Trey Parsons, RN, vice president of clinical operations for ASD Management in San Diego, Calif., identifies new procedures that can add volume to an ambulatory surgery center.
1. Selected spine procedures. Spine procedures currently being performed in ASCs are cervical fusions, lumbar fusions, discectomies and laminectomies. Some ASCs are also hosting vertebroplasties and kyphoplasties, but it is often difficult to get insurance coverage for these.
2. Lap bands. Laparoscopic adjustable gastric bands, commonly referred to as a lap bands, received FDA approval in 2001. "Payors are increasingly offering coverage for lap bands because they recognize that they can reduce long-term healthcare costs for obese and diabetic patients," Mr. Parsons says. Some payors are limiting coverage to facilities that have been designated centers of excellence by board certification bodies for colorectal surgeons. The center of excellence designation requires the ASC to meet certain standards. Gastric bypass surgeries, on the other hand, will remain inpatient procedures.
3. Sling procedures. Urology-oriented ASCs are starting to add sling procedures, which correct urinary incontinence in women and traditionally were an inpatient procedure. "The condition primarily affects younger women who have just gone through childbirth," Mr. Parsons says. "Their bladders have collapsed and the sling lifts the bladder back up." The sling itself costs $700-$1,200, which is usually covered by private insurance. As sling and other procedures for female incontinence become more popular, some urologists are even beginning to limit their practices to this field.
4. Implanting pacemakers for incontinence. To treat older female patients with incontinence, urologists have been implanting pacemakers that function much like cardiac pacemakers. Surgeons insert the guide wires through fluoroscopy. "This is perfect for an ASC," Mr. Parsons says. "It's not something that a hospital would want to tie up its OR with." The implants are expensive, costing $14,000 each, but they are Medicare-reimbursed. ASCs with a lot of volume in this procedure would have to have substantial cash on hand, because the pacemakers have to be bought first and before applying for reimbursement.
5. Minimally invasive general surgery. General surgeons are beginning to perform laparoscopic cholecystectomies and hernia repairs on an outpatient basis. "Bringing these procedures out of the hospital and into the ASC depends on how comfortable physicians are with doing them on an outpatient basis," Mr. Parsons says. Some of these laparoscopic surgeries are in danger of turning into open surgery, which would require the hospital venue. This necessitates rigorous patient selection. But laparoscopic technology has improved and the volume is there because "there are a lot of gallbladder surgeries out there," Mr. Parsons says.
6. Laparoscopic-assisted vaginal hysterectomies. Gynecologists have kept their practices hospital-based because a lot of their work involves open procedures that have to be done in the hospital. But the advent of laparoscopic-assisted vaginal surgery has the potential for bringing these cases into the ASC. Since the major complication of this surgery is bleeding, good patient selection is crucial and the number of appropriate cases may initially be fairly low. However, as physicians get more comfortable with laparoscopic-assisted surgery, ASC-based volume may take off.
7. Partial arthroplasties on shoulders. Orthopedic surgeons have been starting to perform partial shoulder arthroplasties in ASCs. The high level of initial pain in this surgery previously limited it to inpatient venues, but now enough local anesthetics can be delivered to patients through catheters to get over initial pain. In contrast, many orthopedic surgeons still will not perform total knees and total hips on an outpatient basis. Patients tend to be Medicare beneficiaries, and Medicare won't reimburse for these procedures on an outpatient basis. Younger patients, however, would be better candidates for ASCs and private insurers may cover ASCs for this. "We're a more active society and people are going to wear out their joints faster," Mr. Parsons says.
8. Implanting spinal cord stimulators. Implanting spinal cord stimulators is an outpatient procedure typically done using a local anesthetic and a sedative. The implant costs about $10,000 and some private insurers cover it, while others still do not.
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