Overall, much like ophthalmology (see "Meeting the Current Business Challenges in Ophthalmology," starting on the cover, for more), the keys to success and profitability in ENT lie in being able to perform a large number of procedures, and to do them as efficiently as possible.
"It’s a mature specialty — it was one of the original groups to leave the hospital to start ASCs," says Steve Blom, RN, MAHSM, CASC, administrator at the Specialty Surgery Center in San Antonio, Texas, which performs about 4,000 ENT cases annually. "It’s predominantly bread-and-butter procedures: generic sinus, ear tubes, tonsillectomies and adenoidectomy. ENT got a slight increase from CMS, but we still have to run lean. So we have to carry on with the same pressures for reimbursement, the same pressures for supply costs."
However, there are some business and clinical issues specific to ENT and new technology that merit further examination. Here is what experts have to say.
1. Accommodating pediatrics
Because a large portion of procedures are T&As and ear tubes, ENT brings more pediatric patients to the ASC than other specialties do. As a result, accommodating the needs of this specialized patient population is always a challenge.
"Some states require that you have special pediatric isolation recovery rooms and waiting rooms," says John Seitz, the CEO of Ambulatory Surgical Group. "So what we’ve done in two of our centers is dedicate a morning every week or every other week, depending on volume, for pediatrics. On those days, we bring out the miniature furniture and toys and turn them into pediatric facilities for that half-day."
Not only can this help meet state regulations, it also gives you an opportunity to specialize staff who may have pediatric advanced life support training or who are particularly good with children.
"It’s very patient-friendly," says Mr. Seitz. "It’s easier for the physicians’ schedulers, and the everyone knows when they’re coming in that day exactly what to expect."
2. Steps to combat low payments
One of the big challenges that the inherently large pediatric population poses is that it can mean a large portion of Medicaid cases at your center.
"Medicaid reimbursement is very low and will only pay on one procedure. Here, we are doing anywhere from 25 to 32 percent Medicaid a month," says Mr. Blom. "And the fact of the matter is, you won’t make money, but you can’t consistently lose money."
To that end, he says, it is key that you "case-cost absolutely everything." For example, he says, Medicaid reimbursement for a regular tonsillectomy runs about $500 per case; he knows that overhead on such a case is about $230, plus
supplies and salaries.
Further, you must "take a hard line with physicians on supply costs," says Mr. Blom. "You can buy ear tubes for $78 or $14. It’s just a piece of plastic; we buy the $14 ear tubes and use them on everyone to maximize reimbursement
regardless of payor."
Brian Weeks, MD, an ENT surgeon in San Diego, Calif., says that sharing supply costs with physicians is an effective method for getting them to help keep expenditures down.
"I do 300 to 400 sinus procedures — what if the staff opens a handheld cautery on every one?" he says. "I know that’s $100 a case. I don’t ever use it, so why would it be part of the pack? I push for that to be removed from the pack; I can’t stand to watch people waste."
With per-case margins so small, high volumes are necessary to make them pay off on a larger scale.
"We had a center where we had just one ENT, but it didn’t work well for anybody; we moved him to a center with four others, and it was a great fit," says Mr. Seitz. "I’d say you have to have at least three or four for the specialty to start to make sense, so you can hit critical mass on volumes. You need to be able to make a production line of it, have them go rapid-fire in order to make it profitable."
Dr. Weeks notes that your surgeons can help keep turnover times short, too.
"For example, it can be something as simple as giving the anesthesiologist a heads up that I’m 10 to 15 minutes from finishing," he says. "That way, as I’m putting in the packing, the patient’s starting to cough. That’s ideal, and then I’m on my way to the next case."
Further, by providing a place for your surgeons to efficiently perform these high-turnover cases, you’ve already won half the battle.
"Fifteen or 20 years ago, physicians used to make 30 percent of their money at the clinic and 70 percent on surgery — now that’s reversed, and probably more like 80-20," says Mr. Blom. "Time is absolutely imperative to them. They don’t want to break off a clinic day to go to the hospital. If you can start offering more complex cases at your center, you may be rewarded with higher reimbursements and better physician relationships."
Dr. Weeks agrees: "I don’t like to jump around; that’s inefficient. If an ASC can accommodate me with my bigger cases, I’m more likely to bring all my cases there."
