Shifting spine procedures to an ASC setting and participating in a free market healthcare environment.
SmartTRAK: This is Julianne Burns, senior analyst of SPINE for SmartTRAK. I'm here with Richard Kube, MD, spine surgeon and founder of Prairie Surgicare Spine Surgical Facility in Peoria, Illinois. Dr. Kube also cofounded the Illinois chapter of Free Market Medical Association. Dr. Kube, thanks so much for joining me.
Richard Kube, MD: Sure thing. Thanks for having me.
Absolutely. So, I'm going to jump right in. We're tracking a noticeable shift in spine procedures to an outpatient or ASC setting. What percentage of your spine cases are performed in an ASC and how do you think that compares to your peers?
RK: Well, currently 100 percent of the procedures I do are performed outside of a hospital setting. They're done in ambulatory centers and facilities. I think that's certainly a lot more than the average person in spine. I'd say probably the average spine surgeon is still doing a relatively small percentage of their procedures in an ambulatory setting.
Sure, and which were your first procedures that you started shifting to an ASC or an outpatient setting?
RK: I started with some of the simpler things like laminectomies, microdiscectomies, and procedures of that type. Those kinds of patients were being sent home relatively, well pretty much all the time, when we were in a hospital setting. So, that was a very easy first jump to be able to take those patients to an outpatient setting. Basically you're just dealing with medical issues at that time. Is the patient medically sound enough, safe enough? What's their anesthesia ASA score and so forth. So as long as they were relatively healthy, there wasn't really anything from the spine procedure itself that would require an overnight or something along those lines.
Certainly an outpatient setting from surgeon standpoint, most surgeons who've done both hospital and ambulatory would probably almost universally tell you they prefer the ambulatory setting. But the reality is then we started trying to basically determine what else can we bring into that arena.
I was fortunate in our particular area to have access to a facility that can have people overnight. We even had an extended care license. And so between what we did at the hospital and then what I did there, it was a natural progression where fusion patients and things like that. You go from the standard, okay they're in the hospital three to four days and then start just thinking well, what can I do to improve this? How can I bring it to two days? And then to one day, then to how can I get them home the same day?
And I had the ability through just doing what I was doing at the hospital, mixed in with what I had access to in our region to start pushing that. And whether it's a matter of patient education and expectations would be some part of it, because when I started doing things in an ambulatory fashion for spine 10 years ago. And so, certainly there's a very rare instance at that time and the public perception was certainly that their surgery couldn't or shouldn't be done in that setting. So some of it was expectation. Other components were just adopting different techniques that were increasingly less invasive so that the postoperative pain would be less, postoperative mobility would be higher. And then beyond, that also using different types of anesthesia techniques, working with anesthesia providers who understood different things that they could do to help minimize that pain postoperatively so that the patient could be up, could be mobile, could be moving around, didn't have to have a lot of narcotics. And as we did that the road was no looking back.
Both facilities, I have the ability to keep people overnight when necessary, if necessary. So we feel pretty comfortable doing three to even four level cervical spine cases here. Two to three level lumbars. I have done a single four level lumbar case here, but that's really pushing it. By and large though, one and two level cervical and lumbar cases, regardless of what it is, from just laminotomies, laminectomies, to disc replacements, fusions. Pretty much any of those things are possible from a spine standpoint in these facilities and I think that's really the nature of our practice now, how it's evolved and gotten there.
Wow. It seems like you're really ahead of the curve in this and I wouldn't be surprised if the market followed. As people are starting to shift their procedures to an ASC or an outpatient setting, what are the biggest challenges the surgeons need to be anticipating?
RK: I think the biggest challenges probably would be a combination of their local hospital system and the insurance industry. I think that frankly would be the biggest challenge in my mind.
And what about the benefits of shifting to an ASC setting?
RK: Well, I think in an ambulatory setting, typically speaking, a lot of these facilities are surgeon driven and surgeon run. And so as surgeons, we're looking for ways to make the patient's life easier, the patient outcomes better and our own lives easier and better in addition to that. I mean certainly surgeons are looking for ancillary revenue streams and those things as well, but the reality is at the end of the day, I think while that's certainly a driver as well, I think by and large, a lot of the buy in is for surgeons to take on this new processes that you have greater control over what happens in the operating room. And that's important I think for the vast majority of surgeons, it's probably one of the biggest driving factors.
