More ambulatory surgery centers are bringing in higher acuity cases, such as total joint replacements and spinal procedures, but it takes a considerable amount of time and resources to lay the foundation for a successful program.
Here are five important considerations for ASC owners and operators as they consider the transition:
Patient safety and selection
Patient selection is the most important considerations because these cases have a higher potential for risk.
"It is imperative for ASCs to establish a steadfast patient selection criterion that determines which patients can undergo higher acuity procedures in the ASC and which should undergo these procedures in a hospital," says Jessica Nantz, president of Outpatient Healthcare Strategies. "For example, patients with comorbidities or a history of significant health issues, such as cardiac problems, are not likely appropriate surgical candidates for the ASC."
High body mass index and patients with pain medication dependence are also at higher risk for complications and may be better off in the hospital setting, according to Ms. Nantz. She suggests forming a committee with physicians and clinicians to develop the patient selection criteria.
"Make sure you have determined whether there are instances when you would not allow physicians to perform these cases in your ASC and ensure your schedulers and the physicians' offices are aware of these rules," says Ms. Nantz. "ASCs must always prioritize patient safety, even if it means less patient volume."
Further steps for identifying the right patients and ensuring patient safety include:
• Discussing anesthesia levels with physicians and developing appropriate protocols around these anesthesia levels
• Develop strict safety protocols, including for infection and risk management
• Plan for postoperative care
• Develop education for home caregivers and physical therapists
Sometimes physicians already using the center will be able to transition their higher acuity cases to the outpatient setting; other times ASCs may need to recruit new surgeons in the community with the skill and expertise for less invasive procedures. The clinical staff is also an important element to successful cases.
"ASCs will want to recruit physicians and/or utilize existing partners who feel comfortable performing the procedures in an outpatient setting, and specifically in the ASC," says Ms. Nantz. "ASCs must ensure the clinical staff has been fully and properly trained to support the physicians performing these procedures. If the numbers are favorable and the ASC moves ahead with the transition, it is worthwhile to have the physician performing the higher acuity cases to walk and talk through the procedure multiple times with the clinical staff and address any questions they might have."
One of the most common mistakes Ms. Nantz sees ASC leaders make is rushing to do cases once they find a physician willing to perform them. While it's great to have the service available, issues could arise without the proper pieces in place.
Ms. Nantz advises ASCs not to move ahead with scheduling cases until:
• Patient selection criteria is established
• Staff are educated
• Necessary equipment is acquired
• Policies and procedures are developed for preop, postop and emergency care
"ASCs would be wise to carefully conduct their due diligence into the new cases," says Ms. Nantz. "Ask the physicians to project their volume and then assume the figure will be at least 30 percent lower. Speak with payers to determine whether they will cover the cost of the cases. Speak with your suppliers and GPOs to determine exactly what supplies will cost. Make sure there's a positive return on investment. If the numbers don't add up favorably for the ASC, these cases could hurt the facility financially."
Another important consideration is operating room flow. Keep in mind higher acuity cases often take longer than lower acuity cases. "ASCs will want to determine whether it is in the ASC's best interest to tie up an operating room for a longer period of time for a single case or whether that OR can be used more effectively for more lower acuity cases," says Ms. Nantz. "The ASC must project enough volume of these new cases to justify the investment in equipment, training and other preparation costs."
The ASC may need to add overnight stays. There are also federal and state regulations to consider when bringing new cases into the surgery center. In some states, ASCs are able to keep patients for 23-hour stays to monitor their recovery; others prohibit overnight stays.
"Check with your state health department on any regulations and requirements for 23-hour stays," says Ms. Nantz. "If 23-hour/overnight stays are permissible, evaluate your special and flow needs and assess what length for clinical shifts — eight, 10 or 12 hour — make the most sense."
If the center does decide to move forward with higher acuity cases, negotiating the appropriate payer contracts is a crucial next step. Determine whether the payer will cover the new procedure and whether you can achieve appropriate rates. This requires ASC owners and operators to analyze all costs associated with the procedure, including implants, equipment and staffing.
"Reimbursement — or what payers and patients pay — must exceed the total cost of the procedure, have additional profit, and must bring in enough volume to cover the cost of adding the procedure and earn enough to justify the time and money invested in the program," says Ms. Nantz.
When the appropriate contract is in place, provide coders and billers with necessary education to bill for the new procedures.
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