Image by sungmin cho from PixabayAs federal regulators push to eliminate the Medicare Inpatient Only (IPO) list, ambulatory surgery centers (ASCs) stand to benefit from a wider range of eligible procedures.
But to fully capitalize on the change, ASC operators may need to refine their patient-selection process. Being able to efficiently determine whether a patient is right for a procedure in an ASC will become increasingly critical.
This is something many ASC leaders are already thinking about. During Tenet Healthcare’s (NYSE: THC) second-quarter earnings call, for example, CEO Saum Sutaria discussed how the proposed rule presents a clear opportunity for the company’s ambulatory surgery platform, so long as ASCs are discerning about who they operate on.
“As you know, the patient selection criteria and expertise makes a big difference there, so that you’re doing the right things clinically,” Sutaria said. “Those are all areas in which we’re pretty advanced as an ASC operator and platform. So I think it plays to our advantage.”
Ultimately, the shift away from inpatient-only designations will require collaboration with physicians to develop the right protocols for the freestanding setting, Sutaria added.
“It gives us a platform to work with physicians to build the right protocols for many of these things, to move into that more freestanding setting with the right patient selection,” he said.
Layered processes
Michelle Kastler, nurse administrator at Four Peaks Surgery Center in Sun City, Arizona, told ASC News her center uses a tiered screening process to flag patients who may not be appropriate for outpatient surgery.
Four Peaks Surgery Center specializes in urology, orthopedics, gastroenterology and ophthalmology.
“The office knows not to refer patients who are too obese or have too many comorbidities,” Kastler said. “But if they do refer someone, we have a screening process that starts with our schedulers. Then our nurses take the next look, another layer of screening. If there’s still any question, they’ll send [the case] to me.”
The process doesn’t stop there, she added.
“On the day of surgery, I do one more review before we ever take the patient back,” Kastler said.
For Tammy Straub, administrator of perioperative services at Lehigh Valley Health Network, state regulations play an important role in patient selection. In Pennsylvania, there are strict rules around which patients can be treated in freestanding ASCs.
“A lot of that is surrounded around their comorbidities,” Straub said. “If they meet that criteria, then obviously we support those patients being [taken care of] in our ASC. If their comorbidities are more complex and don’t meet that criteria, then that would be a procedure that’s set forth for the hospital.”
But clinical screening can also intersect with financial clearance, particularly when insurers deny outpatient care, Straub said.
“If it goes through the verification process and it’s denied, we’ll try and do our best to override that denial,” she said. “If that doesn’t work and the patient still wants surgery in the ASC setting, we set up payment plans or offer them alternatives.”
Those alternatives may include hospital-owned outpatient departments, which are sometimes covered under different contracts.
“We have hospital ASCs that are owned by the hospital,” Straub said. “It may be an option for them to be done in one of the hospital department ambulatory sites.”
The human factor in patient selection
Screening for comorbidities is essential, but it’s not enough, Katie Pierson, regulatory specialist at Ambulatory Healthcare Strategies, told ASC News. Social and logistical factors can determine whether an ASC is the right site of care, too.
“The medical piece is only a part of the pie,” Pierson said. “We really have to look at it from a [holistic view]: ‘Do you have somebody at home? Do you have a bed that’s going to be high enough for you to get into? Do you have all the things that you’re going to need to be able to recover in your home safely?’”
In the hospital setting, patients who lacked those resources could often be discharged to a rehab facility. That’s not the case for ASC patients, Pierson said.
“At the ASC, you don’t have that option,” Pierson said. “Everybody has to go home.”
It’s also important to really connect with patients and explain their options, Straub said.
“It’s always about patient safety,” Straub said. “It’s not just, ‘We can’t do your surgery here.’ It’s reaching out and connecting with those patients to help them understand and help them navigate [questions like] … , ‘Where can I go? How can I still get this care?’”
A path forward
As surgical migration accelerates, more procedures are shifting into the ASC space, even ahead of the IPO change.
Straub said her system is actively evaluating which cases and specialties can be moved safely.
“We’re looking to expand total joints, plastics, complex ENT, ophthalmology,” she said. “We already have some of these in our ASCs, and we’re assessing which ones we can expand further.”
Having multiple outpatient sites has allowed the system to move quickly and safely, even for patients who enter through the emergency department, Straub added.
“If somebody comes into the emergency department and has a minor fracture, we don’t have to admit them,” she said. “We can send them home and bring them in within a short period of time to have it done at an ASC.”
Straub, who previously ran her own ASC and worked for AMSURG, said preserving the viability of the ASC model will require more than clinical excellence. It also demands savvy contract negotiation and a clear understanding of both direct and indirect costs.
“ASCs are more efficient. They cost less. The patients have better satisfaction,” she said. “But as things become more challenging financially, we have to be on top of those things to keep them viable.”
She encouraged systems to take a close look at reimbursement differentials, not just the revenue figures.
“Let’s say the hospital gets reimbursed $5,000 for a carpal tunnel and the ASC gets $3,500. You’ve got to do a deeper dive. What’s the overhead? What’s the indirect cost?” Straub said. “ASCs continue to prove that the overhead is less.”
