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Case Study: How One ASC Introduced Total Joint Procedures Into the Outpatient Environment

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In January, St. Augustine (Fla.) Surgery Center announced the launch of a total joint program including total hip, knee and shoulder replacement. This is the first ASC in the state to introduce a total joint program supported by robotic technology.

Tod Northrup, DO, a board-certified orthopedic surgeon with, Florida Sports Medicine Institute, and St. Augustine Surgery Center, initially proposed the idea of a total joint program. "He spent time discussing the improvements in technique that made it possible and what he would need, which sparked me to start Stephanie Martindoing some research," says Stephanie Martine, BSN, RN, CNOR, CASC, administrator of the surgery center. The surgeon's commitment is a crucial part to any new ASC program or service line.

As with any possible new service line, administrators begin with research. Total joint procedures often require surgery centers to adopt new technology. St. Augustine Surgery Center used Apex Robotic Technology, developed by OMNIlife Science, to support the program. The system does not require preoperative CT scans or MRIs.

Anesthesia advances play a big role as well. The art of keeping these patients comfortable, nausea-free and mobile requires using a variety of resources. Ahmed Bata, MD, an anesthesiologist with Coastal Anesthesia, addresses this challenge. "We use a multi-modal approach to minimize pain and nausea by using alternatives to narcotics in conjunction with a take home pain pump."  The pump provides pain relief directly to the local area as opposed to traditional systemic narcotics.

Ms. Martin and Peggy McGriskin, the surgery center's clinical director, observed Dr. Northrup perform a number of total joint procedures in the hospital first. They discussed the idea with their staff to build a level of comfort.

"We wanted people to get used to the idea and address concerns openly and thoroughly, "says Ms. Martin. "If there was any question about a particular item, we researched it until we had addressed every possible option. We wanted to know what to expect if everything went right, and then the top three ways that something could go wrong and be prepared for it all."

Any vendor, existing or potential, was met with to prepare. The local anesthesia group entered the discussion and, though it was decided patient selection criteria would preclude the need for blood products, Ms. Martin reached out to the director of the local blood bank as a precaution.

The next step in the process was negotiating payer contracts. Total joint replacement in the ASC setting is an attractive option for many centers, but an important step in making the idea a reality is analyzing the financial feasibility. Reimbursement for total joints performed in an ASC setting varies from market to market.

"Third party payers follow the lead set by Medicare," says Ms. Martin. Since Medicare does not currently reimburse for total joint replacements in ASCs, payers don't have that baseline and negotiations start from scratch. For St. Augustine Surgery Center, reimbursement has been the greatest challenge associated with the new program. "Reimbursement is a continuous struggle, some pay and some don't. Reimbursement is all over the board," says Ms. Martin.

Technology and healthcare are continually evolving; new challenges and opportunities arise every day. Ms. Martin and her team plan to recruit new surgeons and expand their center's capabilities to allow future growth of the total joint program. "This program has proven that quality care for more complex cases can be safely and efficiently delivered in the outpatient surgery setting," says Ms. Martin. As total joints begin to steadily migrate to the ASC setting, St. Augustine Surgery Center will have a strong foundation for the expansion of higher complexity case load.

More Articles on ASC Issues:
ASC QI Projects: Best Ideas for Biggest Impact
Are Physicians Ready for ICD-10? How to Make a Smooth Transition
Bringing Non-Profit Work to the ASC: Q&A With Dr. Sheryl Lewin of K & B Surgical Center

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