Hooman M. Melamed, MD, is a board-certified orthopedic spine surgeon specializing in disorders of the spine for children and adults. He specializes in minimally invasive spinal surgery; complex cervical spine disorders; cervical, thoracic and lumbar degenerative disc disease; revision spine surgeries; second opinions; spine trauma/tumor and pediatric and adult scoliosis and kyphosis. He currently serves as Director of Scoliosis at Marina Del Rey Hospital in California. Dr. Melamed was a spine consultant at Shriners Hospital. He is assistant clinical professor of orthopedic surgery at Touro University Medical Center in Las Vegas, Nev. He has performed outpatient spine surgery since 2006.
Q: What spine procedures do you perform on an outpatient basis in an ambulatory surgery center (ASC)?
Dr. Hooman Melamed: I started with simple procedures, such as lumbar decompressions, microdiscectomies, laminotomies — very simple, basic, one-level procedures. Then I started performing two-level and up to three-level decompressions. I then went into performing one-level neck fusions, then two-level neck fusions. I’ve performed posterior cervical foramenotomy and done up to four-level cervical decompressions.
I have performed anterior lumbar interbody fusions (ALIFs) as an outpatient procedure. I’ve done front and back lumbar surgery one-level fusions and one-level fusion extreme lateral interbody fusions (XLIFs). In the future, I would like to maybe perform two- or three-level XLIFs and three level anterior cervical discectomy and fusions (ACDFs).
At our practice, we can keep patients for up to 23 hours. I could probably do twice as many cases in the outpatient setting if we were allowed to keep patients for 48 or even 72 hours, or if we were even allowed to have two-night stays versus one-night stays. I could probably perform two-level lumbar fusions and three-level ACDFs if the rules changed.
Q: Why are you comfortable and confident in performing spine surgery in an ASC?
HM: It’s about trusting your team around you and knowing the setup. We have a very capable nursing group. I know the equipment we use. I know the way the setup will be for every case. We have state-of-the-art equipment. To perform spine surgery in an ASC, you have to be able to do minimally invasive procedures. If you’re not comfortable with minimally invasive techniques, you can’t perform these cases in the outpatient setting. But if you get comfortable with this approach and you have the proper equipment, nursing personnel and anesthesiologist, it’s definitely safe to do these cases in the ASC. Once I performed one or two procedures, my confidence started to build. Then I started doing more and more complicated procedures to the point where now I have a high comfort level.
Q: What do you think makes ASCs such an appropriate setting for spine surgery?
HM: If I could do every single case of mine as outpatient, it would be a dream come true. The reason is efficiency and safety. Outpatient surgery centers — the way they’re set up — are more efficient, more well run and things go much more smooth than in the hospital. We can do all of these minimally invasive procedures because of the minimally invasive instruments available that allow you to do all of these cases very efficiently. When all the members of the team are on the same page, then there are less likely to be errors and hence [it is] safer for the patients. You have much less infection than in a hospital setting. There are top-of-the-line nurses. It’s like a seven-star hotel. The patients love it. A lot are skeptical initially, but once they have their procedure, they’re amazed. They get one-on-one — or sometimes two-to-one — nursing care, and they’re very happy.
Q: What are some of the other benefits of performing spine surgery in an ASC?
HM: For patients, a well-run surgery center that’s well staffed and has the right equipment is potentially safer than anywhere else. You’re much less likely to get any of those horrible infections you see at the hospital. At our practic, we’ve done some 7,000 cases, I think we’ve had maybe one infection. No hospital is going to be able to have that record.
And then there’s the quality of care patients receive; the one-on-one care with specialized nurses. Patients receive care from a nurse that understands spine surgery; someone who has been caring for spine surgery patients for years, so they’re well in tuned. It’s the same surgical team every time — it’s not different people like you get in the hospital. And the cost overall, because it’s run much more efficiently, ends up being cheaper for the patient. So patients get a better surgery, better service, less chance of complications and the outcomes are a lot better. There’s all of those benefits and it’s cheaper.
For me as a surgeon, everything is run much more efficiently. I’m done with cases faster, and by the time we finish one case and the patient goes out the room, I start the next case in 15-20 minutes. That’s amazing turnaround time. Not many hospitals in this country are even close to that turnaround time. Go to some hospitals and you’re looking at a few hours for turnaround time. Sometimes performing procedures in hospitals is like reinventing the wheel.
As a surgeon, when you are going to do the same procedure over and over again, you like to just show up and have all of the equipment ready for you. You just want to focus on operating on the patient. You don’t want to have to worry about whether the right equipment will be there. At the ASC, I don’t have to worry about anything. At the hospital, if a new tech comes in, I don’t know if he or she will know what’s going on, and sometimes they don’t. Sometimes you get an anesthesiologist who may not be as much as in tuned with what needs to happen, and it takes them awhile to wake the patient up or put them to sleep. That starts adding time to the overall OR time. In the ASC, they’re on anesthesia less. The patients go to sleep and they wake up right away.
At the ASC, I know the patient is getting unbelievable care. The nurses get the patients up right away and get them going on their way to recovery, which is nice. Sometimes in the hospital I will do surgery in the morning and when I give the patient a call at night, I find out that nobody got the patient out of bed the whole day. I’ve had to essentially postpone discharging a patient a day because the nurses in the hospital didn’t get the patient up enough.
Q: What are some of the challenges you have faced in bringing spine surgery to the outpatient setting?
HM: The number one hurdle is the insurance companies and what they’re willing to pay for these cases. You can’t do these procedures on what insurance is paying. Spine surgery is not like a knee scope where you have minimal equipment and minimal cost. Spine surgery has costs. The instruments and equipment — all of these things have cost. Insurance companies are paying you less than the cost. Now it’s impossible to do the cases, and a lot of patients get upset about that.
When that happens, and the patient goes to the hospital, it becomes a more expensive case. It’s higher risk, patients don’t get the same good care and it’s not as efficient. Patients may have to stay in the hospital longer and that increases the chance of the infection. If the patient ends up with an infection, now they need to stay even longer. It ends up costing the insurance company more and has a negative impact on patient’s health.
Q: The primary mission of the Society for Ambulatory Spine Surgery (SASS) is to support the migration of spine to the ASC setting? Why do you think this is valuable?
HM: With an organization like SASS, it can help us to show spine surgery can be performed in a minimally invasive fashion where patients no longer have to worry about having their back left wide open and susceptible to infection while they lay in a hospital for a week. We can show that outpatient spine surgery is as safe as people doing an appendectomy or hernia repair at an ASC, and at significant cost savings.
I had a patient that recently paid cash for surgery. We quoted the hospital, we quoted the ASC. The outpatient case came out $35,000, the hospital quoted $50,000. If insurance was covering the whole procedure, the patient would have received care for $15,000 less at the ASC and the patient would have received better care. I think it would be great if we can continue to tell the insurance companies these types of stories and get them to open their pockets up a little bit.