HHS pandemic plan unlikely to receive adequate funding

Prompted by 2006 legislation, the Department of Health and Human Services (HHS) released its first National Health Security Strategy last month, hard on the heels of the H1N1 pandemic.

The plan is focused on protecting people’s health during a large-scale emergency, according to a statement from HHS, and includes 10 objectives and an implementation guide to assist public and private healthcare organizations prepare for and manage health threats.

The policy is unlikely to receive adequate funding in the near future, according to Joseph White, professor of public policy, epidemiology and biostatistics, and director of the Center for Policy Studies at Case Western Reserve University in Cleveland.

“The details in the interim strategy seem reasonably well-considered, [but] the overall rhetoric is boilerplate,” says White. “There won’t be much result because the budget situation is awful, and there is unlikely to be real money.”

BIRD FLU PROMPTS NEW PLAN

The security strategy was mandated in the Pandemic and All Hazards Preparedness Act, passed shortly after the avian flu scare in 2005 and the SARS epidemic in 2003. The legislation directed the HHS secretary to develop the plan with an accompanying implementation process by 2009 and to revise the documents every four years. HHS stated, however, that it will update the implementation plan every two years to reflect advances in public health and medicine.

“As we’ve learned in the response to the 2009 H1N1 pandemic, responsibility for improving our nation’s ability to address existing and emerging health threats must be broadly shared by everyone—governments, communities, families, and individuals,” HHS Secretary Kathleen Sebelius said in a statement. “The National Health Security Strategy is a call to action for each of us so that every community becomes fully prepared and ready to recover quickly after an emergency.”

White believes this policy is, in part, the Obama administration’s attempt to better define duties between the HHS and the Federal Emergency Management Agency (FEMA), which joined the Department of Homeland Security after 9/11. Before the terrorist attacks, FEMA took an “all hazards” approach to disaster management, which included health epidemics, White says.

“A lot of serious public administration people whom I know said at the time that putting FEMA in DHS was a terrible idea,” he says. “So ‘all hazards’ was eliminated, and FEMA basically stopped paying attention to little things like hurricanes and epidemics.”

The goals of HHS’s strategy, such as building community resilience and strengthening and sustaining emergency response systems make sense, he says, but are unlikely to be high priorities.

“I’d be shocked if there is real money behind it,” he says.

“Fable Hospital” Illustrates ROI from Evidence-Based Design

To demonstrate the return on investment on evidence-based design elements, the Center for Health Design in 2004 imagined a hospital that would include key features of recently built or redesigned facilities. Numerous research studies have shown that these design elements reduce costs and increase patients and employee satisfaction.

Fable Hospital, an imagined $240 million replacement hospital with 300 beds, would have the following design innovations, with their projected extra costs:

1. Larger private patient rooms: $4,717,500. These rooms add space for family, staff activities and in-room procedures.
2. Acuity-adaptable rooms: $816,000. Includes technology hook-ups so that patients don’t have to be moved as their conditions change. 
3. Larger windows: $150,000. To let in more light, the typical three-foot-by-five-foot window in patient rooms is enlarged to five feet by eight feet.
4. Larger double-door bathrooms: $1,509,600. This enables caregivers to more easily assist patients to and from the bathroom.
5. Hand-hygiene: $1,071,000. Hand-washing sink is installed at the doorway of each patient room and alcohol-based hand-rub dispenser is put at the bedside. 
6. Decentralized nursing stations: $556,800. Alcoves near beds provide a charting surface and access to information technology.
7. HEPA filters: $270,000. High-efficiency particulate air filters improve filtration of incoming outside air and eliminate recirculated air. 
8. Noise-reduction: $430,000. Carpet and special wall and ceiling tiles absorb sound and wireless communications eliminate overhead paging.
9. Additional family & social spaces: $510,000. A family-style great room and family kitchen placed on each patient floor.
10. Health information centers: $95,200. Centers on each floor offer brochures, books, videotapes and Internet access to patients, visitors and staff.
11. Meditation room: $61,200. Quiet spaces for family and staff meditation are located on each patient floor.
12. Staff gym: $342,500. This facility includes exercise equipment, changing rooms, toilets and showers.
13. Artwork: $450,000. This figure represents the additional artwork allowance beyond the typical budget. 
14. Healing gardens: $1,050,000. Figure includes meditation garden, strolling garden, pond, outdoor meeting area, outdoor dining and children’s playground.

TOTAL EXTRA COSTS: $12 million added to the construction budget.

Also based on studies, the center came up with the following projected savings and revenue due to the new features in the hospital’s first year of operation:

1. Reduction in patient falls: $2,452,800 savings. 
2. Reduction in patient transfers: $3,893,200 savings.
3. Reduction in nosocomial infections: $80,640 savings.
4. Reduction in drug costs: $1,216,666 savings.
5. Reduction in nursing turnover: $164,000 savings.
6. Increased market share: $2,108,100 increased revenue.
7. Increased philanthropy: $1,500,000 increased revenue.

