Outpatient Cardiology Update

What to consider when contemplating adding this emerging specialty to your ASC.

Even though some minor heart procedures have been taking place in outpatient settings for years, performing more complex same-day cardiovascular interventions is very much in its infancy.

That is starting to change, however, as Medicare and Medicaid are beginning to cover more of these interventions. There’s also an increased desire by patients to undergo these procedures in non-hospital settings — and cardiologists are working with strategic partners who pioneered outpatient cardiovascular centers to open new facilities.

Small but growing segment

Some of the country’s approximate 5,800 ambulatory surgery centers will be able to add a limited cardiovascular service line to their multispecialty mix, even though the work is highly specialized and can be challenging to incorporate. On a larger scale, independent cardiologists and health systems are partnering with the companies that have run cardiology-only ASCs, like National Cardiovascular Partners, as the migration to the outpatient arena begins.

While rare — it’s estimated there are only 50 or 60 such ASCs across the country — many of those are already involved and are working to expand the movement’s momentum and are excited about the future of covering even more new ground.

“We believe we are just beginning to see the promise and possibilities of outpatient cardiovascular care,” says Chris Churchill, BA, MBA, president of National Cardiovascular Partners (NCP), which operates 17 cardiology ASCs in seven states. “The ‘triple aim’ of providing better outcomes and improved experiences to patients, offering more independence and autonomy for physicians and delivering care at a lower cost to our health system will drive accelerated growth in the coming years.”

Regulatory hiccup

TWICE AS NICE ORs for coronary work must be about two times larger than standard operating rooms to fit equipment such as stationary C-arms and long radiolucent tables.

Outpatient cardiology began around 2006 in the form of peripheral angiography and interventions, and a small number of pacemaker and implantable cardioverter-defibrillator (ICDs) generator change outs. A major step forward took place in 2019, when the Centers for Medicare & Medicaid Services (CMS) added 17 cardiac-specific codes for diagnostic catheterization procedures to its ASC-approved list that were already being performed safely in hospital outpatient departments. The momentum carried into 2020, when six codes were added that allowed ASCs to bill for minimally invasive percutaneous coronary interventions (PCIs) such as balloon angioplasty and stent placements. In 2021, the migration continued with the funding of 11 more PCIs, including lower extremity intravascular lithotripsy and atherectomy.

“Commercial payers have been reimbursing ASCs for this work for years, but the CMS approvals were crucial, as more than half of the patients requiring a cardiovascular procedure are covered by Medicare,” says Kelly Bemis, RN, BSN, NCP’s chief clinical officer.

However, in 2022, CMS removed many of the new codes from the ASC-approved list. After a request to review some of the codes on an individual basis, a few were returned to the ASC-approved list this year, resetting the stage for outpatient cardiology surgery growth after the regulatory setback.

“We continue to lobby the federal government to approve more coronary procedures in a safe, high-quality outpatient setting,” says Ms. Bemis. “As long as we continue to demonstrate, through clinical data, that patients can be treated safely, I believe we will see many more cardiovascular cases migrating out of the hospital in 2024 and beyond.”

Key considerations

Existing multi-specialty ASCs can add the cardiology service line, provided they proceed in a cautious and thoughtful manner. “These ASCs could do some limited device work, such as loop recorder implants, and defibrillator and pacemaker generator changes without significant changes to their existing operating rooms,” says Ms. Bemis. “In addition, some peripheral vascular procedures can be done in a traditional OR with a mobile C-arm.”

Doing work beyond that requires additional space, specialized equipment and highly trained staff. The first step is to check your state’s rules and regulations. There are still many states that don’t allow outpatient coronary work, despite the CMS approvals. You’ll also need to understand your state’s requirements for expanding service lines. Certificate of Need (CON) states make such ventures lengthy and more difficult.

Adding cardiology isn’t as simple as adding some other specialties to an ASC. A cardiovascular interventional suite is comprised of three rooms. The operating room must be large enough to house a large, fixed imaging system, a long radiolucent table and various ancillary equipment. The second space includes an area that serves as a separate equipment room that runs the fixed unit and the third is a control room for monitoring the patient. So, a four- or five-OR facility would have to be willing to give up two of those rooms to make room for one new cardiology suite. A healthy volume of cases is crucial to making the model work, as the room isn’t conducive to use for other types of surgery.

