ENT has long been a staple specialty for ASCs. For surgery centers to continue finding success and growth with ENT, it is important to remain informed about the issues that could contribute to or limit success. Here are five trends, developments and challenges in ENT facing ASCs today.
1. Patient population “swings”
As with any specialty, a significant swing in patient population from a high-paying commercial payor to a lower paying commercial or government payor may cause financial stress on a center.
For example, the Specialty Surgery Center in San Antonio, Texas, has faced recent swings in the percentage of its Medicaid patient population.
“We swung from 19 percent to 25 percent in the Medicaid population we were treating, and it was a bit of a punch to the financials,” says Steven Blom, RN, MAHSM, CASC, regional director for the center. “When we get a swing in the Medicaid population, you kind of feel the pinch because they only reimburse for one procedure and it’s usually at a fairly low rate.”
While asking surgeons to perform these Medicaid cases in a different setting would seem to solve the problem, “cherry-picking” has not been a feasible option for the center.
“The (surgeons) can’t really split up their time,” says Mr. Blom. “We can’t say ‘do your Medicaid in the hospital because the surgery center can’t really make any money on Medicaid and do your commercial stuff here;’ they need to do all of their cases in one setting and move on. That’s a challenge. We just watch it closely, have to be efficient and do case-costing. When you’re working in the surgery center and the physicians are owners, everyone pays attention. You just have to be prepared.”
2. More procedures coming from the hospital
Mr. Blom has seen a migration of some of the more complex cases leaving the hospitals and coming to the surgery center over the past five years. The latest to significantly shift is thyroidectomies.
“They might have done a partial thyroidectomy here in the past, but now we’re doing full thyroidectomies; parathyroidectomies as well,” he says.
The reason the Specialty Surgery Center can now perform these cases does not have to do with the complexity of the surgery but rather that the patients were kept in the hospital for the lab testing, such as a parathyroid hormone test run on the patient before and after the surgery which then dictates whether the patient returns home on a calcium medication. The center realized that it could outsource the labs and, therefore, perform the cases.
With the ability to outsource the labs and improving technology, Mr. Blom says he expects to see more complex cases related to thyroid treatment coming to ASCs.
Even some procedures commonly performed in the surgery center, such as tonsil and adenoid removal surgery, are seeing greater migration from the hospital, says Pam Wrobleski, CRNA, MPM, CASC, administrator for Southwestern ASC in Pittsburgh, Pa.
“Our medical community in the Pittsburgh area tends to be pretty conservative, so I think there are still a lot of ENT practitioners that like to do those cases in a hospital setting and like to keep the patients longer,” she says. “But we’re seeing more of those cases than in the past as I think the (growing) trend is that some of the younger guys are maybe a little more comfortable in the freestanding setting and do not feel the need to keep their patients as long.
“There have been recent studies that show that outcomes and complications are the same whether tonsillectomy patients are kept in PACU for two hours or four hours because most instances of post-op bleeding occur in the very immediate post-op period or else after several days. Therefore, the perceived need for a hospital backup should become less and less.”
3. Advancements in technology
Newer technology has expanded the type of procedures ASCs can perform, and new technology on the horizon should continue to grow opportunities for ASCs. Here are just a few of the new technologies ASCs can consider for their centers.
• ArthoCare wands. The newest piece of technology that Mr. Blom has seen stick around in the surgery center is a single-use wand developed by ArthoCare.
“It does more like an ablation in taking out the tonsils and adenoids,” he says. One technique to remove the tonsils and adenoids involves snaring then using a suture to essentially sew up the hole, which also involves cauterizing.
“This ArthroCare wand does kind of the same thing as the cautery but it seals it so it doesn’t require any of the suturing,” Mr. Blom says.
It has become popular in his center — with three of his eight ENT surgeons insisting on using it all of the time — because the device cuts down on instrumentation use. The one concern Mr. Blom has with the device is that it is a single- use instrument and costs about $90 per case, he says, whereas, before, the surgeons using the device used instrumentation that was re-sterilized. The increase in cost can become very significant, particularly with Medicaid cases.
“But that particular technology seems to be working and it’s moving into the future,” he says. “The younger guys really like it.”