TOTAL REVENUE & SAVINGS: $11,475,406 in the first year of operation.

Source: Center for Health Design

5 Best Specialties for ASCs Now

1. Orthopedics. Rising ASC reimbursement for orthopedic surgery is transforming a sometimes break-even field into a money-making one, says William G. Southwick, president and CEO of HealthMark Partners in Nashville. For example, shoulder surgery used to be so underfunded it needed to be supplemented by income from other procedures, he says. Now, under Medicare’s ambulatory payment classification system, reimbursement for orthopedic ASCs is expected to increase 100 percent.

Orthopedics, along with otolaryngology and general surgery, is on Mr. Southwick’s list of specialties with enhanced value for ASCs. “These specialties are good for Medicare patients and are saving the healthcare system significant dollars,” he says.

Jerry Ippolito, director of perioperative services business development at Southeast Anesthesiology, Charlotte, N.C., also puts orthopedics at or near the top of his list. “Orthopedics is a big winner under APCs,” he says. “It has some lucrative cases, such as knee arthroscopies and it is not isolated to one payor population.” For example, while total joint procedures focus on Medicare patients, “some of the most severe joint injuries happen to younger people who are on private insurance,” Mr. Ippolito says.

2. Spine. Naya Kehayes, CEO of Eveia Health Consulting & Management in Issaquah, Wash., sees a great deal of promise for this specialty. “Spine is probably the newest, biggest most costly surgery done in the hospital that can be done outpatient,” she says, but she cautions that ASCs should contact payors before deciding to add any specialty. “The biggest mistake an ASC can make is to buy all the equipment and then talk to the insurer,” she says. Ms. Kehayes also sees great potential for ASCs that add cochlear implants, vaginal hysterectomies and some of the larger urology cases to their list of procedures..

Robert S. Bray Jr., MD, a neurosurgeon who runs a spine ASC in California, believes that “the future of spine surgery is in the ASC. “Spine will literally be a game-changer for ASCs in the next 10 years.” He warns that ORs have to be larger than at the average ASC to accommodate spine surgery equipment and ORs have to be “ultra clean,” so they cannot be shared with specialties like gastroenterology. And it takes a while to convince insurers that spine can be performed safely in an outpatient setting, he says.

3. Bariatrics. Along with spine and retina, bariatrics is on Mr. Southwick’s list of specialties with growing value for ASCs because they have been slowly moving out of the hospital setting. Laparoscopic gastric band procedures, or lap-bands, are the only bariatic procedures that are typically performed in an ASC, he says. In contrast, he says gastric bypass surgery requires two or three days of hospitalization and costs a great deal more.

Mr. Southwick notes that the recession has dampened demand for lap-bands, which cost $10,000-$15,000 and are often paid by the patient out of pocket. But popularity is expected to rebound, because an estimated 5-7 percent of the population is eligible for bariatric surgery.

However, “keep in mind that bariatrics needs the whole array of services [for the ASC] to be a bariatric center of excellence,” warns Ms. Kehayes. These include patient support services and features such as patient-lifting equipment, wide doorways, floor-supported toilets and sensitivity training for the staff.

4. Retina. Many ophthalmology ASCs limited to cataract surgery are adding retina surgery, which is usually handled by a separate subspecialty of some 1,300 ophthalmologists. These procedures are longer and more complicated and, until recently, were almost always done in the hospital.

While retina is now safe to do in ASCs, ophthalmology surgeons were discouraged from moving out of the hospital by low reimbursements that didn’t cover costs in the ASC. However, under the new Medicare APC system, retina payments will rise 100 percent, according to Leo T. Neu III, MD, a retina surgeon who runs an ASC in Springfield, Mo. He says the average payment for a standard pars plana vitrectomy, the most common retina procedure, will rise 145 percent by 2011, to $1,540.

On the professional fee side, Dr. Neu adds that declining reimbursement for some retinal procedures will lure retinal surgeons out of the hospital and into the ASC. For example, Dr. Neu reports that the Medicare professional fee for a vitrectomy with epiretinal membrane peeling fell by 24 percent in 2008.

5. Pain management. Along with gastroenterology and ophthalmology, pain management is on Mr. Southwick’s list of specialties with continued value for ASCs. “These specialties continue to be successful in ASCs, if expenses are managed carefully, even as reimbursements for them are cut,” he says. While most of the cutting has been due to Medicare APCs, “private payors are beginning to reflect those cuts,” he says.