3. Transitioning thyroidectomy to outpatient
A recent study shows that, with careful patient selection and prophylactic calcium supplementation to minimize hospital stay, thyroidectomy can be safely performed in ASCs. "Outpatient Thyroid Surgery is Safe and Desirable," presented at the 2006 Annual Meeting of the American Academy of Otolaryngology — Head and Neck Surgery Foundation, examined 91 patients undergoing thyroidectomy who were segregated into inpatient (39 — 26 for 23-hour stays, 13 admitted) and outpatient (52 — discharged directly from the ambulatory recovery unit) groups.
"Despite the trend toward outpatient surgery, surgeons who perform thyroid and parathyroid surgery have been reluctant to adopt this approach primarily out of concern for bleeding and transient hypocalcemia," write the authors. "However, the advent of new ultrasonic technology … has improved the ability to achieve and maintain a bloodless field. This technology has led to a conclusion by many that surgical drains, a soft plastic tube that drains fluid out and sources of infection of the area, offer no benefit to the patient, and if anything, result in a higher rate of infection and bleeding."
Several surgical techniques were used, including a Kocher incision, minimally invasive thyroid surgery with access to the thyroid compartment, and endoscopic thyroidectomy. Laryngeal nerve monitoring was employed as required. Vocal cord mobility was assessed and documented preoperatively and again in the post-anesthesia care unit or on the ward using flexible fiberoptic laryngoscopy. In post-op, outpatients were assessed and discharged once ambulatory, tolerating a diet and managing their pain with oral medications.
"A second major deterrent to performing thyroid (and parathyroid) surgery on an ambulatory basis is the fear of life-threatening hypocalcemia, or low blood calcium level," write the authors. "Ten years ago, researchers described a regimen of oral calcium administration following parathyroidectomy, supporting outpatient status in nearly all cases performed at a major hospital. Researchers for this current study provided oral calcium supplementation in patients undergoing total or completion thyroidectomy to accomplish outpatient thyroid surgery safely. This method has proven uniformly successful with the study subjects, with none displaying any signs of calcium deficiency in the blood."
Finally, and most importantly, the authors found that costs were significantly lower for outpatients ($7,814) than for inpatients ($10,288) and that operative time was lower in the outpatient group (102 versus 144 minutes). This suggests that "for carefully selected patients who prefer convalescence at home, and are not weak due to age and disease, outpatient thyroid surgery is safe and cost-effective, even when a total or completion thyroidectomy has been performed."
Mr. Blom is seeing more thyroidectomies transition out of the hospital and into his center and other ASCs in the region.
"The only thing really holding this transition back now is the global reimbursement, which means the ASC doesn’t get reimbursed for running labs — you have to contract that service out and pay out of your reimbursement," he says. "But as reimbursements go up through 2011, this procedure may become more attractive."
4. Picking a modality for visualization
Aside from the high-volume pediatric cases, functional endoscopic sinus surgery (FESS) is another procedure that makes up a large percentage of ENT case volumes. The minimally invasive surgery is used to remove unwanted tissue in paranasal sinuses in order to facilitate normal respiration, ventilation and outflow for the patient; it has replaced more conservative sinus procedures as it has been shown to improve on their outcomes. In fact, a 2007 study published in the Journal of Laryngology and Otology even showed FESS significantly improved all symptoms when used in the management of chronic rhinosinusitis.
But with a new gold standard procedure comes new challenges. The biggest with FESS is accurately targeting tissue to be removed while navigating around anatomical structures in order to avoid injury to vulnerable structures. Computer-aided navigational technology for visualization of sinus surgery has been gaining a foothold for years. However, whether it is the new gold standard is up for debate.
Mr. Blom says that use of computer-assisted navigation in conjunction with FESS has been largely specific to certain regions of the United States, but that it may be increasingly popular, as surgeons feel that the visualization leads to better outcomes and potentially faster operative times (though the literature jury is out on OR time). Unfortunately, the equipment to add this can be expensive. So is it worth it? Here is a summary of two options.
• Image-guidance. In the first and older of the two technologies, images created by CT, MRI or fluoroscopic imaging systems are used to build an anatomical "roadmap" that the surgeon can see on a monitor. This technology also maps the progress of the surgeon’s tools into the sinuses.
