Dr. Abbey Vandersall, Dr. Jason Cuéllar and Jessica Roberts-Becerra at the Ambulatory Surgery Center News Investment & Operations conference.A confluence of factors, including patient preference and federal approvals, are spurring the shift of complex procedures into the outpatient space.
Yet from the physician perspective, one of the chief motivators is a better surgical experience.
“I do, at this point, at least 80% of my spine surgery cases in an ambulatory surgery center (ASC), and that means I don’t have to run them through the hospital,” Dr. Jason Cuéllar of Cuéllar Spine said during the Ambulatory Surgery Center New Investment & Operations conference. “I can come home with my family at 3 or 4 p.m. after doing four spine cases, whereas, in the hospital, I can barely do two by 7 p.m.”
Jupiter, Florida-based Cuéllar Spine is an orthopedic surgery center.
Other ASC industry insiders agree with those sentiments.
“When I first started my nursing career in a surgery center, there were so many independent physicians, and there still are – about two-thirds of them,” Jessica Roberts-Becerra, co-founder and managing partner at Vertex Surgical Solutions, said at the conference. “One of the advantages they have is a better work-life balance, and we do our best to support and maintain that.”
Vertex Surgical Solutions provides regulatory, administrative and leadership services for the ASC industry.
Higher-acuity procedures gaining traction in ambulatory surgery centers include orthopedic surgeries, such as total joint replacements and spinal surgeries, and cardiac and vascular procedures, particularly in centers equipped with the right technology and staff.
Surgeons and patients both benefit from shorter recovery times and fewer hospital-based complications, Roberts-Becerra and Cuéllar said.
And there are cost savings, too. For example, researchers found that the cost for total hip and knee replacements in an ASC was 40% less than the cost in the hospital. On average, outpatient surgery costs $11,677, with inpatient surgery costing $19,361.
The U.S. Centers for Medicare & Medicaid Services (CMS) has gradually expanded the list of procedures eligible for ambulatory settings. Notable examples include total knee arthroplasty, and some spine and cardiac procedures.
And smaller sets of advanced orthopedic, spine, and cardiac procedure codes are periodically reviewed and approved by CMS each year, further opening the door for ASCs to take on more complex cases.
Outpatient facilities looking to embrace higher-acuity surgeries should lead with their strong outcomes, low complication rates, zero or minimal infection levels and strict patient selection protocols, Cuéllar and Roberts-Becerra said.
Dr. Abbey Vandersall, SVP and chief clinical officer at AMSURG, echoed those notions.
These measures can help secure favorable contracts with payers who are increasingly interested in cost-effective care.
“Keep patients at the top of everything you do,” Vandersall said at the Investment & Operations conference. “The margins do help scale, but at the end of the day it’s about good quality care and patient safety.”
Tennessee-based AMSURG operates over 250 surgery centers nationwide.
Big-picture forces driving higher acuity
On a macro scale, shifting demographics mean more patients than ever need surgical interventions, especially in orthopedics and cardiovascular care.
And hospitals may not have the capacity to meet surging demand.
“We have a rapidly aging population,” Vandersall said. “Especially if you’re talking orthopedic procedures, or if you’re talking cardiac procedures, there’s a real exponential curve, unfortunately, in demand for those procedures. So the question is: How do we reimagine the supply side?”
By offering faster scheduling, lower infection rates and often lower costs, ASCs are well positioned to capture higher-acuity volumes, Roberts-Becerra said.
“Health systems are typically looking to have an ASC strategy, as I think we’ve all heard, because ASCs are really the future way to go, and health systems have to have a game plan if they expect to keep those patients in-network,” she said. “Once these cases start coming off [the inpatient list], they’re going to be pushed to the ASC, and it’s going to be really important to work out an ambulatory footprint and ambulatory strategy.”
While higher-acuity procedures are shifting into ASCs, centers need to ensure they’re able to handle that volume safely. Chasing higher-acuity volumes may help an opportunity grow, but it could also set the center up for failure if it’s not prepared.
Cuéllar outlined what he called a three-part equation: the surgeon, the team and the equipment.