Even though reimbursement to ASCs for pain management will fall 2 percent under APCs, volume is rising. A study conducted last year by KNG Health Consulting found that pain management was one of the few ASC-based specialties where most of the new procedures in centers were not simply moving out of the hospital. While 77-95 percent of new volume in orthopedics, ophthalmology and other specialties came from hospitals, the figure for pain cases was 15 percent. The new volume represents “significant changes in insurance coverage and advancement in the pain management clinical treatments [that] have evolved in the past seven years,” the study said.

8 Top Hospital and Health System Trends of the Past Decade

1. Loosened cost controls. HMOs in the late 1990s had successfully slowed growth in healthcare spending, but by the end of that decade they had come to be regarded as heartless conservators of the bottom line. Managed care’s tight controls began to loosen and “the negotiating power slipped back into the hands of the providers,” says Dick Clarke, president of the Healthcare Financial Management Association. Healthcare costs again began increasing faster than the general rate of inflation. “It’s not clear yet how much of that will change if providers come under more pressure to contain prices,” he says. 

2. Healthcare IT. Healthcare information technology, still rough around the edges in 2000, became a major force in hospital operations by the end of the decade, says Michael Rowan, COO and executive vice president of Catholic Health Initiatives in Denver. Innovations like computerized physician order entry and electronic medical records have been shown to improve safety as well as efficiency. Now, thanks to billions of dollars in incentives in the 2009 HITECH legislation, healthcare IT holds the promise of becoming virtually universal in the next few years. But Mr. Rowan reports that HITECH funds will pay for only about a quarter of the cost of the new technology. 

3. Patient safety movement. At the start of the decade, hospitals were just beginning to hear word of one of the most influential reports in the history of U.S. healthcare: “To Err Is Human: Building a Safer Health System,” published in Nov. 1999 by the Institute of Medicine. It concluded that from 44,000- 98,000 people die annually — the equivalent of 10 fully loaded 757 commercial airliners crashing each week, the report stated — due to errors in inpatient hospital treatment.

As a result, “hospitals started to get much more serious about quality and safety,” says Mr. Clarke at HFMA. The industry embraced continuous quality improvement, adds Thomas Dolan, president and CEO of the American College of Healthcare Executives. “Everybody realized that we have to constantly improve quality and it actually lowers costs because it reduces waste,” he says.

4. Physician entrepreneurialism. Many physicians became entrepreneurs, investing in ASCs, imaging centers and specialty hospitals as a way to supplement declining income due to lack of increases in reimbursements and become more efficient. The trend, however, put physicians into conflict with hospitals, who were concerned about losing market share to the leaner, physician-run organizations. By the end of the decade, it seemed that hospitals and regulators had blunted the trend.

“The ban on physician-owned hospitals in the health reform legislation signals the decline of the entrepreneurial physician,” says Nicholas Wolter, MD, a former MedPAC commissioner and CEO of the Billings (Mont.) Clinic. However, ASCs seem to have become a permanent fixture in U.S. healthcare, offering discounts too big for payors to pass up. 

5. Healthcare consumerism. “The future of market-oriented health policy and practice lies in ‘managed consumerism,’ a blend of the patient-centric focus of consumer-driven healthcare and the provider-centric focus of managed competition,” declared Jamie Robinson, a professor of health economics at the University of California, Berkeley, School of Public Health, in 2005 in the journal Health Affairs.

With the decline of HMOs, consumer-driven healthcare became a new way to contain costs. High deductible plans, with or without tax-free health savings accounts, would make patients cost-conscious consumers. Ratings of doctors and hospitals, from HealthGrades to CMS’ Hospital Compare site, would aid patients in choosing the best providers. Retail clinics opened to serve these new consumers. Hospitals developed a new fascination with patient satisfaction surveys. Brand-new hospitals lavished spending on patient-friendly design features, such as single rooms, sunlit atriums and concierge services, and these features seemed to shift market share. 

6. Shortages of healthcare personnel. In July 2007, the American Hospital Association reported 116,000 open positions for registered nurses in hospitals, and the existing RN workforce was aging. Mr. Rowan at Catholic Health Initiatives observes that the recession has erased the shortage for now, at least, as RNs were forced back into the workforce or into full-time work as family income fell.

Physician shortages also emerged. In a dramatic about-face at the beginning of the decade, the federal Council on Graduate Medical Education abandoned its long-held forecast of a physician surplus and predicted a shortage of 85,000 physicians by 2020. Since then, medical schools have been substantially increasing class sizes, but Congress has not removed a cap on the number of Medicare-funded graduate medical education positions for physicians that has been in place since 1997.

“Current evidence suggests that the United States is headed toward an aggregate shortage of physicians,” the Association of American Medical Colleges declared in 2009. “Given the extended time required to increase U.S. medical school capacity, and to educate and train physicians, the nation must begin now to increase medical school and GME capacity to meet the needs of the nation in 2015 and beyond.”

