The movement of cardiology cases to the ambulatory surgery center (ASC) setting has been gaining momentum across the country since 2016 when the Centers for Medicare & Medicaid Services (CMS) approved the first cases for reimbursement in ASCs.
Bain and Co. had projected that by the mid-2020s, about one-third of cardiovascular cases would be successfully performed in ASCs. This figure was calculated before percutaneous coronary interventions were added to the ASC covered list in 2020, leading pundits to believe that this figure could reach 50%.
What are organizations and/or providers to do if they want to migrate those procedures to ASCs? These a few of the key steps to developing a well-thought-out plan to successfully transition cardiology cases out of the hospital setting:
1. Develop a business plan
2. Acquire coding and billing expertise specific to cardiology
3. Create a strict patient selection criteria
4. Set new patient expectations within the office setting
5. Build partnerships with the cardiology industry
The business plan is the starting point for any new venture. This includes a market analysis of selected location, anticipated payor mix and demographics of the communities served. The plan would also include a lease versus purchase/build analysis. Lastly, it would include a comprehensive financial proforma that includes procedure growth projections and staffing and supplies expense projections to determine realistic profitability. Keep in mind that ASC reimbursement is about 52% of hospital outpatient department reimbursement.
Adding cardiology to an ambulatory surgery center doesn't just impact the clinical team. The ASC needs a carefully considered process for coding and billing these new procedures. The decision should be made whether to outsource cardiology revenue cycle management or spend the time necessary to train existing business staff to code and bill these procedures correctly or hire new staff with cardiology coding and billing experience.
The next, and probably most important, step in a successful transition is the selection of patients suitable for the ambulatory setting. Any initial bad outcomes will dramatically alter growth projections and possibly damage ASC's reputation in the community. Patient selection should follow a set criterion. Patient selection should be based on the interventionalist's professional medical judgment, which may include consideration of the patient's risk factors and comorbidities, the patient's lesion risk, and the patient's overall health status.
As for patients to avoid, these conditions warrant scrutiny:
• >50% diameter stenosis of left main artery proximal to infarct-related lesion, especially if the area in jeopardy is relatively small and overall LV function is not severely impaired
• Long, calcified or severely angulated target lesions at high risk for PCI failure with TIMI flow grade 3 present during initial diagnostic angiography
• Lesions in areas other than the infarct artery (unless they appeared to be flow limiting in patients with hemodynamic instability or ongoing symptoms)
• Lesions with TIMI flow grade 3 in patients with left main or three-vessel disease where bypass surgery is likely a superior revascularization strategy compared with PCI
• Culprit lesions in more distal branches that jeopardize only a modest amount of myocardium when there is more proximal disease that could be worsened by attempted intervention
• Chronic total occlusion
As performing cardiac caths in the ASC is a relatively new endeavor, patient education and expectations should be performed and established in the physician office prior to the procedural date. Many patients are expecting a visit to a large medical facility with a two- or three-night stay and may not feel comfortable with the idea of this new setting. Every effort must be made to ease patient concerns regarding the ambulatory surgery setting.
The safety, quality and efficiencies of the ASC should be explained to the patient by the physician's staff. This educational process should include discussion of a radial artery catheterization approach and the benefits of this approach versus the "norm" of a femoral artery approach. An expected four-hour recovery in a recliner versus a hospital gurney should be described as an expectation. Thorough, complete instructions upon discharge should be reviewed with the patient and family prior to the procedure so that the patient and their family feel comfortable with being sent home on the same day of the procedure.
Partnership with medical device companies, suppliers and service providers, among others, within the cardiology industry can also help improve the likelihood of success for a new ASC cardiology program. Developing such relationships can assist with reducing potential capital costs in designing and building a new center or procedural room. These types of relationships can also assist with room design, layout and identifying new technologies on the horizon. Medical device company partnerships are also valuable in assisting with reducing cost per case, overhead costs and longer-term device maintenance for pacemaker and internal defibrillators procedures.
While there more potential considerations for ensuring the success of transitioning cardiology cases to an ASC, these five focal areas are the foundation for the successful launch, annual growth and long-term success of an ASC cardiology program.
Jack O' Connor, MBA, MHA, is a consultant on cardiovascular outpatient services for Avanza Healthcare Strategies, which provides healthcare organizations with strategic guidance, with a focus on outpatient services. Mr. O'Connor brings more than 30 years of healthcare experience to Avanza, including experience opening new cardiovascular centers and clinical experience as a cardiovascular perfusionist. He has led many initiatives in the transition of cardiovascular patients from a traditional inpatient status to the outpatient setting in areas such as peripheral vascular procedures, cath/PCI procedures and electrophysiology procedures.