I was moving these cases into an ambulatory setting far old before I had any financial interests of any kind in a facility. So while that financial motivator ultimately can be out there for a lot of people, as I said, I was pushing my stuff hard that direction before there was really any financial interest in a facility for me to do so. It was really a matter of having the efficiency of a facility like that where they were interested in me, interested in the cases that I was bringing there, and interested also in the outcomes of the patient. Because again, what we are and were doing at that time especially was not really mainstream. And so the concern you always have when you're doing something new is to make sure that everything, you're really being very careful and very attentive to the details to make sure that you don't have complications or don't have problems or don't have the one-offs because those kinds of things can shut down the entire process.
So after you do several thousand cases, you might have a patient that has an issue here or an issue there, but then it's apparent that those are exceptions and not the rule or it's not something that's inherently problematic if you have an ambulatory center. I mean everybody is going to have some complication or adverse event or require for a transfer at some point in time if you do enough cases. I think you really have to be aware what those things are, have good processes to handle them and then execute those processes when and if that time arises. But I think, in general, having the ability to set up an operating room the way you want, use the tools and methods you want, not having to adhere to some cookie cutter, one size fits all, that is typically the hospital setting. And there are reasons and valid reasons for that.
If they've got 10 different spine surgeons there, from a cost standpoint, it's pretty tough for them to have 10 different setups and systems and it just doesn't work in their model the same way versus a smaller facility can be a little more nimble and can be a little more tailored and that's I think a huge advantage and it also allows us to implement new things. We've always been at the forefront of adding new types of spine procedures to the community and a lot of these things just simply wouldn't get through in the hospital. A great example I could think of, it's been years now, but when Coflex came out from Paradigm Spine several years back, you know Coflex gained it's FDA approval while we were at the North American Spine Society that year. I trained while I was there, came home and we want to do cases and we had roadblocks at the hospital. Their reviewers looked at those cases and said, well this is probably just going to lead to more surgeries and isn't what we really think we should be doing here. Which in reality that flew in the face of all the published data that in fact the reoperation rate in the appropriately selected people was lower using the Coflex procedure. And so ultimately we did the first procedures in Illinois using Coflex, period, and those were in ambulatory settings.
Very interesting. All right. Now to shift gears here at the end. Can you tell me a little bit about your involvement with the Free Market Medical Association and why you feel that work is so important?
RK: Well, we started posting prices several years back at our facility in our practice. And we really thought that in our world I was looking and saying, well, I'm a solo spine surgeon. It's a bit of a dying breed and I felt like we continue to try and have a greater access to greater numbers of patients. My practice is largely internet driven and people travel from a variety of places to get the types of services that we provide. As I started seeing the trends in Madison, where you'd have these rising deductibles that were occurring. You also in spine were starting to encounter scenarios where insurance companies were just denying treatment period. I can tell you specifically there are lots of procedures that five, six, seven years ago would have been almost a rubber stamp and the patient would be allowed to have a procedure and move on with life, that we can't get authorization for some of these things and it's not just fusions or some of these things that people tend to demonize or vilify.
I mean 20 something year old person with a disc herniation and radiculopathy can't get a microdiscectomy approved by their insurance company. This is one of the longest tried and true procedures with some of the best outcomes in all of spine surgeries. A microdiscectomy for an isolated single level disc herniation with associated radiculopathy, it doesn't get any clearer than that. And we're even having people have denied access for that much less when you start talking about things like disc replacements or Coflex or fusions or some of those other items. And so looking at that made sense that going into a cash arena was more than just a business opportunity. It was a solution. Well it was a business opportunity because it was a solution to what I felt was going to become a growing problem in this country, which was access.
The prices for things keep going up. And in the current system and the current model, the primary way that costs is being contained is by rationing the care and rationing the services. And so we as physicians go into medicine to help people, to be able to provide our knowledge and our skillsets and our hands to make meaningful change. And in my world in orthopedic spine, it's typically quality of life issues. I'm not saving lives, for the most part. I'm not a cardiac surgeon or pulmonologist. Most of our items are about quality of life. Can you walk, can you do activities of daily living, what is your pain level like while you're undergoing those things. And so that's all very important. And as we posted the prices and started going and digging into that, we had an occasion to encounter this Free Market Medical Association and their mantra and their pillars and goals and ideals really spoke to what we were trying to accomplish as well.