7. Accountable health organizations. While entrepreneurial physicians continued to spin off from hospitals throughout the decade, Dr. Wolter, the former MedPAC commissioner, says an opposing trend also emerged. Many young physicians were eagerly becoming employees. Accountable health organizations such as Mayo Clinic, the Cleveland Clinic and Geisinger Health System thrived by closely aligning hospitals and doctors to make care more efficient and effective.

Mr. Rowan at Catholic Health Initiatives says accountable health organizations seemed to be taking a lesson from the ASC playbook. Incentivizing physicians can make healthcare more efficient. But he adds that the trend is not easy for hospitals. “Many hospitals have no expertise in running practices,” Mr. Rowan says. “We’re hospital people, not group management people.” Hospitals used to hire doctors merely to generate business. Now, he says, “hospitals want doctors to take financial responsibility for outcomes.”

8. Recession. “The decade will be known for the financial turmoil that came at the end,” says Mr. Clarke of HFMA. In March 2009, Thomson Reuters reported that the median profit margin of U.S. hospitals has fallen to zero percent. Hospitals tightened their belts and many of them ended the decade solidly in the black. But the numbers of non-paying patients are still high and many leaders like Clarke believe we are entering an era of having to do more with less.

Silent PPOs under scrutiny

There recently has been a national legislative trend to restrict or limit the use of “silent PPOs,” “non-directed PPOs,” “ghost PPOs,” or “blind PPOs,” all of which refer to the same thing. This has been a major legislative priority for the American Medical Assn, as well as state and local medical societies.

On November 23, 2008, the National Conference of Insurance Legislators (NCOIL) adopted model legislation aimed at regulating silent PPOs. Some states, such as Ohio and Florida, have already passed legislation restricting the use of silent PPOs and others may consider passing legislation similar to the model legislation in the next legislative session.

STATES NOT SILENT

For example, Texas recently considered, but did not ultimately pass, a silent PPO bill that would have strengthened the existing law. Texas has had a silent PPO law on the books since 1999, which provides that PPOs may not sell, lease or otherwise transfer data regarding the payment or reimbursement terms of the contract without the express authority of and prior adequate notification of the other contracting parties.

Texas may ultimately revisit the manner in which to regulate silent PPOs when the next legislative session convenes in 2011.

Because of increased regulatory attention in this area, contracting parties, including PPOs and providers, should consider monitoring any developments with respect to the regulation of silent PPOs.

Silent PPOs are many times described as arrangements whereby organizations access discounted rates for healthcare services from healthcare providers without contractual authorization from the providers.

LISTEN TO THE LEGISLATION

The model legislation adopted by NCOIL sets forth specific requirements for contracting parties, providing that a contracting entity may not grant access to a provider’s discount unless the provider network contract specifically states that the contracting entity may enter into an agreement with a third party. The legislation also provides that the third party accessing the provider network contract is contractually obligated to comply with the terms of the provider network contract.

Further, in an attempt to provide transparency, the model legislation contains certain disclosure requirements. For example, a contracting entity that grants access to a provider’s services and discounts must identify and provide to the provider, upon request, a list of all third parties to which the contracting entity has executed contracts or will grant access to the provider’s services and discounts, thereby allowing providers to determine if the networks and the discounts have been properly accessed.

Among other requirements, the model legislation also sets forth obligations for third parties that have been granted access to a provider’s healthcare services and discounts, and provides that unauthorized access to provider network contracts is an unfair insurance practice. Because the regulation of silent PPOs has received national attention as well as increased scrutiny in many states, contracting parties should continue to monitor any new developments.

This column is written for informational purposes only and should not be construed as legal advice.

Abbott Cuts Use of Oil and Coal by 35 Percent

Abbott Cuts Use of Oil and Coal by 35 Percent

Blind may regain a useful level of vision

Inspired by the success of cochlear implants that can restore hearing to some deaf people, researchers at MIT are working on a retinal implant that could one day help blind people regain a useful level of vision.

The eye implant is designed for people who have lost their vision from retinitis pigmentosa or age-related macular degeneration, two of the leading causes of blindness. The retinal prosthesis would take over the function of lost retinal cells by electrically stimulating the nerve cells that normally carry visual input from the retina to the brain.

Such a chip would not restore normal vision but it could help blind people more easily navigate a room or walk down a sidewalk.

“Anything that could help them see a little better and let them identify objects and move around a room would be an enormous help,” says Shawn Kelly, a researcher in MIT’s Research Laboratory for Electronics and member of the Boston Retinal Implant Project.

