March 17, 2021

Outpatient total joint programs can benefit from the addition with proper planning and efficient operations.

FROM THE HIP CMS' addition of total hip replacements to the ASC-approved procedure list provides an enormous growth opportunity for surgery centers and increased access to care for patients.

The Jan. 1 policy shift by the Centers for Medicare & Medicaid Services (CMS) that moved outpatient total hips to the ASC-approved procedure list clearly affords outpatient total joints programs across the country a tempting opportunity to increase volume at their facilities. But do more cases always equate to more profitability?

Not necessarily, according to Darci Nagorski, CEO of St. Cloud (Minn.) Surgery Center, who suggests that even established outpatient total joints programs should proceed with caution, as Medicare's reimbursements for the procedure are lower than those from private payers. "The keys to moving forward with success are good patient selection, efficient staffing, solid relationships with implant vendors and consistent ongoing reimbursement negotiations with the private payers," says Ms. Nagorski.

The migration of these procedures from hospitals to ASCs will benefit older people in your community who are in pain, and who your facility and the physicians who operate there are committed to helping. However, Ms. Nagorski notes that not all Medicare beneficiaries are healthy enough to have total hip procedures performed in surgery centers, as patients are generally discharged around four hours after they leave the OR. Patient selection is more important than ever with total hips, given the fact that the prospective patient pool will likely have more disqualifying comorbidities. Managing patient expectations by educating them preoperatively and managing their pain with nerve blocks will be crucial as well, she says.

Relationships with vendors are also vital to success with total hips. A total joints program partially funded by Medicare must be run as efficiently as possible, as it survives on thin profit margins. Ms. Nagorski suggests working closely with vendors to secure reductions in implant prices and supplies. Get a capitated price for implants your doctors can confidently use in Medicare and non-Medicare patients. Involvement with a management company could help your center secure small payment increases from private payers as you increase the number of cases paid at fixed Medicare rates.

"If facilities follow these strategies, they could expect to see profit margins of about $2,500 to $3,500 per case for Medicare total joints," notes Ms. Nagorski.

As CMS authorizes increasing numbers of procedures performed at ASCs, how can your facility best tap into this service line?

HEART HEROES Cardiac ASC ORs require staff who are highly specialized and experienced in the discipline and collaborate well with their team.

Driven by reimbursement trends and the steady beat of progress, cardiac surgery is the next frontier for same-day surgery. The service line is packed with promise, but ASCs must fully understand the specifics of cardiovascular care to best determine if launching the line will be both profitable and safe.

Before 2019, CMS reimbursed ASCs only for implantations of defibrillators and pacemakers. In 2019, it added 17 cardiac-specific ASC codes for diagnostic cardiac catheterization procedures already performed in HOPDs. Six more codes came online in 2020, adding minimally invasive procedures referred to as percutaneous coronary interventions (PCI), specifically placing stents and angioplasty. This year, 11 more complex PCI procedures were added, including lower extremity intravascular lithotripsy and atherectomy.

Kelly Bemis, RN, BSN, chief clinical officer at Azura Vascular Care and National Cardiovascular Partners, operates cardiac ASCs across the country. Fifteen years ago, her company began building cardiac ASCs in states where commercial payers and regulations were accommodating. Here's her advice on what it takes to build and operate a cardiac ASC.

• Adhere to state regulations. Your local government may or may not allow cardiac procedures at ASCs, even if CMS will pay for them. As CMS continues to add cardiac ASC codes, however, states are reacting in turn by licensing the procedures.
• Fixed C-arms are required. The main piece of equipment needed is a permanently fixed C-arm designed for cardiac procedures that mounts to the ceiling or floor. Smaller mobile units are not suitable for cardiac procedures, says Ms. Bemis. All told, the required capital equipment — as well as an ultrasound machine, micropuncture needles and an assortment of sheaths, guidewires and stents — can cost upwards of $1 million, she says.
• Plan additional space. To house the fixed C-arm and other equipment, you'll need more room to move than found in a traditional OR. Most of Ms. Bemis' ASCs have just one or two ORs, referred to as interventional suites, whose walls are lined with lead due to the heavy use of fluoroscopy. These ORs consist of three distinct spaces: the main OR with a fixed C-arm, radiolucent table and ancillary equipment; an equipment room; and a control room. "You basically need the square footage of two traditional ORs to have enough space," says Ms. Bemis.
• SPD isn't necessary. Supplies used at Ms. Bemis' centers are almost exclusively single-use. "For the most part, we use disposable instrument trays, which have lowered concerns and risks surrounding infection control," she says. "In most of our centers, we didn't build an SPD." For the few reusable instruments and supplies involved, her centers contract with third-party vendors or local hospitals for reprocessing.
• Highly specialized staff are required. "It's a small pool of qualified providers you're pulling from, with a lot of entities trying to pull from it," says Ms. Bemis. "You need experienced, well-trained cardiology nurses and a dedicated radiology tech, which most traditional ASCs don't have." Because the degree of knowledge and collaboration necessary in cardiac ORs is so high, it's not the type of discipline you can simply assign to existing staff. "It doesn't really translate," says Ms. Bemis. "You can't cross-train OR nurses and make them cardiology nurses." Of course, she adds, "You want to work with committed cardiologists who are willing to bring appropriate outpatient cases to your facility."
• Choose a business structure. For regulatory reasons, starting a cardiac ASC in most states requires choosing one of two models: co-management or hybrid. Under co-management, an ASC contracts with a cardiovascular medical group to develop, implement and manage a program within the facility. Under hybrid, an office-based laboratory (OBL) — essentially an office-based version of cath labs found in hospitals — is co-located within the ASC facility. Under the more popular hybrid model, a facility must alternate as an OBL or an ASC on different days, or at different times of the day. Each must maintain separate tax IDs and National Provider Identification (NPI) numbers, medical records can't be accessed by the other, and each entity must bill at different rates.

