Launching an ASC total joint program — key elements and lessons from an administrator

Carolina Bone & Joint Surgery Center in Myrtle Beach, S.C., launched its total joint program at the end of 2016. Administrator Georgia A. Kapshuck spoke to Becker's ASC Review about the program's key elements and shared advice for other administrators.

Note: Responses were lightly edited for style and clarity.

Question: What are the key elements of a successful outpatient total joint program?

Georgia Kapshuck: In our case, a successful total joint program begins with surgeon leadership. Having an experienced surgeon craft a clear protocol outlining the general formula for perioperative management sets the stage for success. Couple this with a cadre of total joint surgeons who buy into that protocol, and the program is nearly guaranteed to start out on the right foot.

However, to ensure that the program maintains quality and grows from its successful inception, an able, detail-oriented total joint coordinator is an absolute necessity. This person must be a skilled communicator, able to interface with patients, surgeons, OR staff and clinical staff both in the surgery center and in surgical offices. A good coordinator also can keep track of the numerous prerequisites that patients must have in place prior to surgery: medical optimization, lab studies, home health arrangements, education, perioperative medications, physical therapy arrangements ... the list can be daunting.

Lastly, patient selection is a fundamental aspect of a successful outpatient total joint program. Meeting with patients ahead of surgery allows staff to gauge both the objective health of the candidate as well as the more intangible qualities that help promote success: drive, perspective, reliability, tolerance, support.

Q: How does your center handle reimbursement for total joint cases? Do you have any bundled payment contracts set up?

GK: We secured payer contracts with three of our largest managed care contracted payers. We proposed a total cost reimbursement plan (bundled payment plan). This amount was comprised of knowing our actual costs to start with — implant cost, time and materials, extras like lunch for the patient and family member, lodging for any patient too far to travel, physical therapy, home health, and overhead. We ensure all preauthorizations and insurance coverage has been verified prior to the procedure and all deductibles and coinsurances are paid up front and in full prior to surgery. We also submit, within one day of the surgery, the bill to the payer for processing. It is not unusual to get our reimbursement within 10 days. We get paid prior to receipt of the invoice for the implant cost, thus keeping our cash flow stable.

Q: Looking into 2020, how do you plan to grow your ASC's total joint program?

GK: Now that we are three years into our total joint program, we are looking to accommodate more procedures per day. To this point, our limiting factors have mainly been logistical — available beds, available recovery space, limitations in physical therapy scheduling, staffing later in the day. We are looking to address these in ways that maintain the center's culture of safety and quality but also accommodate a growing demand for services.

Q: What's the biggest lesson you've learned since launching the total joint program in 2016?

GK: The biggest lesson we learned in the formative period of our total joint program was the importance of establishing surgeon-approved exclusion criteria for patient selection. Not only must these criteria be established, but they also must be adhered to firmly. The more objective and quantifiable the criteria are, the easier they are to enforce. It can be dismaying to inform a patient that they do not meet the criteria for outpatient total joint surgery, but in our experience, it can also be uniquely motivating. We have had multiple patients fail to meet BMI or hemoglobin A1c thresholds initially, only to have them reappear on the schedule a few months later after having made significant changes to their lifestyle such that they now qualify. This helps us to recognize a driven patient who will work hard to achieve a good outcome, and it helps the patient reap the benefits of goal-directed care.

Q: What advice do you have for administrators thinking of introducing total joints at their own centers?

GK: For any administrators contemplating an outpatient total joint program, the best advice that we can give is to ensure that you establish good payer contracts specifically carved out for total joints at the outset. A surgeon-established perioperative protocol can significantly help to demonstrate surgeon commitment and a focus on quality. Involve members of every department in your facility to learn what needs to be done to provide the best experience for patients. Consider bundling all extra patient costs, such as physical therapy, home health services, meals and overnight accommodations, into a single fee to make it easier on both the facility and the patient. Lastly, follow up with patients to learn how you can improve. Word-of-mouth from patients who had good experiences with total joint has helped us generate numerous new patients, and it has allowed us to incorporate lessons learned into other aspects of patient care at our facility. We honestly feel like we provide better overall services now than before we began the total joint program — a very gratifying upshot.

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