The research team, which includes scientists, engineers and ophthalmologists from Massachusetts Eye and Ear Infirmary, the Boston VA Medical Center and Cornell as well as MIT, has been working on the retinal implant for 20 years. The research is funded by the VA Center for Innovative Visual Rehabilitation, the National Institutes of Health, the National Science Foundation, the Catalyst Foundation and the MOSIS microchip fabrication service.

Led by John Wyatt, MIT professor of electrical engineering, the team recently reported a new prototype that they hope to start testing in blind patients within the next three years.

Electrical stimulation

Patients who received the implant would wear a pair of glasses with a camera that sends images to a microchip attached to the eyeball. The glasses also contain a coil that wirelessly transmits power to receiving coils surrounding the eyeball.

When the microchip receives visual information, it activates electrodes that stimulate nerve cells in the areas of the retina corresponding to the features of the visual scene. The electrodes directly activate optical nerves that carry signals to the brain, bypassing the damaged layers of retina.

One question that remains is what kind of vision this direct electrical stimulation actually produces. About 10 years ago, the research team started to answer that by attaching electrodes to the retinas of six blind patients for several hours.

When the electrodes were activated, patients reported seeing a small number of “clouds” or “drops of blood” in their field of vision, and the number of clouds or blood drops they reported corresponded to the number of electrodes that were stimulated. When there was no stimulus, patients accurately reported seeing nothing. Those tests confirmed that retinal stimulation can produce some kind of organized vision in blind patients, though further testing is needed to determine how useful that vision can be.

After those initial tests, with grants from the Boston Veteran’s Administration Medical Center and the National Institutes of Health, the researchers started to build an implantable chip, which would allow them to do more long-term tests. Their goal is to produce a chip that can be implanted for at least 10 years.

One of the biggest challenges the researchers face is designing a surgical procedure and implant that won’t damage the eye. In their initial prototypes, the electrodes were attached directly atop the retina from inside the eye, which carries more risk of damaging the delicate retina. In the latest version, described in the October issue of IEEE Transactions on Biomedical Engineering, the implant is attached to the outside of the eye, and the electrodes are implanted behind the retina.

That subretinal location, which reduces the risk of tearing the retina and requires a less invasive surgical procedure, is one of the key differences between the MIT implant and retinal prostheses being developed by other research groups.

Another feature of the new MIT prototype is that the chip is now contained in a hermetically sealed titanium case. Previous versions were encased in silicone, which would eventually allow water to seep in and damage the circuitry.

While they have not yet begun any long-term tests on humans, the researchers have tested the device in Yucatan miniature pigs, which have roughly the same size eyeballs as humans. Those tests are only meant to determine whether the implants remain functional and safe and are not designed to observe whether the pigs respond to stimuli to their optic nerves.

So far, the prototypes have been successfully implanted in pigs for up to 10 months, but further safety refinements need to be made before clinical trials in humans can begin.

Wyatt and Kelly say they hope that once human trials begin and blind patients can offer feedback on what they’re seeing, they will learn much more about how to configure the algorithm implemented by the chip to produce useful vision.

Patients have told them that what they would like most is the ability to recognize faces. “If they can recognize faces of people in a room, that brings them into the social environment as opposed to sitting there waiting for someone to talk to them,” says Kelly.

More information: “Development and Implantation of a Minimally Invasive Wireless Subretinal Neurostimulator,” Douglas Shire, Joseph Rizzo, et al. IEEE Transactions on Biomedical Engineering, October 2009.

Giving Back

On the surface, Kenny Spitler and Marcy Sasso would seem to be from two different mindsets, let alone two different parts of the country. But each has a passion for giving back to their communities — in two distinct ways — that can be infectious. And both stress the importance for ASCs to get involved in their local communities.

“We’re in the healthcare industry and in particular, in economic times that are tough as what we’ve been going through, the healthcare industry has still been strong,” says Spitler, senior vice president of development for HealthMark Partners in Nashville, Tenn. “So giving back to the community is essential, in my mind.”

Sasso, director of operations at the ASC of Union County, in Union Township, N.J., explains that giving back is paramount for ASCs, and not just to serve the community, either. “We as surgery centers, are often thought of as ‘cherry pickers,’ that we take the best cases from the hospitals. But we can provide exemplary service to everyone involved, physicians as well as patients.”

ASCs 2009

Spitler was given the task of organizing a volunteer project as part of the Ambulatory Surgery Center Association’s 2009 annual meeting held in Nashville last April. Previous projects had volunteers planting sunflower seeds in New Orleans to remove lead that had seeped into the soil around the city after Hurricane Katrina, and cleaning up the grounds at the Fisher House in the Brooke Army Medical Center in San Antonio, Texas. But he wanted to do something that would give some tangible results to the volunteers participating.

“My biggest goal was I wanted to do something that’s going to endure,” notes Spitler. “I wanted something that would have a little more lasting effect for the Association.”