While emergency events are rare, when they do occur you must be prepared. An additional dedicated crash cart will be kept in the cardiovascular suite, as well as an intra-aortic balloon pump, a pericardiocentesis kit, temporary pacemaker, and, if possible, covered coronary stents.

Staffing is among the biggest challenges, as highly skilled and experienced cardiovascular nurses and radiology technologists are needed, which can be tough to secure. Those seasoned professionals are sparse, considering hospitals in large cities with 15 to 20 ORs might have only one or two cath labs — if they have any at all. “You can’t just assume that existing ASC staff can be cross-trained and quickly adapt to cardiology,” says Ms. Bemis. “You need highly specialized teams with years of experience.”

Relying on trusted partners

SUITE SETUP Interventional suites are divided into three areas: the procedure area, a control room and an equipment space.

NCP looks to partner with independent physicians or cardiology practices to start new ASCs and find the staff to work there. Sometimes a health system is involved as a third party if that makes sense in a particular market.

A cardiology ASC allows its physicians to perform a spectrum of cardiac procedures safely and successfully in the outpatient center where high-quality personalized care can be delivered in ways that are easier and more convenient for patients than navigating through a big health system. The arrangement also frees up the hospital and its staff to focus on the most complex coronary cases.

The centers that NCP manage are a mix of ground-up new construction projects and office-based cath labs converted to ASCs. In addition to acting as developer and construction project manager, NCP takes the lead on licensing, accreditation, equipment purchasing and steering through the regulatory maze. Once opened, NCP has a strategic sourcing team that essentially acts as a group purchasing organization, as well as a payer contracting team to negotiate commercial insurance contracts and a government affairs team to work with CMS. The NCP clinical team runs staff education and training programs, as well as sharing industry best practices. The company also covers the facilities’ HR and IT functions.

“I haven’t yet met a physician who enjoys navigating the complicated state and federal licensing and regulatory processes, managing site construction or negotiating with device manufactures,” says Mr. Churchill. “We have the foundation and the expertise to take care of all of that, so they can focus solely on caring for their patients and attending to their practice.”

Mettle-proving pandemic

Outpatient cardiology faces the usual challenges inherent to the field even in the best of circumstances, yet it’s how these specialty ASCs performed in the first several months of the pandemic in 2020 that is perhaps the biggest cause for optimism for future expansion. Hospital outpatient departments canceled all elective surgeries for months.

As the country soon learned, however, some procedures are “elective” in name only. A bunionectomy, for example, is obviously nonemergent and could wait. Postponing cardiological diagnostic and intervention cases, on the other hand, can have serious repercussions.

So NCP’s surgery centers provided a place for cardiologists to perform peripheral vascular interventions, pacemaker implants, stent placements and catheterizations for their patients who needed them.

We are just beginning to see the promise and possibilities of outpatient cardiovascular care.
Chris Churchill, BA, MBA

Doing so provided an added plus for hospitals, which could then dedicate staff to treat COVID patients in ICUs and conserve critically needed personal protective equipment.

“We’re very proud that we were able to accommodate those cardiovascular cases from the hospitals and provide essential care to their patients,” says Ms. Bemis. “I think what we did during the pandemic brought to light how well we can handle this work and illustrates how many areas of the country still need convenient access to this essential care.”

Mr. Churchill says he looks forward to the years ahead when outpatient cardiology centers are allowed to safely perform even more complex procedures such as structural valve repairs and replacements.

“We are incredibly proud of what we and our physician partners have been able to accomplish, and honestly, we are just getting started,” says Mr. Churchill. “The industry is evolving very quickly and clearly recognizing the safety, efficacy and advantages of outpatient cardiovascular care. This is great for us, our physician partners, for the broader health system by reducing cost of care, and most importantly, it is a huge win for our patients.” OSM