Finding the 'New Spine': 7 Procedures Moving Into the ASC Setting

If surgery center leaders can identify and add an up-and-coming procedure to their list of approved procedures prior to their competitors doing such, they may be able to corner the market and profit tremendously before the surgery becomes widespread. Lori Vernon, regional vice president of operations for Health Inventures, and Goran Dragolovic, senior vice president of operations for Surgical Care Affiliates, discuss seven procedures and subspecialties that could provide expansion opportunities for ASCs.

1. Unicompartmental knee replacements. According to Ms. Vernon, unicompartmental knee replacements were performed in the inpatient setting about 10 years ago, but quickly fell from popularity because of adverse outcomes. As implant technology has improved, however, she has seen a resurgence of unicompartmental knees. "They've developed new implants, and it seems that the success rate for the new implants has really improved," she says. "There are physicians that are beginning to think they have a very valuable physiologic impact."

She says unicompartmental knees are not appropriate for all patients. The surgery is most appropriate for a younger group of patients whose health makes them eligible for outpatient surgery. Unlike some other emerging orthopedic procedures, unicompartmental knees are approved by Medicare. She adds that because the implant costs $3,500-$4,000, surgery centers must ensure profitable payor contracts before adding the procedure.

Mr. Dragolovic says while payors in some markets are open to the cost-saving opportunity in unicompartmental knees, others simply do not regard the procedure as a priority. "Surprisingly enough, we have some markets where we can't get the payor's attention about the savings," he says. "In some markets, we are told that while they recognize the savings, they have much bigger items to tackle that have a much bigger total dollar."

2. Baha and cochlear implants. Historically, Baha and cochlear implants were performed in an inpatient or HOPD setting, Mr. Dragolovic says. "ENT physicians are expanding their use of ASCs, and we see an opportunity to provide a cheaper alternative to the patient and payor on cochlear and Baha implants," he says.

Since ENTs have been working in surgery centers for years, he says payors are the biggest challenge in moving these cases into the ASC setting. The procedures have high implant costs, so surgery center leaders must negotiate strong payor contracts to make them profitable. "The objective is to get in front of the payor and offer a cheaper alternative to the HOPD for these types of procedures," Mr. Dragolovic says.

3. Women's health procedures. Ms. Vernon says there may be an opportunity for surgery centers to add more women's health procedures, including laparoscopy-assisted vaginal hysterectomies, partial mastectomies and other breast procedures. "In general, I think women would prefer an environment like an ASC as opposed to an acute-care hospital," Ms. Vernon says. "The ASC represents an opportunity to widen the spectrum of women's healthcare providers because they are more private, more intimate and smaller." She says while payment from commercial payors can vary widely, reimbursement for lumpectomies and partial mastectomies are generally robust, and supply costs are insubstantial.

Mr. Dragolovic says gynecology poses a challenge for surgery centers because gynecologists have historically maintained strong ties with hospital. "In many instances, these physicians are OB/GYNs rather than just gynecologists, and they're wedded to the hospital because of the OB nature of their practice," he says. "Because of this, any surgical activity — even if it's outpatient — is done in the hospital setting." He says Surgical Care Affiliates has been successful in recruiting younger physicians to perform laparoscopy-assisted vaginal hysterectomies — partly because younger physicians are more likely to be trained on laparoscopic approaches, and partly because they haven't spent 20 years building loyalty to the hospital.

Ms. Vernon says certain breast surgery procedures may not be appropriate for all outpatient setting because, depending on location, some ASCs cannot provide the same ancillary services as hospitals. "If the surgeon wants to do any sentinel node work, there has to be a way to access a radioactive isotope," she says. "If they want to use mammography and needle localization, patients have to be able to access those ancillary services." She says these associated components present the biggest obstacles to performing women's health procedures in a surgery center.  

4. General surgery procedures.
Ms. Vernon says there are opportunities in general surgery for surgery centers if physicians are available for recruitment. "The biggest obstacle is the general surgeon," she says. "They are usually so closely tied to an acute-care hospital because of the need to be available for call coverage."

She says she sees opportunities for increased laparoscopic cholecystectomies, especially in markets where lap choles are not performed in the ASC setting. She says she has also seen some surgery centers performing laproscopic nissen fundoplication procedures to treat gastroesophageal reflux disease, but those are "few and far between."

"In the case of general surgery, it's mostly related to the surgeons," she says. "They've always done general surgery in the hospital and they feel comfortable there." If the ASC can convince general surgeons to move into the center, she says, there may be potential to expand the ASC's list of approved procedures.

5. Hip arthroscopies. Ms. Vernon says technological improvements may enable more surgery centers to perform hip arthroscopies in the future. "There are champions of hip arthroscopy out there," she says. "If there is an orthopod who works in the facility who believes in hip arthroscopies and wants to improve their technique and trial some of the new techniques, they can be performed in the outpatient setting." She says the use of a scope in these procedures has been limited so far, but the technique may become more popular as more physicians pursue minimally invasive surgery.

6. Sling procedures. Mr. Dragolovic says Surgical Care Affiliates has started looking at urology for expansion opportunities. "We see sling procedures as having potential in both volume and margin," he says. "We're seeing less of a resistance [from urologists] because they have historically used ASCs more frequently than gynecologists." He says in the case of sling procedures, ASCs may face contract issues because the tape required can cost over $4,000. Surgery center leaders must negotiate contracts that account for tape and mesh implants prior to adding the procedure.

7. Cardiac rhythm procedures. Cardiac rhythm procedures, including pacemaker battery changes and replacements, may have a place in surgery centers in the future, Mr. Dragolovic says. Patient population issues are the biggest deterrent for physicians and payors when it comes to cardiac rhythm procedures, as the majority of patients are elderly and thus more likely to present significant comorbidities. In addition, interventional cardiologists have not traditionally used ASCs.

Mr. Dragolovic says ASCs must establish a very rigorous patient selection process and staff training program prior to adding cardiac rhythm procedures. "In this case, both the physician and the contracting are going to be real critical," he says. Identify cardiologists who are enthusiastic about moving these procedures into the outpatient setting, and work with those providers to acquire necessary equipment and staff and demonstrate clinical safety to payors.

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