In 2008, North Star Surgical Center in Lubbock, Texas, added a gastric lap-banding service line to its cadre of procedures. Though the service line has been put on hold temporarily, due to the untimely death of an ASC physician in May 2011, Mr. Brock says the first few years of the program enjoyed significant success.
"In the articles I read about the best procedures for an ASC, neuro is always up there and orthopedics is always up there, but this should be there too," he says. "It's a great procedure for an ASC. It's safe, we've had outstanding outcomes and it's not overly expensive." Here he shares 10 steps involved in adding a gastric lap-banding service line to a multi-specialty surgery center.
1. Determine a need. The first step in adding a gastric lap banding line is to determine whether your community needs the service, Mr. Brock says. The Lubbock, Texas, medical community is comprised of about a million people because the city draws patients from west Texas and eastern New Mexico. As the largest medical market between Albuquerque, New Mexico, and Dallas/Fort Worth, Lubbock has a large number of patients who might potentially seek lap-band surgery.
Mr. Brock says the community also has a surprising dearth of physicians who perform the procedure. These reasons indicate that the community has a significant "need" for a lap-band service. If your community is smaller in size and already has several well-known physicians offering lap-band services, the procedure may not be as profitable for your surgery center.
2. Achieve buy-in from your physicians and medical director. To add any service line, you need to talk to your physician-partners and gain their approval, Mr. Brock says. He said in order to achieve buy-in, the most important thing is to be completely transparent about the service line you plan to add. "You want to be totally transparent — in other words, what is the procedure going to cost you, and what do you stand to realize from a revenue perspective? What are the risks involved?"
He says in addition to your physicians, it's also important to gain buy-in from your medical director and director of nursing, as they will be heavily involved in implementing the service line.
3. Outline the costs. Before you seriously consider adding a service line, you must know whether it will be profitable, Mr. Brock says. Go over the costs of the procedure as well as your expected reimbursement from your payors. "The greatest costs in doing this procedure are the medical supplies — the band and other medical supplies on top of that," he says. "You should know how long the procedure takes so you can calculate how much your staffing costs will be." Mr. Brock estimates that the gastric lap-banding procedure takes about 1.5-2 hours, depending on the surgeon.
4. Assign a bariatric coordinator and a practice liaison. Mr. Brock says the addition of gastric lap-banding requires two extra roles at the ASC: a practice-ASC liaison and a bariatric coordinator. He says these positions are critical if your ASC wants to earn a Bariatric Center of Excellence designation, a mark of high quality that some payors require to cover the procedure. Mr. Brock hired a liaison and assigned the bariatric coordinator duties to an OR charge nurse who already worked at his surgery center.
The liaison functions as a communicator between the physician practices and the ASC and serves as the contact person for the patient, Mr. Brock says. When patients come in through the website, the liaison pulls those names, contacts them, works with them on their insurance and coordinates informational sessions about the procedure. The bariatric coordinator oversees the clinical aspects of the procedure and makes sure everything is performed to the correct standard of care.
5. Expand your online presence and marketing. Mr. Brock says gastric lap-banding is unique in that patients often use the internet to find physicians, rather than talking to their friends or going through a referring primary care physician. "These patients go and seek out lap-banding on the internet by looking at reviews of doctors," he says. "You have to allocate expense dollars to the promotion of the procedure." He says his surgery center hired a web expert to redesign the website, develop an SEO strategy and reach out to the weight-loss community.
Mr. Brock says his center also markets the procedure by holding seminars to inform patients of their options. "We do two seminars a month locally, and [our physician] also did them in Amarillo, Texas, and Albuquerque," he says. "People come to the seminars, and it's the first step toward changing their life."
6. Develop strict patient admission criteria. Because gastric lap-banding treats patients who often have significant co-morbidities, the patient admission criteria needs to be thorough, Mr. Brock says. Ask your anesthesia provider and surgeon to collaborate and draw up patient criteria based on industry standards and experience. For example, patients may need to undergo sleeping tests to detect the presence of sleep apnea before coming to the ASC for surgery.
Patients with other significant co-morbidities, such as heart problems, may also not be appropriate for surgery at a freestanding ASC. The FDA standard for lap-band surgery is a minimum BMI of 30 with at least one weight-related health condition, though most private insurance companies won't cover gastric surgery in otherwise healthy people with a BMI under 40.