So he took 20 to 25 volunteers apiece in two shifts and went over to the Boys & Girls Clubs of Middle Tennessee in nearby Antioch, to help decorate and landscape an outdoor play area for the 105 children who utilize their afterschool program. The groups built and stained benches and picnic tables, installed bird feeders and a bird bath, planted shrubs and flowers, and prepared a vegetable garden for the children to grow their own vegetables.”

“What they did was a fantastic beautification process,” states John Hamilton, Club director of the Boys & Girls Clubs of Middle Tennessee, “one (that) the kids really love and the community sees it, too.”

And the impact on the children was almost immediate, says Hamilton. “I have heard the children say a few times since then, ‘This is our Club now. This is our home now because it looks like a Boys & Girls Club.’”

“Doing the work was great, but seeing the kids’ faces after it was all done, was really what it was all about,” Spitler declares. “Just complete joy.”

Hamilton also notes the enthusiasm of the volunteers was a key in making the project a success. “They really took the project, and were gung ho (about it.) They began work from the time they got off the bus, until the time they had to leave.”

“We probably wouldn’t have gotten this project done if it wasn’t for them, based on the economy and funding,” says Bob Jacobs, vice president of resource development for the Boys & Girls Clubs of Middle Tennessee. He also points out that so much of this type of service relies on volunteers, which translates into these same children becoming more involved in these types of projects in the future.

Health Fair

When Sasso learned that Union Township, N.J., no longer had its annual community health fair due to the local hospital closing 18 months ago, she saw an opportunity for her ASC to get involved.

“Within three days, I had a unanimous vote from the owners to green light hosting the health fair,” says Sasso. The success of the health fair was due to the participation of physicians, staff members, family members and the Gateway Chamber of Commerce. “It turned a marketing event into an opportunity for saving lives and providing education for the community. The health fair was organized within a two month time frame, although she feels that six months preparation is optimal.

Sasso’s infectious attitude was able to rub off on to the community, where many of the medical and healthcare-related organizations contributed to the event. Twenty booths displayed health screenings, visual demonstrations for surgeries, fingerprinting and bike safety information for children, and most importantly, the chance for her ASC physicians to interact with the community.

“I had a woman tell me afterward that she was so grateful to talk with one of our surgeons for 15 minutes,” Sasso articulates. “Most people don’t get that amount of time, even in a consultation.”

In the end, hundreds of attendees paid a visit to the health fair over an afternoon that gave Sasso plenty of ideas on how to make next year’s event an even greater success.

“If anything, I think if I had six months to prepare, it will make a tremendous difference. I can attract more groups that weren’t able to participate this year,” she reveals. “We just have to communicate to various agencies to attract a broader audience, which of course we will. “This will definitely become an annual event for the ASC Give Back! I know it changed people’s lives. The staff feels very proud of the interaction and positive response from the community.”

Getting Involved

Spitler feels there needs to be a continued effort nationally from the ASC industry to participate in volunteering events like his. “If asked, most of the people in the industry are willing to give back. If there were an ongoing effort to perpetually do something from a charitable standpoint from the industry as a whole, I think it would be well received.”

He points to an event at this year’s annual meeting as an example. A couple of volunteers from the project were given the chance to speak to the general audience, asking for donations for the Boys & Girls Clubs. “There was $2,800 collected that day for the Boys & Girls Clubs,” says Spitler. “Another group bought toys and other items for the club.”

For local ASCs, Sasso suggests to start small. “You always have a little bit to give. Even if you don’t think you have the time, once you start this, hopefully you’ll have the same feelings that my staff and I have.” To go along with the health fair, the ASC of Union County has participated in such things as holiday toy drives, walks for autism and breast cancer patients, a bike ride for multiple sclerosis.

“Giving is such a contagious thing,” Sasso says.

Joint Commission Updates Position on Flash Sterilization

The Joint Commission has updated its position on flash sterilization and has outlined three critical steps to the flash sterilization process, according to a Joint Commission news release.

Flash sterilization refers to steam sterilization that does not utilize a full or terminal cycle. The Joint Commission defines flash sterilization as the process of sterilizing unwrapped instruments using steam for three minutes, at 270 °F at 27-28 pounds of pressure.

The three critical steps included in the Joint Commission’s update include:

• Cleaning and decontamination — Facilities must remove all visible soil prior to sterilization and have manufacturers’ instructions are available for all instruments.
• Sterilization — Steam sterilization of all types, including flashing, must meet parameters (time, temperature and pressure) specified by both the manufacturer of the sterilizer, the maker of any wrapping or packaging and the manufacturer of the surgical instrument. In addition to these instructions, parametric, chemical and biological controls must be used as designed and directed by their manufacturers.
• Storage or return to the sterile field — Each sterilized instrument must be carefully protected to ensure that it is not re-contaminated.  Instruments subjected to steam sterilization using methods other than full cycle sterilization may be transported in “flash pans” or other devices specifically designed for the prevention of contamination during and after the steam process. For full steam sterilization cycles, packs of instruments should be wrapped and sealed.

