the low back (lumbar spine) at St. John's Health Center in Santa Monica, Calif., where Delamarter practiced before joining Cedars-Sinai.

Total hospital costs for patients undergoing disc replacement surgery averaged 49 percent lower than those for fusion patients.

The number of fusions for low back pain is rising rapidly, but Delamarter urges hospitals, insurers and surgeons to consider alternatives, including total disc replacement.

"After safety and effectiveness of a procedure have been documented, cost is an important consideration," he said. "Artificial disc replacement technology appears to offer a promising, cost-saving alternative to fusion, especially for patients with disease at three levels."

The artificial discs implanted in these studies -- the ProDisc-C and ProDisc-L -- were manufactured by Synthes USA Products. Delamarter and his colleagues have evaluated outcomes and written about the devices since the FDA approved them for research and limited use in the United States. Delamarter is a consultant for Synthes and receives royalties on the ProDisc devices. However, he does not receive royalties on devices used for his patients or any other patients at Cedars-Sinai Medical Center.

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Spinal fusion surgery: The science behind Manning's life changing operation

By Christi Sodano | Feb 02, 2012 | Medill Reports Chicago

With his home turf the epicenter of the Super Bowl buzz this season, his younger brother in contention for the NFL championship and a potentially life-changing contract decision only one month away, it is little wonder why Peyton Manning’s recovery is at the forefront of Indianapolis conversation.

Last September, Manning underwent his third neck surgery in two years. The controversial spinal-fusion surgery aimed to correct a cervical disc herniation in his neck has been associated with declines in his on-field performance.

Cervical disc herniation occurs when the cushioned discs, which act as shock absorbers between the vertebrae, bulge and pinch the spinal cord or nerve root that are encased in the spine.

This is generally caused by repeated neck motion or trauma and can result in loss of motor function and numbness or sharp pain, said Dr. Selene Parekh, associate professor of orthopedic surgery at Duke University.

Typically surgery is considered only after the patient has endured prolonged pain of up to six weeks, said Dr. Wellington Hsu, assistant professor of orthopedic surgery at the Feinberg School of Medicine at Northwestern University.

In Manning’s case, disc fragments pinching the nerve root in his cervical spine likely caused acute pain and decreased arm strength.

During the September operation, doctors removed a single disc through a small incision in the front of the neck, alleviating pressure on the nerve root and replacing the disc with bone grafts or a plastic implant. Once the new disc is set into place, the surrounding vertebrae are fused using a titanium plate and screws in the upper and lower vertebrae.

Prior to Manning’s spinal-fusion surgery, he underwent two microdiscectomies in an attempt to correct the problem. After a series of diagnostic tests in September showed his recovery was not on track, spinal-fusion surgery became the next step.

Although the surgery is touted by many industry professionals as more than 95 percent successful, Dr. Kenneth Pettine, an American Academy of Orthopedic Surgeons member, said in a 2010 report, “The perception is that this is a great operation. I’m not saying it’s an awful operation. We’re just presenting the data that it’s certainly not 95 percent.”

“When you get one level fused, the next level up and down has to take all the motion. This very often accelerates into adjacent level dysfunction. That can happen two years later, that can happen 10 years later,” said Shaeffer Bannigan, development engineer at NuVasive, Inc., a spinal surgery technology company.

Hsu, who published a study in 2010 about the likelihood of athletes to return to the NFL after spinal- fusion surgery said, “For a player like Manning, the time frame to play football is closing in and when his arm strength was not improving fast enough, he elected to have the fusion.”

In his study, Hsu analyzed 99 players, some of whom are still on the field, and found on average players treated surgically had a higher return-to-play rate and longer career than players who are treated nonsurgically and position was a key factor in success after surgery.

Performance after surgery largely depends on the player's position and is particularly relevant for quarterbacks, Parekh said.

“Loss of function, even if only by a few degrees, is significant because if neck rotation is inhibited, that can affect your ability to assess what is happening on the field,” he said.

Recovery plans after surgery vary depending on the patient.

According to Parekh’s medical-information blog, the bone usually takes 12 weeks to fuse and after fusion, “a prolonged course of therapy will be needed to regain some of the loss of function, mobility and strength.”

Despite a lengthy recovery process, Hsu speculated that, “Manning will be able to come back to the NFL next year. What his level of play will be after he returns is still yet to be determined.”

However, Hsu’s opinion is not shared by all.

“My personal opinion was that there wasn’t an entirely honest view of what was happening him, there is a real chance that he may never return to play in the NFL,” Parekh said.

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