When starting a cardiac ASC, Ms. Bemis suggests ramping up slowly with diagnostic cases or defibrillator and pacemaker work until you can safely and confidently move into interventional procedures. Safety is paramount because of the relative vulnerability of the cardiac patient population. "They often have more than one comorbidity," she says. "They tend to be older, likely have blood pressure issues and can even have some peripheral vascular disease or diabetes."

Because freestanding surgery centers often don't have direct access to hospital services, safety measures must be strict. "We're extremely careful," says Ms. Bemis. "Our adverse event rate is less than half of one percent, but we always have emergency equipment available."

Speed and accuracy in the OR planning process are critical components of a project's success.

Credit: Getinge^™
Example of Getinge's OR3D Software.

ASC administrators continue to evaluate their facilities' operational strategies in the wake of the COVID-19 crisis. This includes the need to add capacity to handle a backlog of cases, while accommodating the anticipated increase in future patient volumes. Statistical trends strongly suggest that there is an increased likelihood many hospitals in hot spot areas will continue to be forced to redirect elective surgery patients to local ASCs to make room for coronavirus patients.

Hospitals also are gearing up to capitalize on this trend. According to a survey conducted by Avanza Healthcare Strategies and HealthLeaders Media, "many hospitals and health systems are looking to build their own ASCs as well as convert Hospital Outpatient Departments (HOPDs) to ASCs."

In fact, surveyors found that 76% of larger hospitals reported increasing their investments in ASCs.¹

In this environment, speed and accuracy in the OR planning process are critical components of a project's success. Traditionally, architectural and equipment planning firms work directly with ASC management, clinicians and select equipment suppliers to design and populate the OR space. However, there is growing evidence that budgetary constraints and compressed timelines are driving equipment planners to the sidelines as more and more ASCs rely on alternative value-added resources, including Getinge's Planning and Design team.

Getinge understands that even a minor misplacement of surgical lights, tables, booms and ancillary equipment, in association with each other, can have unanticipated long-term workflow and clinical consequences. In this respect, Getinge's exclusive OR3D planning tool helps everyone visualize how the actual installation will look and function.

3D renderings simplify the analysis of the entire OR footprint from wall-to-wall and floor-to-ceiling. OR3D software reveals spatial relationships among clinicians and actual equipment configurations to enhance workflow, clinical efficacy and provider comfort.

In addition, Getinge's OR3D software allows for real time changes in equipment configurations to limit the amount of additional time/resources needed for final project sign-off which, in turn, helps keep the project stay on within its projected timeline.

"Getinge fully understands and appreciates the importance of pre-PO design and planning services. Here at Getinge, we prove this commitment by having our dedicated Healthcare Planning & Design team involved in every step of the design process. From early planning/budgeting in the schematic phase to real time changes with our proprietary OR3D software we're fully equipped and able to meet any of your planning and design needs," says Tim Litwin, Senior Healthcare Planning & Design Manager at Getinge.

Getinge's consultative and collaborative approach has been constantly refined through the design and planning team's participation in more than 950 OR installations worldwide.

The pandemic highlighted the role ASCs play in the delivery of safe and cost-effective care.

It's an exciting time to run an ambulatory surgery center. Many of the short-term changes ASCs made during the pandemic will have long-lasting and positive effects. Facilities also remain well-positioned to capitalize on the growing demand for outpatient surgical care. Elizabeth LaBouyer, executive director of the California Ambulatory Surgery Association, recently provided insights into how ASC leaders expertly adapted to unpredented circumstances over the past year, and how the pivots they made could improve patient care for years to come.

What pandemic-related challenges have surgery centers been forced to manage?

