Tag: TDABC

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Which spine surgeries belong in the ambulatory surgical center?

Neurosurg Focus 60(4):E2, 2026

This study uses time-driven activity-based costing (TDABC) to quantify true costs of common cervical and lumbar spine procedures performed in an outpatient hospital setting and compares these costs to Medicare ambulatory surgical center (ASC) reimbursement. Findings show microdiscectomy, lumbar laminectomy/decompression, and ACDF most often fall below Medicare ASC reimbursement, while endoscopic discectomy and posterior lumbar fusion frequently exceed reimbursement.

The analysis identifies supplies and personnel as primary cost drivers, highlights heterogeneity in Medicare ASC facility fees that do not reflect procedural complexity or number of levels, and argues that reimbursement reform is needed to expand the range of spine procedures economically feasible in ASCs.

Objective Identify spine procedures that are economically suitable to move from an outpatient hospital setting to an ambulatory surgical center (ASC) by comparing true costs (via TDABC) with Medicare ASC reimbursement.

Methods Retrospective cohort (2020–2024) of outpatient hospital spine cases with length of stay ≤ 1 day; procedures: cervical disc arthroplasty, ACDF, lumbar laminectomy/decompression, microdiscectomy, endoscopic discectomy, and posterior lumbar fusion; primary outcomes were total costs and proportion of cases with cost below Medicare reimbursement; regression adjusted for age, sex, BMI, and number of levels.

Costing approach (TDABC) Episode mapped across preop, intraop (wheels-in to wheels-out), and recovery phases; costs included supplies (consumables, implants, meds), personnel time (per-minute rates by role), and overhead.

Key cervical finding ACDF was more often below corresponding ASC reimbursement than cervical disc arthroplasty (71.8% vs 40.0%); adjusted odds favored ACDF (OR 5.3, 95% CI 3.0–9.4).

Key lumbar cost levels Mean lumbar episode cost was $4,640 ± $6,475; posterior lumbar fusion had the highest mean cost ($25,042 ± $15,645) and microdiscectomy the lowest ($3,233 ± $2,142).

Key lumbar viability finding Microdiscectomy (95.3%) and laminectomy/decompression (94.5%) most often cost less than reimbursement; endoscopic discectomy (31.0%) and posterior lumbar fusion (30.0%) were least often below reimbursement; adjusted odds were higher for laminectomy/decompression (OR 6.0) and microdiscectomy (OR 4.7), and far lower for endoscopic discectomy (OR 0.01) and fusion (OR 0.02).

Conclusions (procedures best suited for ASC under current payments) Microdiscectomy, lumbar laminectomy/decompression, and ACDF appear most economically suitable for transition from hospital outpatient to ASC in existing payment structures.

Reimbursement implication Broader feasibility in ASCs likely requires reimbursement reform, given mismatches between procedural complexity/resource use and Medicare ASC payment patterns.

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Does Transforaminal Endoscopic Lumbar Discectomy Provide More Value than Microdiscectomy?

Operative Neurosurgery 29:209–218, 2025

Microdiscectomy (MD) provided greater value than transforaminal endoscopic discectomy (TED) for lumbar disc herniations at this institution, with higher improvement in patient-reported outcomes per dollar spent and shorter operative times. TED had higher costs and a steeper learning curve, but similar reoperation rates.

• This study compares the value of transforaminal endoscopic lumbar discectomy (TED) and microdiscectomy (MD) for lumbar disc herniation using a novel Operative Value Index (OVI).

• OVI measures percent change in Oswestry Disability Index (ODI) per $1000 spent intraoperatively, integrating patient outcomes and time-driven activity-based costing.

• MD had a significantly higher OVI, lower operative times, and lower intraoperative costs than TED; no significant difference in length of stay or reoperation rates was found.

• Only 43.5% of TED cases achieved clinically important improvement (MCID), compared to 66.3% for MD.

• TED was mainly used for foraminal herniations and had a higher proportion of older patients and comorbidities.

• Longer OR setup times and higher costs for TED may relate to the learning curve and surgeon experience.

• Authors suggest OVI is a practical, real-time value metric but note limitations including small TED sample size and retrospective design.

• Future studies should assess long-term outcomes, total episode costs, and track OVI as surgeons gain TED experience.

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How Do the True Intraoperative Costs of Endoscopic Diskectomy Compare With Microdiskectomy for Lumbar Disk Herniations?

Operative Neurosurgery 27:690–697, 2024

Endoscopic lumbar diskectomy (ED) is a minimally invasive option for addressing lumbar disk herniations. With the introduction of value-based care systems, assessing the true cost of certain procedures is critical when creating reimbursement models and comparing procedures. Here, we compared the costs of performing a microdiskectomy (MD) and ED using time-driven activity-based costing.

METHODS: Total cost for the intraoperative episode was calculated using time-driven activity-based costing methodology. Individual costs were obtained by direct observation and electronic medical records and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. A retrospective analysis was performed on 202 patients who underwent lumbar diskectomy through either MD (n = 167) or ED (n = 35) from 2018 to 2022. Personnel cost was calculated by multiplying the cost per unit time for each personnel type by the length of time spent in the operating room. Supply cost was calculated by aggregating the cost of all individual supplies, from medications to consumables to surgical trays, used during the case. Univariate and multivariable regression analyses were performed comparing the costs between these procedures.

RESULTS: The average intraoperative cost per case for ED and MD was $3915 ± $1025 and $3162 ± $954, respectively. Multivariable regression analysis revealed that ED had higher total cost ( β -coefficient: $912 ± $281, P = <.01) and supply cost ( β -coefficient: $474 ± $155, P = <.01) than MD. When accounting for surgeon as a covariate, however, total cost (P = .478) and supply cost (P = .468) differences between ED and MD were negligible.

CONCLUSION: ED has shown to be a better value option in addressing lumbar disk herniations, mostly because of advantages in perioperative care. Here, we show that when correcting for surgeon-level effects, the cost between the two procedures is statistically insignificant, reaffirming the value provided by ED.

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