1. No category

Gastroenterology, Ophthalmology
(and Retina) and ENT, Pain
Management and Bariatrics in ASCs
What Works and What Doesn’t? Tips
For Improving Profits
Anne Roberts, RN
Administrator, Surgery Center of Reno
ASC Communications Conference, October 23-25,2008
Background on Surgery Center of Reno
•
•
Multi-specialty ambulatory
surgery center
Turnaround project with 30
physician partners, a
hospital and Regent
Surgical Health
ASC Communications Conference
October 23-25, 2008
Our Story: Before…
•
•
•
Shrinking profit margin, hospital “department”
Dated décor, low staff moral
Old equipment
ASC Communications Conference
October 23-25, 2008
Our Story: After…
•
•
•
•
•
•
Key strategy to upgrade equipment, bring in
new technology and to meet the changing
needs of our surgeons
Capital expenditure to update facilities, meet
current standards of excellence
Re-energized staff
Renegotiated contracts
Strong physician leader
Established leadership team
ASC Communications Conference
October 23-25, 2008
Physician Champions
ASC Communications Conference
October 23-25, 2008
Development of “Programs of
Excellence”
•
Focus to include:
-Spine
-Orthopaedics
-ENT
-Bariatric surgery
-Pain management
-Other surgical lines include Ophthalmology, General
Surgery, Urology (including Lithotripsy), Podiatry and
Dental
ASC Communications Conference
October 23-25, 2008
Spine
•
Keys to success:
- Partnership with three busy
neurosurgeons
- Purchase state-of-the-art
equipment
- Outstanding patient care and
outcomes
- Average of 190 cases of total
volume of 4700 cases
- Spine carve-outs in our contracts
- Work with third party vendor for
implants
- Represents four percent of total
volume
- Represents 25 percent of net
revenue
ASC Communications Conference
October 23-25, 2008
Spine Procedures in ASCs
•
Typical CPTs done in an ASC setting
- 63030 Microdiscestomy with decompression
- 63075 Anterior discectomy single
- 63076 Anterior discectomy - each level
- 63047 Laminectomy
- 69990 Use of microscope
- 22554 Arthodesis ant interbody
- 22845 Anterior instrumentation
- 20930 Allograft for spine surgery
ASC Communications Conference
October 23-25, 2008
Partnering with Pain Management
•
•
•
State-of-the-art equipment - dedicated c-arm,
new pain table, RF machine
Efficient scheduling
Staffed by PACU nurses and performed in
dedicated procedure room
ASC Communications Conference
October 23-25, 2008
Evolution of a Program
•
QI Project
- Decreased cost with revision of procedure trays
- Fluoro time study
- Block scheduling to maximize utilization of procedure room
- Accounts for 37 percent of total volume
- Average reimbursement $920
ASC Communications Conference
October 23-25, 2008
Bariatrics
Partnered with Western Bariatrics Institutes - Four
Bariatric Surgeons
Restrictive options: Gastric banding
Intermediate options: Roux-en-Y gastric bypass
(laparoscopic)
ASC Communications Conference
October 23-25, 2008
Morbid Obesity
•
•
•
Defined as being 100 lbs. or 100 percent over ideal
body weight of a BME of 40 or more
Approximately three to five percent of the US
population has severe obesity
Surgical therapy succeeds
- 80 percent of hypertension is cured
- 80 percent of insulin-dependant diabetics completely stop requiring
insulin
- Similar improvements in sleep apnea, GERD, etc.
ASC Communications Conference
October 23-25, 2008
Gastric Banding for Your ASC
•
•
•
•
Provides a specialized surgical program that can
separate you from your competitors
Attracts high-quality surgeons performing banding and
general surgery cases
Opportunity to build a relationship with a local acute
care hospital
Profitable and sustainable program that will increase
volume
ASC Communications Conference
October 23-25, 2008
Start-up Costs
•
Start-up costs approximate $250,000
- $60,00 for 20 lap bands
- Purchase of laparoscopic equipment
- Bariatric adaptive equipment: gurneys, scale, BP cuffs,
waiting room furniture, bathroom facilities
- Band vendors expanding and hope for more competitive
pricing in the future
ASC Communications Conference
October 23-25, 2008
Operational Considerations
•
Labor and supplies
- One hour or less in the OR
- Two to four hours in the PACU
- Overnight for Roux-en-Y patients
- Transfer agreement with acute care
- Cost of bands
Reimbursement for the procedure is $9,500 to $20,000
ASC Communications Conference
October 23-25, 2008
Clinical Considerations
•
•
•
•
•
•
Commitment to excellence in the care of bariatric patients with
documented in-services for staff, credentialing guidelines for
bariatric surgery
Bariatric program medical director
Transfer agreement
Board certified anesthesiologists
Equipment specific for bariatric patients, including both surgical
and radiological equipment
Specific guidelines regarding patient selection
-ASA level less than four
-PT to be executed and not in need of artificial airway upon arriving to PACU
-Meet the standard discharge criteria established by the facility
ASC Communications Conference
October 23-25, 2008
Patient Selection
•
•
•
•
•
Ideally BMI less than 55
BMI greater than 55 to be formally reviewed by medical
director, surgeon, anesthesiologist and nursing
Age less than 60
Weigh less than 425 lbs.
No previous history of DVT or PE
ASC Communications Conference
October 23-25, 2008
Measure Outcomes and Quality
Indicators
•
•
•
•
Reasonable expectation of 100 bariatric surgical cases
annually
Develop clinical pathways and outcome measurements
Support groups for patients
Long-term patient follow-up of at least 75 percent at
five years with monitoring and tracking systems for
outcomes
ASC Communications Conference
October 23-25, 2008
ENT
•
•
•
•
•
•
Again, physician partnership
Invest in high-quality, stat-of-the-art equipment
Video towers
Endoscopic equipment
ENT Image Guidance System to enable more complex
sinus surgeries at the facility
Adequate numbers of frequently used instruments
ASC Communications Conference
October 23-25, 2008
Focus
•
•
Limit to primarily reimbursable ENT procedures
Focus on processes:
- Quick turnovers
- Work with physicians to individualize recovery time based on patient
assessment
- Pediatrics - PALS certified staff
- Market to parents of pediatric population
- Pediatric anesthesia providers
- Recovery area conducive to pediatrics
ASC Communications Conference
October 23-25, 2008
Our ENT Experience
•
•
•
•
•
•
24 percent of our total
volume
21 percent of net revenue
Focus on quality
experience for physicians
and the patients and their
families
Monitor outcomes
Market to MD’s
Strive for excellence
ASC Communications Conference
October 23-25, 2008
ENT in the Big Picture
• Reasonable reimbursement
-Need to evaluate the marketplace and ensure not to be
overly dependent on Medicaid
-Our average reimbursement per ENT case: $1,850
-The challenge is controlling costs: gold laser, scopes,
disposables
ASC Communications Conference
October 23-25, 2008
ENT Continues to be a strong
contributor to the bottom line in
an ASC setting
ASC Communications Conference
October 23-25, 2008