There have been a series of them, including ensuring access to PPE, responding to changing guidelines and shutdowns of elective surgical procedures. Surgery center leaders quickly designed and implemented new protocols to reduce the risk of COVID-19 exposure for patients and staff, and managed budget challenges that came from reduced caseloads. Additionally, ASCs had to adopt new virtual systems to communicate with patients and their caregivers differently to reduce unnecessary in-person interactions. ASCs typically have a high volume of cases and rapid OR turnaround times, so it was a business shift to plan for extra time between procedures, and deal with more canceled cases due to COVID-19 screenings.

How will overcoming these challenges ultimately improve the care ASCs provide?

Some of the remote communication practices have been very useful for patients. ASCs are sending them reminders and updates by text message and informing their caregivers of the status of procedures. I'm certain that many of these new communication practices will remain in place. ASCs are designed to be nimble and responsive, so they were able to pivot quickly in handling scheduling adjustments and implementing new safety protocols specific to COVID-19. The challenges of the past year have provided new opportunities to rethink infection prevention practices and ensure the safest space possible for surgical procedures.

How will the pandemic positively impact utilization of ASCs?

Surgery centers have provided a safe alternative site for surgical procedures that kept patients out of hospitals who didn't need to be there. That's been good for many reasons. As hospitals faced a surge of COVID-19 patients, ASCs were able to take on some cases the hospitals didn't have the resources to handle. This coordination between hospitals and ASCs on a regional level helped address community care needs and increased awareness of how ASCs serve a critical role in the healthcare delivery system. Moving forward, hospitals will increasingly view ASCs as important partners.

Additionally, from the consumer perspective, ASCs provided a space for surgical procedures that was free from COVID-19 patients, and that was an attractive option. Some patients who may have previously seen hospitals as a preferred setting may now view ASCs as a safe alternative. It's likely we will see a continued shift of more patients who can be safely treated in an ASC make that choice.

What procedures will migrate from inpatient settings to ASCs in the next five to 10 years?

CMS has added 267 codes to the ASC Covered Procedures List for 2021 and is moving toward elimination of the inpatient-only list by 2024. In 2020, Medicare began paying for total knee replacements performed in ASCs. This year, Medicare added total hips to the ASC-approved list. The increasing volume of total joints performed in ASCs represents significant cost savings for patients, Medicare and private payers. Additionally, Medicare has approved a series of coronary intervention procedures for ASCs, a move that opens up great opportunity for diagnostic and preventive interventions to be done more efficiently.

Research has shown that the utilization of ASCs will result in a projected annual savings for Medicare of $12 billion by 2028. But it's not just Medicare that wants the cost savings. We're seeing private payers such as Anthem and UnitedHealthcare enact policies that direct surgical procedures into the ASC setting unless there is a reason based on patient acuity or geography that the case must be done in an HOPD.

How will the relationship between hospitals and ASCs evolve in the years ahead?

We're definitely seeing increased collaboration rather than competition between the facility types. Through the course of the pandemic, ASCs had to coordinate on a local level with county health officials and healthcare systems to track resources and make plans to address surges in COVID-19 patients. The pandemic accelerated the movement away from large traditional institutions, and expedited the move toward technology, telemedicine and ASCs — and showed the transition can be successful. Health systems are recognizing they must have ASC connections moving forward, and will likely pursue additional investments and partnerships in the future.

Researchers stress that cost savings should never come at the expense of quality or safety.

For many ASCs, spine is a tempting service line to add. For others, the procedures have been part of their case mix for years. A new study highlights the growth potential of performing spine procedures in facilities primed to provide economical and patient-friendly care.

It started a while back, actually. Between 2001 and 2010, as the number of ASC ORs increased by 60%, so were the numbers of spine procedures being performed in them. A team from Rush University Medical Center in Chicago and the University of Toronto studied National Survey of Ambulatory Surgery data and found dramatic rises in the utilization of ASCs for spine procedures between 1994 and 2006; 340% for intervertebral disc disorders and more than 2,000% for spinal stenosis.

These numbers, while not current, show that the groundwork for spine surgeries in ASCs was laid long ago. It confirms the overall value proposition of ASCs to provide safe, efficient and cost-effective treatment options for patients and payers, provided patients are selected appropriately and carefully. The researchers note that ASCs have the advantage of being often smaller and more specialized than HOPDs, with staff who are infinitely familiar with the specifics of the procedures the ASC performs. Patients, particularly those with high co-payment insurance plans, are drawn to ASCs because the lower overall cost of care results in a relative decrease in their out-of-pocket expenses.

The researchers note "a substantial body of data have emerged to support the safety of certain spinal procedures, including lumbar discectomy and decompression procedures." The problem, they say, is that current ASC quality reporting regulations "fall woefully short in their comprehensiveness of quality of surgical and medical care, and the data available in the literature is drawn predominantly from case-series of highly selected patients and comparative cohorts with inherent biases and often ambiguities in the definition of 'outpatient.'" As a result, they say, healthcare providers and policy makers still lack a true, full picture of the actual safety of spinal procedures performed in ASCs.