7. Plan to handle patients paying cash. Understand that many gastric lap-banding patients will want to pay for their procedure in cash, Mr. Brock says. "Some insurance companies don't cover it, which is frankly mind-boggling," he says. "It's not an overly expensive procedure, and all it does is improve enrollees' health going forward." Until insurance companies start to cover the procedure more frequently, he says, ASCs must prepare for patients to cover the bill themselves. He says his surgery center has brought in Care Credit, which offers a healthcare financing plan to the patient to assist them in paying for the procedure.
8. Determine what payors will ask from you. Payors are becoming more comfortable with bariatric surgery, but you still may have to jump through hoops to negotiate a profitable contract, Mr. Brock says. "A lot of payors require that patients show they've done a year's worth of work to lose the weight on their own before covering the procedure," he says. This means you may need to work with the patient to prove prior weight-loss attempts before the payor will cover the procedure.
Mr. Brock recommends gaining an understanding of how each of your payors reimburses for gastric lap-banding. If a patient comes to the surgery center with payor X, for example, you want to know whether the payor covers the procedure, what you will have to do to get the procedure covered and whether you will be able to negotiate carve-outs. Mr. Brock says carve-outs are important for gastric lap-banding to cover the cost of the actual lap-band.
9. Make sure anesthesia providers are comfortable treating obese patients. Most anesthesia providers should have experience treating patients with co-morbidities, but it's worth your time to sit down with your anesthesiologists and discuss their comfort level with obese patients. "These patients have breathing issues and occasional sleep problems, and that's the obvious difference in how these patients are treated," Mr. Brock says. "An anesthesiologist who is knowledgeable of the factors that come into play in taking care of obese patients would be able to perform this case." The anesthesiologist should also be involved in the development of surgical criteria to make sure patients with excessive co-morbidities are sent to the hospital instead of the surgery center.
10. Develop a good relationship with your device manufacturer. Mr. Brock says his surgery center has benefitted from a good relationship with Allergan, the company that manufactures and sells the lap-band they use. He says the device company has been helpful in sharing best practices with the facility and helping the ASC grow the service line. In order to create a good relationship with a device company representative, he says it's important to establish trust and help both parties realize that a mutual beneficial outcome is possible.
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"In the articles I read about the best procedures for an ASC, neuro is always up there and orthopedics is always up there, but this should be there too," he says. "It's a great procedure for an ASC. It's safe, we've had outstanding outcomes and it's not overly expensive." Here he shares 10 steps involved in adding a gastric lap-banding service line to a multi-specialty surgery center.
1. Determine a need. The first step in adding a gastric lap banding line is to determine whether your community needs the service, Mr. Brock says. The Lubbock, Texas, medical community is comprised of about a million people because the city draws patients from west Texas and eastern New Mexico. As the largest medical market between Albuquerque, New Mexico, and Dallas/Fort Worth, Lubbock has a large number of patients who might potentially seek lap-band surgery.
Mr. Brock says the community also has a surprising dearth of physicians who perform the procedure. These reasons indicate that the community has a significant "need" for a lap-band service. If your community is smaller in size and already has several well-known physicians offering lap-band services, the procedure may not be as profitable for your surgery center.
2. Achieve buy-in from your physicians and medical director. To add any service line, you need to talk to your physician-partners and gain their approval, Mr. Brock says. He said in order to achieve buy-in, the most important thing is to be completely transparent about the service line you plan to add. "You want to be totally transparent — in other words, what is the procedure going to cost you, and what do you stand to realize from a revenue perspective? What are the risks involved?"
He says in addition to your physicians, it's also important to gain buy-in from your medical director and director of nursing, as they will be heavily involved in implementing the service line.
3. Outline the costs. Before you seriously consider adding a service line, you must know whether it will be profitable, Mr. Brock says. Go over the costs of the procedure as well as your expected reimbursement from your payors. "The greatest costs in doing this procedure are the medical supplies — the band and other medical supplies on top of that," he says. "You should know how long the procedure takes so you can calculate how much your staffing costs will be." Mr. Brock estimates that the gastric lap-banding procedure takes about 1.5-2 hours, depending on the surgeon.
4. Assign a bariatric coordinator and a practice liaison. Mr. Brock says the addition of gastric lap-banding requires two extra roles at the ASC: a practice-ASC liaison and a bariatric coordinator. He says these positions are critical if your ASC wants to earn a Bariatric Center of Excellence designation, a mark of high quality that some payors require to cover the procedure. Mr. Brock hired a liaison and assigned the bariatric coordinator duties to an OR charge nurse who already worked at his surgery center.