And we were like, wow, these guys are really out there already doing what we think is important. And so we almost immediately in our practice, my CEO and I, Colleen Ingraham and I, formed the Illinois chapter of the Free Market Medical Association. There's been really no looking back. I think having a forum that educates patients, employers and et cetera, of how the current healthcare industry works and where are the prices and costs and so forth are actually driven is important. Again, the healthcare costs keep escalating when you consider a huge percentage, I think probably, give or take, one in three people, who have a commercial insurance plan, they're going to have their insurance provided to them by their employer and employers are increasingly unable to sustain the skyrocketing costs of this care. And so over time there's - we looked at, as an employer, watching my costs continue to go up and up and up.
As a solo practice doc, we were paying well into six figures a year for healthcare plan for our staff. And it's not like I got a hundred employees. We're talking about 15 people and as a solo provider, being able to try and cover the cost of 150 to $200,000 and continue to be on the rise, it's clearly not a sustainable model and we're not the only companies pressed with those issues. You have varieties of companies pressed with those issues. You have teachers unions and city and state employees unions who continue to get squeezed with a lot of these healthcare costs. And the reality is even though the costs are going up as a provider, I'm seeing the other side of the equation where there's no added care occurring. It's not like we're doing greater numbers of procedures on greater numbers of people who are walking through my door anyway. And it just seems to me that if healthcare is going to survive as we know it, and that we don't go to a single payer system, like Europe has, or something along those lines, then we have to have a model that allows us to have a paradigm shift.
And I think creating a market, I mean true free markets work in every aspect of economics and because of the immense ability for those transactions to be tailored to individual micro-economies. The problem with most of the regulatory items that we have out there and try to have these quote unquote healthcare for all and things of that nature. What works in New Jersey, doesn't work in Illinois and also doesn't work in California. And if I come to Illinois, what works in Chicago doesn't work in Peoria. And what works in Peoria doesn't maybe work in Carbondale. And if you have this from the top down kind of model, you're going to have the wheels fall off the wagon and multiple locations, whereby a free market allows people in a local manner to make those decisions on how their transactions will occur. And having the freedom and means to be able to execute those will ultimately drive the best value. What people want to pay for what they get and what they're willing to actually go out and what they find is important to them.
And so that in my mind was why this was important. And I think it continues to be important. I've always been of a mindset, I believed in that form of an economic model. I certainly think Keith Smith and Jay Kempton, who are the founders of the Free Market Medical Association as a whole, see that going. And I think certainly we see immense savings for the people acquiring these services from places like ours or Surgery Center Oklahoma City, and the like. And I really would like to be able to have access to those kinds of care and services when I am old enough to start requiring more of them. And I think that's just important for our posterity to have access to the American healthcare system as we once knew it. Because what we have now has become really, I think treated and really manipulated for the advantage of a few and has not been the best thing for patients in this country. I think certainly a lot deeper dive for these kinds of pieces of information are certainly available. You go to the Free Market Medical Association, whether it's the national website or our Illinois website. Certainly you can see these types of procedures and types of care that we're talking about. You can go to Prairie Surgicare, our website. You'd see the types of procedures and types of pricing that's available, if you want to act and interact in a free market environment. There are multiple other facilities that do this type of work - obviously Surgery Center Oklahoma, where Keith and Jay are, sort of the epicenter of this free market movement. And certainly you go through their website, our website, free market websites, you can gain access to other provider lists and providers who also think this way and are also providing this type of care and this type of environment.
And I think the more that the public is awakened by how the system works, the better off we will all be. I think too many people feel very helpless and very stuck in the system and the current system really enriches a handful of organizations. And I think that certainly these other organizations are necessary to our system, but it cannot be the overwhelming, overbearing, singular direction that can be taken. We have to have people able to access healthcare in a real and meaningful way, and be able to access it at a point of value, and that their treating provider is not shackled or handcuffed to some algorithm, that they actually are able to spend the time to tailor treatment specifically for them because that's when the outcomes will be optimized. When the surgeon is allowed to basically practice his or her art in the way that they have developed through their training and experience to best care for those people coming through the door.
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