"This lets the ENT surgeon more safely perform procedures in the delicate sinuses without damaging any of the surrounding structures," says Mr. Seitz. "This is something that, up until six months ago, was only being done at the hospital. But now the ASCs are getting increased reimbursement. You still need about five ENT physicians to bring in the volumes to make buying a $150,000 piece of equipment viable, but once we hit that number of referrals, it’s a very well-reimbursed procedure that’s opening up some avenues previously exclusive to the hospital."
Another advantage, he says, is that image-guidance lets the surgeons perform the more complex sinus procedures, which come with higher reimbursements. Drawbacks include the use of radiation, a learning curve for surgeons and staff and sometimes-expensive disposables.
• Near-infrared transillumination. In this method, the surgeon uses a light wire to illuminate the sinus of interest, so that he can better visualize where he
is working.
Dr. Weeks enumerates the benefits from his point of view:
• no bulky, space-consuming C-arm;
• no need to wear heavy, radiation-shielding gowns;
• patient positioning is much more simple and straight forward;
• rapid learning curve; and
• faster than image-guidance because the transillumination system is ready to go
as soon as it’s hooked up.
"I like having the freedom to move around the patient, and there’s no radiation on the patient’s head or my hands," he says. "The main light wire costs $150 to $175 a case, but that’s better than the disposable costs for image-guided, in my experience. And this lets an ASC without the capital budget to purchase a large piece of navigation equipment to open up more complex procedures to ENT surgeons."
5. Adding balloon sinuplasty
Currently performed mostly in hospitals, Balloon Sinuplasty devices used as a replacement for or adjunct to traditional FESS is a logical fit for ASCs for a variety of reasons. The minimally invasive, minimally disruptive procedure has a 98 percent patency rate at six months, as well as a strong safety profile and patient satisfaction rating, according to the results of recently published data.
"The Balloon Sinuplasty technology opens up FESS to a wider population of patients because it expands the option of an ENT surgeon," says Robert Wood of Acclarent, maker of the Balloon Sinuplasty devices. "What really sets this technology apart from the traditional instruments used in FESS is the ability to navigate around anatomy and open the obstructions of the peripheral sinus ostia with a minimal disruption to healthy tissue. This is particularly important for patients undergoing FESS for the first time. Traditional instrumentation can be used when tissue and anatomy need to be removed, and this flexible instrumentation can be used when they can stay intact. Balloon Sinuplasty technology broadens the surgical options for treating patients who suffer from this complex condition."
Standard FESS procedure times run about 90 minutes to two hours for an average of six sinuses including ethnoids plus septoplasty. Acclarent’s data shows that using the Balloon Sinuplasty system for the peripheral sinus in same set of procedures saves an average of 51 minutes of OR time, says Mr. Wood, helping to make up for the roughly $1200 in disposable costs per procedure. CPT codes for tools used in FESS, which Balloon Sinuplasty is billed under, are well-reimbursed. While the CMS reimbursement looks positive for sinus surgery, the overall impact will be small, says Mr. Wood.
"This is because 90 percent of ENT procedures are done under private payers, because chronic sinusitis affects people in their mid-40s, working-age people, for the most part," he says. "These are the same age people who are interested in innovation that will relieve their problem with the least disruption to their anatomy or their lives. These are all positive factors for ASCs looking to add growth, especially when you consider ENT and sinus surgery are established bread-winners."
Mr. Blom says that, while he finds Balloon Sinuplasty to be interesting, he worries that it would be too difficult to use on patients who need more than just their frontal sinuses operated on.
"If you want to go and do the back sinuses, then you have to use the old technology," he says. "When you have to use two modalities, suddenly your case cost is out of control, because you’re only getting reimbursed for one procedure."
As a result, he finds its use too narrow for the ASC, but Dr. Weeks says it’s imperative that it be incumbent upon the physician to choose the right patients for the ASC.
"If you do that, using this tool can be very profitable — and it’s such an incredible procedure for the
practice and patients," he says. "Having the transillumination technology allows us to overcome the cost barrier. If you look at the net costs — not having fluoroscopy of image-guidance, not using shavers and other expensive pieces of equipment inherent in FESS, eliminating excessive packing, speeding operative times — you can increase profitability."
Contact Stephanie Wasek at stephanie@beckersasc.com.
