ISASS President Steven Garfin, MD, has written a response to the Centers for Medicare & Medicaid Services Division of Outpatient care regarding agency considering the removal of cervical disc arthroplasty from the Medicare “Inpatient Only” list. The letter is copied below and is also available in PDF format.

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April 20, 2012

John McInnes, MD, JD1
Director, Division of Outpatient Care – C4-01-15
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Dr. McInnes:

I am writing to you and CMS on behalf of the International Society for the Advancement of Spine Surgery (ISASS). ISASS is an international, scientific, and educational society organized to discuss and assess existing strategies and innovative ideas in the clinical and basic sciences related to spine surgery to enhance patient care.

We are aware that the CMS Division of Outpatient Care is considering the removal of cervical disc arthroplasty from the Medicare “inpatient only” list.  We support this move, just as we believed that the removal of the cervical fusion codes 22551 and 22554 from the “inpatient only” list earlier this year was a clinically sound decision for our patients.

There are several reasons that an outpatient setting may be a good choice for select (but by no means all) patients having this surgery:

• Convenience – appropriate patients, recovering at home, often make “easier” recoveries than those in the inpatient setting.
• Lower overall cost – since there are no hospital room and related hospital charges, costs can be lower for outpatient than inpatient surgery.
• Scheduling – in a hospital setting, emergency surgeries and procedures that take longer than expected can delay scheduled surgeries. An outpatient setting can generally stay within a set schedule, and this leads to considerably higher patient satisfaction.

There will, however, always be patients benefiting from in-hospital care, such as those with co-morbidities, airway disorders, neck swelling, bleeding disorder, other anatomic/metabolic issues or concerns, and/or poor home situations.  ISASS supports Medicare policies that will help spine surgeons deliver better and novel treatments to our patient population.  Our experiences have shown us that cervical disc arthroplasty in selected patients can be safely performed in the outpatient setting, just as cervical fusion is now being conducted.

We feel strongly that age, alone, should not be a reason to disqualify an older patient from having cervical disc arthroplasty in an outpatient setting.  Improved technology and advances in anesthesia and pain control have improved patient satisfaction in the peri-operative period, and studies show many patients have a preference for, and satisfaction with, post-operative recovery in the home setting.  We also recognize that each patient, elderly or otherwise, must undergo a thorough medical evaluation before any surgery to determine the best surgical setting for that individual.

Thank you for allowing ISASS the opportunity to comment on this potential action by the Division of Outpatient Care.  We look forward to the proposed rule.

Sincerely,

Steven R. Garfin, MD