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opioid, we will provide injections and cutting-edge treatments where they are needed and will be most effective. With our ASC, we want a place to con- trol how that treatment is delivered and ensure it is provided in the most evi- dence-based way possible.”


Numerous New Treatments One treatment Fujinaka is particularly excited about providing is pain relief through the use of spinal cord stimu- lators. “These are like pacemakers for people’s pain. Instead of going into the heart, we put the pacemaker leads next to the patient’s spine. They essentially offer people an on/off switch to 75 per- cent or more of the pain in their back and lower extremities.” Mowles says she has seen a recent


surge in the usage of spinal cord stimula- tors in ASCs. “This technology seems to work really well with the right patients.” Such patients, Fujinaka says, tend to be those with lower extremity pain generated by spine issues. “There is a surprising number of people with such pain brought on by problems like her- nias and spinal arthritis. When you can isolate that pain, spinal cord stimula- tors can deliver a wonderful therapy.” Another procedure Fujinaka expects his patients to appreciate uses cooled radiofrequency (RF). “It is a phenom- enal treatment for spine arthritis,” he says. “It gives people almost six months to a year of relief. We believe there are little nerves in the back that get dam- aged or hurt by spinal arthritis. When providing other treatments, these little nerves would often get missed because we lacked a ‘magic wand’ to see where they were located. With cooled RF, we can target the nerves precisely.” Fujinaka says his ASC, like many,


will provide fluoroscopy-guided injec- tions. The ASC also will offer ultra- sound-guided procedures. “With ultra- sound, we are able to isolate specific nerves and then cover them in pain medicine,” he says. “Once I have put medicine on the nerve, I can follow


ASCs are where pain management belongs. … Invasive procedures do not belong in an unregulated environment. ASCs have the policies and procedures for infection control and safety that help ensure patients receive quality care.


— Amy Mowles Mowles Medical Practice Management


that up with a stimulator smaller than a silver dollar that I can place right next to the nerve. The ability to target indi- vidual nerves causing pain is a very exciting development.” Look for other new procedures to


make their way into ASCs in the near future, Mowles says. One that she highlights as receiving increased inter- est from pain management physicians is ketamine infusions. “At the moment, this is an office procedure but it should inevitably become an ASC procedure. The challenge is that it is a time-con- suming treatment, so ASCs will need to decide whether it is worth tying up an operating room (OR) to provide it.” Other types of procedures Mowles says are showing up more frequently in ASCs include stem cell and plate- let-rich plasma injections. “These are considered experimental, so there is no valid CPT code associated with them yet. That means they must be self-pay procedures. If you have chronic pain patients who trust their providers and providers say they can give relief with one of these treatments, many patients would be willing to pay for it.”


A Bright Future Underutilized ASCs would be wise to consider adding pain management, Pennell says. “As newer pain proce- dures become more recognized in the


marketplace as viable treatments and receive payer approval, ASC volume will increase. Surgery centers are a bet- ter, safer place for most procedures. If I am in an ASC with open OR time and looking to boost margins and increase efficiencies, pain management would definitely be a focus.” ASCs that want to provide new treatments should engage in discus- sions with their payers. “ASCs can do well with cash-pay patients, but most case volume will ultimately come from patients with insurance,” Mowles says. “Speak with payers about the types of procedures you plan to add and why they are a good fit.” Some ASCs providing pain man-


agement might need to reexamine their existing payer contracts, she adds. In some instances, contracts might cover newer procedures but in a manner that does not make performing these treat- ments financially viable. “We have seen ASCs that, for


example, were not initially performing spinal cord stimulators, so they did not negotiate them effectively,” Mowles says. “These procedures were placed in a payment group that bundled the cost of the implant into the reimburse- ment. When ASCs decided that they wanted to offer these procedures, they needed to go back to their payers and request a carve out for the implant. The good news is that many payers have been receptive to this request.” Pennell expects payers to increas- ingly embrace ASCs as the most appro- priate setting for pain management. “As we saw with GI, payers will help drive the movement of procedures toward the ASC space. More individuals practicing pain management are looking for treat- ments that better manage or even cure rather than provide a quick fix, which is what payers and patients are looking for. ASCs are the most logical place for these services as they can provide the best outcome for everyone.”


ASC FOCUS FEBRUARY 2019 | ascfocus.org 13


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