Alejandro Badia, MD, a hand and upper extremity surgeon at Badia Hand to Shoulder Center and Chief Medical Officer at OrthoNOW in Doral, Fla., discusses four recent trends in outpatient procedures and reimbursements for the hand and upper extremity surgical specialty.
1. The scope of hand surgery is expanding. Ambulatory surgery centers specializing in hand surgery are now more likely to offer a broader range of surgeries that extend up the arm, says Dr. Badia. “Most of this generation of hand surgeons is often trained in shoulder as well, and I handle anything from the brachial plexus to the collar and down,” he says, adding that nearly 30 percent of the cases seen in his center are shoulder surgeries. To more accurately capture the scope of his surgical offerings in a way that was understandable to patients, Dr. Badia chose the phrase “hand and shoulder” when naming his center. He said he felt that the name of his previous group, the Miami Hand Center, left out an important component: the many upper extremity surgeries that were also performed.
2. Hand surgeries are increasingly being performed in ASCs. Dr. Badia says that he no longer performs hand surgeries in hospitals due to the efficiency of the ASC environment. “I am the outpatient surgery center poster boy in that regard,” he says. “In the rare cases where I can’t perform the surgery in the ASC, I will refer that patient to a colleague at the hospital. It’s too inefficient for my time to go to the hospital for my cases.” Dr. Badia can safely perform most cases in his ASC due partially to the presence of a cardiac anesthesiologist who formerly administered anesthesia for open heart surgery patients. “He knows how to handle patients with potential cardiac problems, and he knows which patients can be operated on,” says Dr. Badia. “The patients who do have surgery can have it done very safely.” More surgeries can also be performed at the outpatient level due to advances in postoperative pain care for patients, he says. For example, a recent patient received a shoulder replacement with a prosthesis at the ASC, and the patient went home with an indwelling catheter and a pain pump that connects directly to the nerves in the brachial plexus. The pump completely blocks the pain for two to three days, he says.
3. Hand surgeons continue to battle for reimbursement from payors. There are several reimbursement issues for ASC procedures, but one of the more contentious issues in reimbursement stem from a lack of payment for Medicare patients’ surgeries, says Dr. Badia. For example, Medicare does not reimburse ASCs for implants, which is problematic because hand surgery ofteninvolves many small implants such as those in the base of the thumb or a joint. “I end up not providing that kind of care because the system is not allowing me to perform those surgeries,” Dr. Badia says. Newer hand procedures involving arthroscopic surgery, moreover, are problematic because there are often no billing codes associated with them. “We get reimbursed very poorly as a result,” says Dr. Badia. “It’s like telling people, ‘Don’t innovate and don’t do things that are less invasive because there’s no precedent for it.'”
4. Hand surgery procedures can be marketed to patients nationally and internationally. Due in part to new procedures and online marketing, Dr. Badia’s patient base extends far beyond the local market in Miami. “Nearly 30 percent of my surgical practice is international,” he says. “I did a complex elbow reconstruction on a patient from Trinidad, operated on the shoulder of a patient from Ecuador, and then one from the Cayman Island in the same day.” He also markets to patients by publishing materials on the Internet and authoring articles about innovative hand surgeries, such as small joint arthroscopy for basal joint arthritis. “The traditional surgery for that is aggressive and painful, but I do it with two little holes,” he says. “If you publish materials about it, more patients seek you out.”
5. ASCs are more affordable for patients than hospitals. Patients are increasingly attracted to outpatient surgery centers because the surgeries tend to be more affordable than those in the hospital, and this is particularly beneficial for those who are uninsured, says Dr. Badia, whose recent patients also include those from Alaska, Wisconsin and Louisiana.