• CT-guided imaging for sinus. This technology is a few years old and allows surgeons to perform a scan on the patient, feed the scan into the computer in the OR and then put a special cap on the patient which allows the surgeon working in the sinuses to see on the computer exactly where he is in relationship to the brain.
“We didn’t necessarily acquire it for the surgery center, but many surgeons are using it,” says Mr. Blom. “Some of my surgeons will take these cases to the hospital and will want to use the CT-guided device, but it’s probably 10 percent of the cases on the sinuses that they do that. We looked at acquiring the device, and they do have a code for it, but what you would get paid was really a pittance, so at the time I looked at it, it just didn’t make sense.”
Ms. Wrobleski shares that sentiment.
“It can be pretty cost-prohibitive unless (the center) has a really high volume of those types of cases and you can work out some type of reasonable lease arrangement with the companies that would bring in that equipment because that’s not something that would be used by a lot of other specialists,” she says. “Depending upon what your insurance contracts are and whether they are going to reimburse you for any of that kind of very specialized equipment, you really have to pick and choose carefully.”
• Balloon sinuplasty. This procedure uses balloons that go into the sinuses and then dilate and expand the sinus cavity.
According to Acclarent, the manufacturer of the Relieva LUMA Sinus Illumination System for balloon sinuplasty via sinus transillumination, the technology replaces the use of fluoroscopy C-Arm in balloon sinuplasty procedures. The system shines a lighted guide wire into the sinus to confirm wire location without the need for fluoro-guidance. Other benefits include elimination of the need for staff members in the room to wear lead gowns or thyroid collars and no radiation concern for the patient.
The challenge of this technology is that its use is limited as it can only be used on the frontal sinuses, says Mr. Blom.
“If they have to do the ethmoids and go farther back, then they would still have to use the older technology, and all of a sudden you’re using two technologies on a patient,” he says. “But they’re coming out with derivations of the balloon sinuplasty that might improve it.”
• Sailendoscopy. This procedure involves removing a stone from a salivary gland without cutting into the gland and laying open the salivary duct, says Lynda Simon, RN, director of nursing and manager of head and neck surgery for the St. John’s Clinic: Head and Neck Surgery in Springfield, Mo. The technology was developed through Karl Storz.
“It uses a tiny obturator and sheath that goes down the duct; the obturator is removed and a fine endoscope is passed down the sheath,” she says. “You can then visualize the stone and snare it with a stone basket, much like ureteral stones.”
According to a Karl Storz representative, the procedure is fairly common in Europe but it has not yet become a standard of care in the United States, with very few people performing the surgery.
• Radiofrequency reduction of tongue base. This technology comes from ArthroCare and involves the same equipment used for coblation of tonsils.
“It’s an outpatient procedure and has a post-op course much like a tonsillectomy,” says Ms. Simon. A challenge for ASCs interested in using this technology is that physicians may want to keep the patient for at least 23 hours, according to an ArthoCare representative, so the use of the technology may not be appropriate for all centers.
4. Sharing equipment across specialties.
The decision to invest in new technology can be made easier if the equipment purchased can serve more than one specialty. In the case of Southwestern ASC, the capital equipment needed to perform ENT endoscopy cases can also be used by the center’s orthopedic surgeons.
“We can set up a tower for (the endoscopy procedures) that can also be used for orthopedic cases like knee arthroscopy,” says Ms. Wrobleski. “So you’re able to cross that over among other specialties if you don’t have huge ENT or huge orthopedic volume. That’s another way to (possibly) bring those cases in without having a huge capital outlay for another specialty.”
5. Meeting younger physician demands
If you’re planning to bring in new, young ENT surgeons, the decision about whether to invest in new technology may be made for you. Many of these surgeons will likely have learned how to perform procedures using newer technology. If your center wants to offer or grow these cases by bringing in younger physicians, the surgeons may expect to use the new technology from which they learned their trade.
In the case of ArthoCare wand technology described earlier, Mr. Blom is seeing surgeon demand for its use growing.
“There are some young guys who are coming out of school who won’t do a case without it,” he says.
You will want to determine whether your ASC can still profit by performing cases using the new technology, factoring in the cost of the equipment. If, by investing in new technology, you profit a little less on some cases but can boost your volume and bring in more physicians, the investment may very well be a wise one that can reap long-term benefits.
Contact Rob Kurtz at rob@beckersasc.com.