Ambulatory surgery centers are now able to bring higher acuity cases than ever before. It's easiest for multispecialty centers already performing similar procedures to add in a new specialty, or for single-specialty centers to capture higher acuity cases within the same specialty.
"The multispecialty centers are better equipped to take on these new cases, especially if they are doing the specialty already," says Kelli McMahan, RN, CASC, vice president of operations for Pinnacle III. "Centers that think progressively and ahead of the times, who maintain high quality standards and a great staff, will be the most successful."
Five of the most attractive specialties and procedures for 2014 are:
• Orthopedics — total joint replacements
• Neurosurgery — spinal fusions/disc replacements
• Urology — vaginal sling procedures
• Ophthalmology — retina surgery
• General surgery/ENT — partial thyroidectomies, parathyroidectomies
"Operationally, it's not too difficult to add within the same specialty. For example, if you have an orthopedic surgery center, it's a matter of setting up guidelines and making sure you have the appropriate equipment for total joint procedures," says Ms. McMahan. "If you have to purchase equipment, it will be paid for in a reasonable amount of time because these cases receive higher reimbursement."
However, there are several things ASC owners and operators must consider when adding a new specialty; it isn't as easy as inviting the surgeons to bring their higher-acuity cases in the next week. It's important to have the right equipment, staff training and payer contracts in place for the new cases. Additionally, it may take some time to gauge whether investing resources into adding the new specialty or procedures would positively impact the center.
"Most of these cases are currently being done at the hospital, so you want to make sure surgeons are supported and the center meets their expectations when they bring their patients to the ASC," says Ms. McMahan. "Make sure your expenses will realize a return-on-investment and that your physicians are onboard for bringing new cases. There are some cases that have been done in ASCs for a few years now, but surgeons weren't aware they could take them to outpatient centers."
Prepare for longer postoperative stays — since these are high-acuity cases, patients will likely need a few extra hours to recover before they leave, especially with the first few cases in the center. In some cases, expanding to include overnight, 23-hour stays or partnering with a convalescence center is beneficial.
When the surgeons are well-educated about the potential opportunities at the outpatient center, your next challenge is educating payers about the value of contracting with ASCs on these cases.
"The first challenge is getting the payer's attention so they add you to their priority list," says Dan Connolly, vice president of payer contracting at Pinnacle III. "Currently, most payers are spread thin on contracting and the last thing they want to do is add to their work load. Send them as much information as possible about the cost-benefits of talking to you and amending your contracts to bring new procedures."
Appropriate information to gather for the payers includes:
• Clinical outcomes
• Infection/complication rates
• Efficiency information
• Charges compared to local hospitals
• CPT-DRG bridge
"Most payers have limited knowledge on how to contract for these higher-acuity services at ASCs. From a data perspective, we're building a bridge on reimbursement by taking the hospital DRG and doing the crosswalk to CPT," says Mr. Connolly. "When I first began contracting for these services, I was reluctant to give payers too much information, but now I'm going in the other direction. With all this information, they can have their economics and analytics team crunching the numbers to see how much of a savings they'll have per case at the ASC."
Contractors aren't always upfront about their breadth and depth of knowledge on any particular procedure, and erring on the side of too much information may actually speed up the negotiation. The center's physician leaders can also connect with the payer's medical director for peer-to-peer discussions on the clinical value of ASCs.
"For the most part, if you are a multispecialty center and the contractor is already taking you into consideration for certain specialty areas, it's easiest to amend an existing contract with carve-outs where appropriate as opposed to going from a single-specialty ASC to bringing in a new specialty," says Mr. Connolly. "The reimbursement could be dramatically different. The whole rate structure for the center might not fit."
Now to 2020
Most of these procedures will still be valuable in five years, says Ms. McMahan, potentially even more valuable as the healthcare industry continues to focus on cost-savings. However, it's best to add these procedures soon before they become common at ASCs and payers push for lower rates.
"Five years out, I see value for spine and total joints especially because the aging population continues to grow," says Mr. Connolly. "But it will be vital for ASCs to bring those specialties now rather than later, especially with narrow networks. Payers are becoming more informed about performing these procedures and have more data to slice and dice the rates. They'll see more value in ASCs providing a broader level of services, and the sooner you get in, the better your reimbursement."
In addition to those procedures already valuable for ASCs, there could be other technology developments that would bring additional specialties and procedures currently done in hospitals to the ASC. One of the key areas to watch for in the future is cardiovascular surgery. There are a few minor cardiovascular surgeries being performed in ASCs today, including angiographies on the extremities and stent placements.
"We have one center with several general surgeons doing cardiovascular work," says Ms. McMahan. "Even though most cardiologists are employed by hospitals today, our general surgeons are independent and can do cases at our center. You can also enter into a joint venture with the hospital and explore the potential of allowing their cardiologists to perform cases at the center."
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