The liaison functions as a communicator between the physician practices and the ASC and serves as the contact person for the patient, Mr. Brock says. When patients come in through the website, the liaison pulls those names, contacts them, works with them on their insurance and coordinates informational sessions about the procedure. The bariatric coordinator oversees the clinical aspects of the procedure and makes sure everything is performed to the correct standard of care.
5. Expand your online presence and marketing. Mr. Brock says gastric lap-banding is unique in that patients often use the internet to find physicians, rather than talking to their friends or going through a referring primary care physician. "These patients go and seek out lap-banding on the internet by looking at reviews of doctors," he says. "You have to allocate expense dollars to the promotion of the procedure." He says his surgery center hired a web expert to redesign the website, develop an SEO strategy and reach out to the weight-loss community.
Mr. Brock says his center also markets the procedure by holding seminars to inform patients of their options. "We do two seminars a month locally, and [our physician] also did them in Amarillo, Texas, and Albuquerque," he says. "People come to the seminars, and it's the first step toward changing their life."
6. Develop strict patient admission criteria. Because gastric lap-banding treats patients who often have significant co-morbidities, the patient admission criteria needs to be thorough, Mr. Brock says. Ask your anesthesia provider and surgeon to collaborate and draw up patient criteria based on industry standards and experience. For example, patients may need to undergo sleeping tests to detect the presence of sleep apnea before coming to the ASC for surgery.
Patients with other significant co-morbidities, such as heart problems, may also not be appropriate for surgery at a freestanding ASC. The FDA standard for lap-band surgery is a minimum BMI of 30 with at least one weight-related health condition, though most private insurance companies won't cover gastric surgery in otherwise healthy people with a BMI under 40.
7. Plan to handle patients paying cash. Understand that many gastric lap-banding patients will want to pay for their procedure in cash, Mr. Brock says. "Some insurance companies don't cover it, which is frankly mind-boggling," he says. "It's not an overly expensive procedure, and all it does is improve enrollees' health going forward." Until insurance companies start to cover the procedure more frequently, he says, ASCs must prepare for patients to cover the bill themselves. He says his surgery center has brought in Care Credit, which offers a healthcare financing plan to the patient to assist them in paying for the procedure.
8. Determine what payors will ask from you. Payors are becoming more comfortable with bariatric surgery, but you still may have to jump through hoops to negotiate a profitable contract, Mr. Brock says. "A lot of payors require that patients show they've done a year's worth of work to lose the weight on their own before covering the procedure," he says. This means you may need to work with the patient to prove prior weight-loss attempts before the payor will cover the procedure.
Mr. Brock recommends gaining an understanding of how each of your payors reimburses for gastric lap-banding. If a patient comes to the surgery center with payor X, for example, you want to know whether the payor covers the procedure, what you will have to do to get the procedure covered and whether you will be able to negotiate carve-outs. Mr. Brock says carve-outs are important for gastric lap-banding to cover the cost of the actual lap-band.
9. Make sure anesthesia providers are comfortable treating obese patients. Most anesthesia providers should have experience treating patients with co-morbidities, but it's worth your time to sit down with your anesthesiologists and discuss their comfort level with obese patients. "These patients have breathing issues and occasional sleep problems, and that's the obvious difference in how these patients are treated," Mr. Brock says. "An anesthesiologist who is knowledgeable of the factors that come into play in taking care of obese patients would be able to perform this case." The anesthesiologist should also be involved in the development of surgical criteria to make sure patients with excessive co-morbidities are sent to the hospital instead of the surgery center.
10. Develop a good relationship with your device manufacturer. Mr. Brock says his surgery center has benefitted from a good relationship with Allergan, the company that manufactures and sells the lap-band they use. He says the device company has been helpful in sharing best practices with the facility and helping the ASC grow the service line. In order to create a good relationship with a device company representative, he says it's important to establish trust and help both parties realize that a mutual beneficial outcome is possible.
Related Articles on GI and Endoscopy:
Study: Laparascopic Surgery May Be Safer Than Open Bariatric Surgery
Median Survival Time for Colon Cancer Increases 17-Fold
IBD Patients Face Higher Risk of Skin Cancer