Joint Commission surveyors will update their survey processes in order to reflect these updates.

Read the Joint Commission’s news release on its updated position on flash sterilization.

6 Challenges Facing Ophthalmology in Surgery Centers and the Best Ways to Overcome Them

Ophthalmology is a growing specialty in surgery centers and is currently represented in 38 percent of all surgery centers, up 27 percent since 2007, according to recent data from the SDI 2008 Outpatient Surgery Center Market Report.

As more surgery centers add ophthalmology and new ophthalmologic procedures to their services, it is important to consider some of the challenges unique to this specialty. Here are six challenges currently facing ophthalmology in ASCs and best practices for overcoming them.

1. Adding retina procedures can be expensive but profitable. Retina procedures require a significant initial investment for surgery centers that are interested in adding these surgeries to their services.

“A good retinal machine requires a significant capital investment,” Jason Jones, MD, a physician at Jones Eye Clinic in Sioux City, Iowa, says. He also notes that the case load will be lower for retina procedures. “A center will do a few hundred of these procedures a year, not thousands, so it is important to weigh the costs while considering adding this procedure,” he says.

Dr. Jones also notes that retina procedures use many products that are designed for single use. However, he says that this can be balanced by the greater efficiency that single-use products can have because time is not required for the cleaning and care that multi-use equipment needs.

Margaret Acker, CEO of the Blake Woods Medical Park Surgery Center in Jackson, Mich., agrees that the new equipment needed for retina procedures will mean a significant hit to a center’s bottom line. As a result, it is important for centers to ensure that they have enough physicians who can fill the schedule and use the equipment for retina surgery.

Silicon oil and Perfluron used in retinal surgery can also be costly, but if surgeons are working effectively, Ms. Acker notes, supply costs can be easily maintained.

“You need to find your breakeven point — how many procedure need to be done in a year to justify the costs,” Ms. Acker says. “Also, it is important to ask how many cases did your physicians do and how many would they bring to the surgery center.”

Ms. Acker says that exact reimbursement for retina procedures depends on the payor, but her center usually receives around $1,500 per code and that her center generally uses multiple codes.

Ms. Acker notes that a good portion of patients who have retina procedures will probably need to have another procedure in the future. “If a surgery center does a good job of taking care of their patients, retina patients included, there is a good chance that if patients need to have another procedure a few years down the road, they will return to the center,” she says.

2. Patient selection can require special considerations. While most ophthalmologic procedures don’t require general anesthesia, there are still some risks certain patient populations can pose for surgery centers.

Ms. Acker notes that most retina patients are elderly and not in very good health. “Most of these patients are under local anesthesia or a periovular block, but it is important to have an anesthesiologist who is well-versed in taking care of elderly patients,” she says.

Patients should be monitored closely and make sure that they have proper oxygen saturation during the procedure, according to Ms. Acker.

Dr. Jones says that because retina procedures require heavier sedation, longer postoperative care is also needed.

Ms. Acker mentions that in her surgery center, staff members make sure that elderly patients who come in for retina, cataract surgery and other procedures are awake and alert before discharge, which may also require a longer stay in the PACU, as their recovery times from anesthesia are slower than other patients. “They usually come out of the OR fairly aware,” she says. Ms. Acker also notes that having proper arrangements for follow-up care, such as arranging for a ride to the physician’s office for the next day, is also important.

Another patient population that can provide special concerns for ophthalmology in surgery centers is pediatrics. “You can’t do ophthalmologic procedures on children without a general anesthetic,” Dr. Jones says.

By the same token, Dr. Jones has also encountered mentally challenged patients, such as those with Down syndrome, who come in for ophthalmologic procedures. “Sometimes we need to give these patients general anesthesia, but it depends on the availability of general anesthesia at the surgery center and the affect it will have on the patient,” he says.

3. Some cataract surgeries can run over the scheduled time. Cataract procedures can sometimes be cumbersome because if a newer lens, such as Toric intraocular lenses, is used, extra surgery time is required, says Ms. Acker. This extra time is needed because a surgeon needs to mark a patient’s eye before positioning the lens. “Often, a surgeon doesn’t know that they will have to use the new lenses until patient comes in,” she says.

To resolve this issue, Ms. Acker’s surgery center added five minutes to every cataract procedure. Additionally, in order to keep staffing cost down, many members of the staff agreed to work a little later, if need be, and the center was not required to make a hiring adjustment.