“If we started having complications happening, then it’s going to be all downhill from there,” he said. “Not all surgeons should do their cases in the surgery center. Patient selection is a really big part of that. I’m not bringing my severe comorbidities to a surgery center.”
While outpatient spine surgery can be performed safely, facilities must have the right tools, such as a cell-saver for potential blood loss, and they must strictly select appropriate patients to avoid complications or emergency hospital transfers, Cuéllar continued.
Patient selection criteria should include operational considerations, such BMI thresholds, and medical clearance and personal considerations, such as whether a patient has the support network at home to handle same-day discharge.
“There is also a highly personal social determinant, and no two patients, even with the same check boxes on a form, will necessarily be the same fit,” Vandersall said.
Dr. Abbey Vandersall at the Ambulatory Surgery Center New Investment & Operations conference.
Operational and logistical considerations
When ASCs look to scale and integrate higher-acuity service lines, careful planning is essential. Roberts-Becerra recommended starting small.
“I wouldn’t necessarily start with the most difficult case, but really choose your patients,” she said. “Start with an easier patient population to begin with, and then advance as your staff gets comfortable.”
Leaders should keep a close eye on costs, particularly the price of implants and supplies, as well as any capital expenses required to accommodate bigger cases, Roberts-Becerra said.
For example, using propofol sedation rather than moderate sedation for colonoscopies offers several operational, clinical and quality advantages, she said. And fully sedated patients are generally more willing to undergo the procedure because it’s more comfortable, which, in turn, improves compliance rates.
“Think about the long-term cost to the payer if a whole population ends up with colon cancer simply because they avoided screenings due to the type of anesthesia offered,” she said. “When you consider all these factors, there’s a clear way to communicate this to the payer, especially if you involve a clinical expert in the negotiations. It really helps.”
While payer strategies around higher-acuity cases remain highly variable, often differing by state and insurance product, the ASC sector can push payers in a more favorable direction by providing robust data, Vandersall said.
Still, some payers may be receptive to working collaboratively, while others may take a more conservative stance. Regardless, success often depends on coming into meetings with data prepared, she said.
“I was very fortunate to be able to go into a literal dashboard with all of our centers and track and trend all of our clinical quality metrics,” Vandersall said. “We were able to see that in real time, and that can be done even if you’re a single independent center just track and trend locally – keep the pitch deck in your back pocket.”
This helps with proving value to payers, she said.
“If we were a small independent center, I’d just track and trend on paper for a year, define a contract, put it in front of them, and say, ‘Here’s the data,’” she said.
Cuéllar agreed, adding that leveraging proven results is crucial when negotiating rates, especially for complex procedures.
“We have zero infections, zero hospitalizations,” he said. “We can give better contracts if we keep track of that data.”
Dr. Jason Cuéllar and Jessica Roberts-Becerra at the Ambulatory Surgery Center New Investment & Operations conference.
Looking toward the future
Moving higher-acuity cases into an ASC demands expert clinicians, particularly in anesthesia, nursing and surgical technology, Cuéllar said.
Although there have been recent efforts to extend more responsibilities to CRNAS in light of the anesthesiologist shortage, Cuéllar recommended airing on the side of caution.
“You can’t have a CRNA who doesn’t know how to handle those cases,” he said. “If something goes bad, you need someone with experience so that the patient doesn’t die.”
Recruiting and retaining staff is an ongoing challenge, especially with hospitals often offering competitive wages. However, the ASC value proposition can be compelling: no on-calls, no weekends and a more focused scope of practice.
And some operators even explore more creative models, like equity and employee ownership models, Roberts-Becerra said.
“We have seen some centers that develop a model so that staff has some sort of equity or ownership as well,” she said.
Forging a sustainable path for higher-acuity care in ASCs will require deliberate growth, thorough patient selection and a focus on outcomes, Roberts-Becerra, Cuéllar and Vandersall all underscored.
“Have a plan for what you’re going to do,” Roberts-Becerra said. “Create goals. Five-year plans, 10-year plans, 15-year plans, … and be ready to pivot if you have to.”
Most of all, it is important to take a measured approach so that centers do not overextend themselves clinically or financially, Cuéllar said.
“You have to build a team that has experience in those high-acuity cases,” he said. “You can’t be doing that for the first time in an ASC.”
