Janet Carlson, executive director of ambulatory surgery centers for Commonwealth Pain & Spine.Having nurse administrators at the helm of an ambulatory surgery center (ASC) can help the facility better weather staffing shortages. It can also help centers come up with more “creative” solutions, some industry leaders believe.
“There’s a place for folks that are non-clinicians in ASCs, but I just don’t think it should be as the administrator,” Janet Carlson, executive director of ambulatory surgery centers for Commonwealth Pain & Spine, told Ambulatory Surgery Center News.
Commonwealth Pain & Spine, a health care provider in Louisville, Kentucky, specializes in minimally invasive spinal surgeries.
Beyond staffing, Carlson in her conversation with ASC News also delved into broader issues that impact ASC operations, such as surgeon disenfranchisement and rising reimbursement disparities. The industry veteran also spoke about why young physicians may be hesitant to invest in ASCs despite the long-term benefits, as well as how payers and legislators could better align payment models to support cost-effective care settings.
Highlights from the interview are below, edited for length and clarity.
ASC News: I’m curious about your views on requiring ASC administrators to be registered nurses.
Carlson: That’s something that I implement in all the surgery centers I work in, that I’m part of, that I’m building, or I’m operationalizing.
I think it’s a best practice that may not be very popular with my non-nursing friends. However, I think it is imperative, because nurses “speak surgeon,” right? They’re fluent in “physician,” meaning anesthesiology and surgery. Nurses can jump in when somebody’s day care calls and they have to leave, and nurses can jump in and fill that gap, whether it’s to pre-op a patient, help circulate a room, or help recover a patient, and the nurse manager can jump right in. We’re not going to cancel cases or delay care because somebody had to go take care of their family member.
I also think that nurses are very savvy, creative. They look at things the way that we look at patients. Basically, we triage a situation. We look at the patient and think, “What’s their chief complaint? What do they need from us? And how can we help them?” That type of thinking helps you take care of your patients and serve your surgeons, and it keeps a really healthy culture with all of your folks in the ASC who are primarily clinicians. And so I feel like the culture is key for recruitment and retention, and that the clinicians really identify with another clinician.
I know physicians are drawn to ASCs for ownership stakes and better hours. What about recruiting nurses, especially with the current staffing shortage?
Typically, we want nurses with experience, because in an ASC I expect them to work at the top of their license. For example, our nurses are ACLS-trained and must be able to identify cardiac rhythms and make clinical decisions: If a patient shows up hypertensive, we won’t medicate them for hypertension, then rush them into surgery; or if a patient goes into AFib, we won’t proceed because the patient could throw a clot. So our nurses must have sharp critical-assessment skills.
ASCs also offer Monday-to-Friday schedules – no nights, weekends, or holidays, and no on-call shifts. Clinicians know when they’ll work, and usually when they’ll go home. You can make personal plans, which is very appealing to nurses coming out of hospital systems who are burned out from 12-hour shifts and being on call.
Some people like 12-hour shifts, so in high-acuity centers, like those doing spine fusions or total joints, I’ve offered those schedules. Otherwise, you might work four 10-hour days or four 9-hour days; it can be flexible depending on the center’s needs.
ASCs also tend to work straight through the schedule until the day’s cases are done, rather than shutting down rooms prematurely like many hospitals do. If we know a physician is on vacation for one week, we can encourage other staff to take their time off too, to align with lower case volumes. Another perk is that if we finish the day early, staff can leave and not be forced to use PTO hours just to fill the schedule. That can help with retention, because people like knowing they have PTO in the bank if they need it.
On the other side of the coin, are there any common issues that push surgeons out?
Surgeons are often disenfranchised because they do their first case, which may or may not start on time, then they wait for room turnover, which can be inefficient in a hospital setting. Hospital operating rooms aren’t lean; they take longer to turn over rooms. Surgeons can’t manage their patient loads the same way they can in an ASC, assuming the patient is an appropriate fit for an ASC.
Additionally, physicians may be forced to use devices or implants approved by the hospital system, rather than what they prefer or trained on. It takes forever to get new devices approved in many health systems. If they’re employed by the health system, they’re often required to take ER calls, on top of running their own busy practices and working in an ASC. It’s exhausting, especially post-COVID, when nobody has fully recovered from years of heightened stress.
Another factor is the RVU (Relative Value Unit) structure. Surgeons get an RVU bonus if they meet certain metrics, but that can be affected by referrals, when the hospital night shift referrals [go] to new fellows the next year, it dilutes the existing physician’s pool of referrals. So there are many reasons surgeons feel disenfranchised.
I know that fewer young physicians have ownership stakes in ASCs. Any thoughts on why?
They don’t fully understand the long- or short-term value of investing in an ASC. They simply aren’t taught about it during medical school, so they have no context for what a good investment it can be. By the time they finish their boards and are ready to become partners, many are in a life phase where they’re buying a house, getting married, having kids, and are saddled with medical school debt. They may feel they can’t afford a full share. However, they could still buy a fraction of a share, start there, and expand over time as they pay down debt and build their income.
I’d love your thoughts on reimbursement disparities between ASCs and other settings.
In a nutshell, hospitals are paid reimbursement based on the hospital market basket. So that is one thing to look into. So are HOPDS, which are, for all intents and purposes, an ASC. An HOPD is an ASC paid like a hospital. That’s the disparity I’m talking about. ASCs are paid on the consumer price index. So I’m making 57 cents to the dollar while on the hospital market basket; for example, let’s say they’re making 87 cents on the dollar. But I’m providing the same service. I have the same cost. I’m paying labor, supplies, you know, rent, all the things, med supplies, pharmaceuticals. I’m paying all those bills just like the hospital is, but I’m being reimbursed less and have better outcomes. So it’s a huge disparity. There’s a scaler on the HOPD payment amount, and I’ve lobbied Capitol Hill twice about removing the scale of HOPDs to make things a more level playing field for ASCs.
Interesting, and how is that going?
I mean, it’s slow. I don’t think folks in legislation at the state and national level always know what an ASC does and understand the value proposition.
We would really love it if things were more equitable, but it’s going to be, hopefully, some payers recognizing that we can do things for less and do it better. It’s payers understanding that we can take care of patients sooner. We as an industry can point to our quality outcomes and our patient satisfaction, which is always very high. Our adverse events and really bad patient outcomes are so small, minimal, and we’re very transparent with our pricing. We’ll do cash pricing quotes, and we’ll work with people, whereas hospital systems, traditionally, they’re less flexible.