According to Dr. Jones, several other types of patients and procedures have special requirements when it comes to scheduling. As previously mentioned, surgery on pediatric patients, because they need general anesthesia, will require extra time. Dr. Jones also notes that some patients will have unusual anatomic needs that require specialized suture or implants that will also take more time.

“[A center] needs to strike an overall balance with the types of cases they take,” says Dr. Jones.

Dr. Jones says that working with friendly owners and staff at surgery centers that allow surgeons adequate access to the center can help make scheduling go a little smoother.

4. Although ophthalmology remains stable, reimbursement issues can still raise concerns.Because most ophthalmology patients and procedures are covered by Medicare, surgery centers haven’t seen the significant hit that other specialties have, according to Ms. Acker. However, she does note that there is a planned 2 percent decrease in payments for the 2010 Medicare payment schedule.

Ms. Acker says that her surgery center has not seen any significant drop-off in the payments from third-party payors, but as the unemployment rate increases, the increase in the number of patients on COBRA or government subsidies may affect payments.

Dr. Jones says that some procedures have had specific issues with reimbursement. For example, in corneal transplants, such as endothelial keratoplasty, payors have not been paying well for donor corneal tissues that are required in the procedure.

One way to account for these changes is to collect payments upfront, an approach taken by Ms. Acker’s center. “By doing this, we haven’t had any real issues with losing revenue,” she says.

Dr. Jones mentions that ASCs treating some patients who require IOL exchanges may have difficulty getting reimbursed for implants that are better performing but cost more. In most cases, surgeons will use the implant that is covered, but for some patients, certain implants or devices are the only choice.

In some situations, a small percentage of patients who elect a premium lens require an IOL exchange, according to Dr. Jones. This can be problematic because insurance companies may be unwilling to pay for an additional procedure. “If the patient is unable to adapt to the premium lens despite efforts to help them adjust, then the indication for exchange could be considered a mechanical malfunction of the lens and it may be covered [by insurance],” Dr. Jones says. “If the lens is of the wrong power for optimal performance, then the exchange likely would be considered elective and not covered.

“The percentage of patients who require this is low,” he says. “Then it becomes an issue of payment. We try to account for this issue ahead of time.”

One such way is for the surgery center to receive reimbursements for what they can and collect additional fees from the patient. Another way is to have the patient pay up front via an “a la carte” fee for the implant and have the rest covered by insurance.

Ms. Acker suggests that surgery centers can prepare for changes in reimbursement by being frugal. “Watch your supply and staffing costs while safely taking care of your patients,” she says.

One way in which Ms. Acker’s surgery center has reduced costs is by standardizing the equipment all of the ophthalmologists use for surgery. “When you can use the same pack and equipment, it can save money,” she says. “We also look at our packs from time to time, see what we aren’t using and get rid of it.”

5. Many patients are deferring surgery because of the economy. Dr. Jones says that some patients are choosing to put off surgery or are not seeing referring physicians for their regular eye exams. This means that some patients who may require surgery have not been seen by their regular physician and are not coming into the surgery center.

This trend may also account for the overall slowing of surgery cases that Dr. Jones has seen. However, he notes that by reviving an interest in eye surgery and raising the bar for care, surgery centers can make themselves a more inviting alternative to hospitals or in-office surgery. “The surgery center can be seen as a positive extension of the office visit,” he says. “Patients are able to have an operating room and a certified staff, as opposed to the office, and there is no need to go into the hospital.”

Dr. Jones also says that although his center hasn’t seen much of a change, physicians in his region have seen an increase in the use of CareCredit and other healthcare financial services to help that patients pay for their surgeries. “There is less credit available,” he says, “and this has often been the decision-maker for patients [as to whether or not they will have surgery.]”

6. The economy has had other effects. Aside from the increase in uninsured and government-subsidized patients and less patients coming in for surgery, other areas of ophthalmology have been affected during this tough economic time

Dr. Jones has seen, since Fall 2008, a decreasing trend in the number of patients selecting “premium” IOL implants, which would result in higher reimbursements for surgeons. However, this may be a temporary situation, and Dr. Jones says that he has started to see more patients opt for the “premium” lenses in recent months.

Physicians are encountering more savvy patients who ask for more information beyond cost in the current market. “Patients are more informed or want to be more informed, even if they get a routine lens,” Dr. Jones says. “This can mean a bigger burden on the clinical end of operations to provide this information, but overall, it is very rewarding.”

Certain regions and states in the United States have felt a bigger impact because of the economy. In Michigan, for example, Ms. Acker says that business tax has increased, and surgery centers have seen their expenses go up while their reimbursements have decreased. “We continue to take care of patients and make a living,” she says. “Just keep watching staff costs and take proactive and frugal measures to preserve profits.”

Contact Renée Tomcanin at renee@beckersasc.com .

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