In recent years, Medicare rule changes have been a key driver to accelerating the migration of surgical procedures to ambulatory surgery centers.
Commercial payers have followed suit and today, the majority of orthopedic procedures present with opportunity for migration to the ASC setting, and with recent rule and policy changes total joint replacements and spine surgery, have gained momentum and are increasingly performed on a same-day, outpatient basis.
At a symposium sponsored by Pacira BioSciences, Inc. at Becker's 28th Annual Meeting: The Business & Operation of ASCs, Naya Kehayes, partner and ASC practice leader at ECG Management Consultants, facilitated a discussion with two industry experts about optimizing the migration of surgeries to the ASC setting:
- Christine Jackson, RN, executive director, Lighthouse Surgery Center in Hartford, Conn.
- Gary Schwartz, MD, vice chair, department of anesthesia, Maimonides Medical Center in Brooklyn, N.Y.
Five key takeaways were:
1. Successful patient selection depends on defining the appropriate clinical selection criteria. Not every patient is a good candidate for surgery in an ASC. The anesthesia and medical directors at Lighthouse Surgery Center have developed exclusion criteria which identify the types of patients who are not candidates for Lighthouse Surgery Center. "Examples include patients with new onset arrhythmias, uncontrolled hypertension, restrictive lung diseases or individuals on dialysis," Ms. Jackson said. Patients who meet the criteria, are carefully evaluated before coming in for surgery to ensure they are prepared for surgery in an ASC setting and to optimize their success. They must be in the best shape possible, especially for total joints. Clinical selection criteria, however, are not cast in stone. Dr. Schwartz noted that his team re-evaluates selection protocols on a yearly basis which is a standard practice.
2. Patient education is a team effort. Patients must understand the procedure and the medications that will be needed both pre- and post-operatively. "We ensure that patients have any adaptive devices that they will need in advance of the surgery”, said Dr. Schwartz. Ms. Jackson added that LSC confirms that there is a caregiver at home, and they strongly encourage the caregiver to come tour the Lighthouse Surgery Center with the patient prior to surgery which helps to inform the caregiver of the post-op care. “This also helps the patient to understand the ASC mentality and to be prepared for going home on the same day”, said Ms. Jackson. Dr. Schwartz added, "That's crucial. We strongly encourage caregivers to come to at least one of the surgical appointments”. In addition, Lighthouse Surgery Center created a nurse concierge program, so patients and caregivers have a contact person before and after procedures. This has been very effective and is highly recommended.
3. Staff must have the training and expertise to run ASCs effectively and accommodate different case types. "Nurses need to have an ASC mentality, which means understanding that patients are going home after their surgery," Ms. Jackson said. During COVID-19, when case volumes were low, Lighthouse Surgery Center paired younger nurses with more seasoned staff for coaching and mentoring. The nursing team also works in close collaboration with anesthesia, physician assistants and the surgeons to ensure that procedures are done efficiently.
4. Perioperative pain management protocols support enhanced recovery at home. Dr. Schwartz focuses on three questions when migrating surgeries to the ASC: Can the patient leave safely? Can the patient stay at home safely with no complications? And will the patient be comfortable while at home? " Protocols like ERAS [enhanced recovery after surgery] are the most important for discharge planning. Discharge planning and patient experience is a whole team approach. We want people moving as soon as possible after surgery. Zero pain isn't our goal, but we want people to move comfortably," he said. Both Dr. Schwartz's team and Lighthouse Surgery Center use EXPAREL ®, bupivacaine liposome injectable suspension, for interscalene brachial plexus nerve blocks and fascial plane blocks. Unlike opioids, liposomal bupivacaine doesn't cause side effects like nausea, vomiting or urinary retention, which can prevent patients from going home after a successful procedure. "What I find really impressive about EXPAREL ® is that it smooths out the patient's recovery," Ms. Jackson said. "They slide through the acute period when they would have significant pain much more easily. That is often reflected directly in their Press-Ganey scores."
Dr. Schwartz commented that postsurgical opioid use after ambulatory surgery may lead to unnecessary healthcare resource utilization and referenced, Opioid-related adverse events (ORAEs) and the importance of getting the patient home and keeping them home. Dr. Schwartz said, “You can think of this as marketing for your center; are patient’s staying home comfortably? If the surgery went well, they are walking again, and meeting recovery milestones, but if they have side effects such as constipation, it can ruin satisfaction scores even after everything went well.” Finally, Dr. Schwartz noted that many states, such as New York, have limitations with the quantity of opioids prescribed and they track them closely.
5. Business success in the ASC market requires careful financial planning. "Many surgery centers make the mistake of performing the case, then they look at the economics," Ms. Kehayes said. "If 'A plus B equals negative C,' you will never make up the difference on volume." Savvy ASCs utilize physician preference cards, evaluate case costs for drugs, medical supplies and implants and identify capital cost requirements for new equipment and maintenance agreements. Ms. Kehayes advised that evaluating commercial payer contracts, determining the rates that are needed and re-negotiating contracts with rates that are inadequate prior to performing cases, are critical for success. And, if the ASC is using EXPAREL ®, the ASC should factor this into the contract negotiation by pursuing separate reimbursement and or factoring it into the reimbursement rate for the case. Finally, Ms. Kehayes expressed caution with performing cases when contracts have inadequate reimbursement for performing the case. Once the cases have been performed, the payer views a rate increase as an increase to their unit cost rather than a reduction in the total cost of care. When an ASC can demonstrate to the payer that cases can migrate from the hospital and it reduces the total cost of care, a payer is more likely to align with the ASC and re-negotiate rate increases that are needed to perform the case.
To successfully migrate patients and procedures to the ASC, healthcare leaders recognize that careful and comprehensive planning is needed across clinical, operational and financial requirements. A focus on patient selection and education, staffing, enhanced recovery protocols and proactive financial planning can make the difference between success and failure.