A Look Inside Urology ASCs

High-volume, short-duration, low-cost caseloads  require maximum efficiency to ensure profitability.

Already common in hospital outpatient departments (HOPDs), urology has become a profitable high-volume line for a relatively small but growing number of ambulatory surgery centers (ASCs).

Brad D. Lerner, MD, FACS, CASC, president of Chesapeake Urology Associates in Owings Mills, Md., oversees Summit ASC, which comprises 16 urology-focused ASCs, and is ASC medical director for United Urology Group (UUG), a management services organization that partners with urology groups throughout the U.S. to help develop their ancillary services, including ASCs. Its current affiliates are Tennessee Urology in Knoxville, Colorado Urology in Denver, Arizona Urology Specialists North in Phoenix/Scottsdale and Arizona Urology Specialists South in Tucson.

About 90% of the surgical cases Chesapeake Urology’s doctors perform are in its ASCs. “Basically, any case that can be done on an outpatient basis can be done at an ASC,” says Dr. Lerner of urology’s high-volume, short-duration, low-cost cases. “I don’t know many specialties where you can say 90% of all surgical procedures procedures can be done in an ASC — and 75% of the volume can be done under local anesthesia,” he adds.

Opportunity abounds

Gary Kirsh, MD, president of The Urology Group in Cincinnati, is also president, CEO and co-founder of Solaris Health Partners, a national platform for independent urology practices. He calls the Solaris network the largest provider of urology care in the U.S., and The Urology Group’s Cincinnati facility the largest independently owned urology-only ASC in the country, with a typical day involving up to 100 cases in eight rooms.

Dr. Kirsh says the Solaris model integrates all urology services a patient could need. “We have offices where we see patients as well as numerous ancillary facilities — not only ASCs but also pharmacy, radiation, clinical research and radiology services.”

Some surgeries performed at Dr. Lerner’s ASCs, such as transurethral resection of the prostate (TURP), penile implants and percutaneous kidney stone removals, not so long ago required multiday hospital stays, but he and likeminded urologists started pushing them to HOPDs — a process that went smoothly. The next step was shifting them to ASCs, where Dr. Lerner says they can be performed even more efficiently.

Dr. Kirsh agrees that ASCs are more efficient and less expensive sites of service than HOPDs. “ASCs are paid 60 cents on the dollar versus HOPDs for many procedures,” he says. “Increasing the number of procedures done in the ASC is in the interest of the public, both payers and patients.”

Dr. Lerner cites an estimate that, by 2030, 72 million people in the U.S. will be 65 and over, increasing the demand for urology services. “While we operate on people of all ages, urology services are certainly suited for people as they get older and have prostate or incontinence issues,” he says. Last year, exemplifying the growing critical mass around outpatient urology, Dr. Lerner’s UUG organization formed a joint venture partnership with Tenet Healthcare subsidiary United Surgical Partners International (USPI). The partnership provides UUG greater leverage with commercial payers, enhanced management and reporting capabilities, scaling of some general and administrative expenses, and improved efficiencies in staffing, inventory management and supply procurement. “We felt as we were continuing to grow nationally and encountering numerous challenges, it made sense to bring in a partner such as USPI,” he says.

A wealth of procedures

TOOL OF THE TRADE Devices for performing prostatic urethral lift procedures to treat benign prostatic hyperplasia, such as this one used by Dr. Douglas Grier in this 2020 photo, are commonplace at urology-focused ASCs.

Which urology procedures are safe to perform at freestanding ASCs? According to both doctors, the question really is which aren’t. “There are probably about 25 type of cases we do at our ASCs, with some one-offs here and there,” says Dr. Lerner. “But probably 95% of what we do falls within about 25 CPT codes.” The list includes cystoscopies, prostate biopsies, vasectomies, stone removals via ureteroscopy with laser lithotripsy or shockwave lithotripsy, minimally invasive procedures for benign prostatic hyperplasia (BPH), laser vaporization of the prostate, placement or removal of ureteral stents, transurethral resection of bladder tumors, percutaneous kidney stone removal, circumcisions, penile implants, and sacral neuromodulation for patients with bladder control issues.

Dr. Kirsh says much of the work at his Cincinnati ASC involves endoscopy. “Many procedures we do involve putting a scope into the urethra and doing something in the bladder, ureter or kidney,” he says. These include kidney and ureteral stone removals, BPH treatments, prostate resections, and even bladder cancer procedures. The facility also hosts somewhat more invasive non-endoscopic surgeries such as hydrocele removal, hernia, circumcision, penile prosthesis, female incontinence procedures, device implants for incontinence and lithotripsy.

