David Holst is COO of Covenant Surgical Partners in Nashville, Tenn., which partners with single-specialty ambulatory surgery centers, mostly in GI.
Q: Is the single-specialty ASC still realistic for GI?
David Holst: It is still a very viable way to go. A single specialty allows you to get very good at what you do. Your patient flow is very, very consistent. You have the same kind of patients and same kinds of procedures. I have nothing against multispecialty centers, but they cannot be as efficient. The preps, patient instructions and processes are going to be different for each specialty. Patients' questions are going to be different. There are many different protocols and pathways to keep straight. This is a drag on efficiency that can also affect patient satisfaction.
Q: Is there still confusion about the mandatory waiver of patient payments for screening colonoscopies?
DH: Yes. The new rule, which went into effect last October, bars insurers from charging a co-payment for a screening colonoscopy. But the rule only applies to group health plans that have made a significant change in plan structure after Sept. 2010. This exception can be very confusing. Therefore, ASCs always need to verify each patient's coverage with the insurance company in advance. Make sure the group health plan has not had a material change.
Coding is another potential area for confusion. After the procedure, correct coding of the colonoscopy is essential. If a polyp is found, a modifier has to be added to the code to indicate that the procedure, while therapeutic presented as screening. The medical record must support this fact.
Patients, in particular, can be confused about their financial obligations with screening colonoscopies. They may think they will have no out-of-pocket expense for the procedure, but their insurance company could apply coverage differently. This requires careful communication with the physician office as to why the patient was scheduled, whether for a screening or diagnostic colonoscopy. ASC personnel need to find out from the insurance company how much the patient has already paid toward the deductible. Verify the patient's insurance in advance and contact the patient before the procedure.
Q: Is there sufficient opportunity to contact the patient before the procedure?
DH: There are at least four opportunities to interact with patients before they show up for the procedure. The first is when you send patients their written rights and responsibilities. The second time is when you make a follow-up phone call to patients to make sure they received the written copy. The third is a phone call telling them the out-of-pocket amount. And the fourth is when you call to review clinical information.
On each of these occasions, you want to give the patient as much information ahead of time as possible. Look at this as an opportunity to communicate rather than as, "Man, I got to do one more thing."
Q: Has the new waiver on out-of-pocket payments for screening colonoscopies led to a bump up in colonoscopy volume?
DH: We have not seen an increase in volume from the change. It could come eventually, but it's hard for the average person who is asymptomatic to feel the need to get a colonoscopy.
Q: Could the poor economy be affecting volume?
DH: The economy has hurt. Many employers are raising their deductibles and coinsurance, which creates a greater disincentive for patients. People are putting off elective procedures, which is great thing for the insurance companies. They get the premium and don't have many procedures to pay for. But it's a bad thing for healthcare providers.
The bad economy is probably having more impact on GI than on any other specialty. People seem more likely to put off colonoscopies than other elective procedures. They seem to perceive different levels of urgency for different elective procedures. If your knee or your vision is bothering you, you want to get it fixed. But the reason you have a colonoscopy done is not because you feel bad. And then the prep you have to take actually makes you feel worse. People think, "Why am I doing this?"
Q: How can GI ASCs get the message across about the new colonoscopy benefit and the need to have a colonoscopy?
DH: The most effective strategies are reaching out to primary care physicians and to groups. GI physicians offices should communicate with referring physicians on why screenings are important. Contacting primary care physicians can be very successful. Physicians at GI practices and ASCs can take advantage of speakers' bureaus at civic clubs, such as the Rotary and the Lions.
Other marketing methods don't seem to work as well. We tried billboards briefly and they did not move the needle. They had no impact. Maybe it was the placement of the billboard ads because that can be tricky. The location could be wrong or they could be facing the wrong direction on the highway. We also tried newspaper ads, but we did not see enough of an increase to justify a continuation. We haven't written them off, though. Something that did have an effect was Katy Couric's colonoscopy on TV. That was a national event that moved the needle.
Q: Should GI ASCs install an electronic health record?
DH: Implementing EHR is important, but the essential step is integrating the whole system, including bill-paying and clinical matters. The ASC documents only a small sliver of the patient's health record, going from a little before the patient arrives to a little bit after discharge. The ASC needs to collect billing and clinical information to file claims for a screening versus diagnostic visit. For a colonoscopy, the biller needs to see what was the pre-certification and of those match up to the screening in order to provide the right modifier for it to be billed as a procedure. The EHR also allows the ASC to aggregate information to assess quality. For example, you can monitor how many patients had H pylori of all the patients with stomach pain.
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