What’s not safe to perform at an ASC? Dr. Kirsh points to any procedure that involves a high likelihood of needing a hospital stay for recovery, or that requires the support of a hospital for things like blood transfusion or access to an ICU. “People are pushing those boundaries,” he says. “A good example is robotic prostatectomy, which these days is the most common and least invasive means of removing the prostate for cancer. When robotics for prostate removal came on the scene some years ago, patients were admitted to the hospital after the surgery overnight.” Now, both doctors say some ASCs — not yet their own— are beginning to perform same-day robotic prostatectomies.

The biggest disqualifying issue for urology at ASCs largely revolves around the condition of the individual patient. “We have absolute and relative contraindications regarding comorbidities for surgical procedures in the ASC, typically cardiovascular issues related to heart function, because even though a patient may be cleared for surgery, doing the surgery in a freestanding ASC where you have no cardiology and/or vascular backup can be somewhat problematic,” says Dr. Lerner.

In addition, some patients’ anatomy isn’t well-suited for certain urology procedures at an ASC — for example, procedures for benign blockage of the urinary channel by the prostate. “If the prostate is particularly huge, there’s more risk of bleeding afterwards, so we want to keep that person in the hospital,” says Dr. Kirsh.

What it takes

Starting a urology line requires capital investment. Dr. Lerner says big-ticket items include a variety of flexible and rigid endoscopes for use in the lower and upper urinary tracts, a portable C-arm for intraoperative fluoroscopy and lasers to break up stones and treat benign prostate disease. Dr. Kirsh says that because urology revolves so much around endoscopy, fluoroscopy and video capability are paramount. “We need video so we can see what we’re doing, and fluoroscopy is intrinsic to doing a lot of these procedures, especially stone procedures,” he says.

“There are also significant disposable costs,” adds Dr. Kirsh. “When you take a stone out, for example, you use wires, baskets and other devices.”

Given this, Dr. Kirsh says that while running a urology line or single-specialty ASC can be profitable, it’s not profitable by default. He advises connecting with a consultant that knows the urology business well before launching a urology line, and modeling volumes carefully to confirm there’s an upside for you. “Facility reimbursement is not necessarily as rich as it is for orthopedics or some other specialties. You have a lot of implants in orthopedics, but we have some implants also in urology that are high cost,” he says.

Dr. Kirsh advises ASCs to avoid adding procedures where reimbursement doesn’t cover overhead. “That happens a lot,” he says. “Somebody will come to market with a slick new gizmo and procedure, but what Medicare wants to pay doesn’t cover your costs.”

Cost accounting is crucial. “When you do a procedure to remove a kidney stone, you need to document exactly what disposables were used in the electronic medical record,” says Dr. Kirsh, who adds that savvy leaders examine case cost trends by doctor. “You might need to point out to certain doctors that they are wasteful of resources by, for example, using too many wires and baskets to take out a stone, and counsel them to do it more efficiently. You need to pay attention to your case mix and your margins and do your best to track costs.”

Dr. Lerner says successful urology ASCs have policies and procedures followed to the letter by a well-trained, consistent, supportive staff. “If you manage and operate the center consistently, it really can flow very smoothly,” he says. He finds it typically may take two to three times longer to do a case in the hospital than in his ASCs because of his engaged, focused staff. “At the hospital, the staff may not necessarily be as efficient, especially from a support and room turnover standpoint. You may work with different staff who don’t understand your routine. At our ASCs, we’re working with the same people all the time.” Many of his staff even subspecialize in certain areas like prosthetics, percutaneous kidney stone removal or microsurgery.

“I’ve worked with the same nurse for 15 years on local anesthesia cases,” he says. “I joke that I don’t have to say a word to her all day. Every case goes off without a hitch because she understands what we’re trying to do. She knows how to prepare the case, how to set it up, how to break it down, how to turn the room over. If you can get that rhythm going where staff is aligned with your vision, things can go very smoothly.”

Dr. Lerner says that while anesthesia personnel aren’t required for many of his cases, it’s vital to establish a collaborative relationship with an anesthesia group that makes financial sense, especially given that specialty’s movement towards guaranteed daily subsidies. “You want to be extremely efficient with scheduling of your anesthesia cases,” he says.

Urology facilities can further cut costs on devices and disposables by engaging with vendors because of their volume, says Dr. Lerner. His centers sometimes acquire supplies and devices on consignment, for example. “We don’t pay for it until we use it, and we don’t have inventory sitting on the shelf that we’ve paid for,” he says. OSM