2010 Management Guide

Dealing with Survey Deficiencies

After receiving 23 pages of citations and a threat of losing its license, a Texas ASC (that had gone three years without a state/Medicare survey) recognized its desperate situation. While many of the citations concerned the new conditions for coverage and multiple notes for the same deficiency, the center still needed to respond with corrections within 10 days. Typical of smaller facilities, the employees responsible for compliance activities are the same individuals involved in routine care. While intending to comply with regulations, patient treatment takes priority and administrative paperwork falls behind.

In addition to their daily routine, management now needed to research, evaluate and interpret the regulations in order to rewrite/update their policies within the response time. The practitioners (both administrative and physician) realized that the task they faced required the resources and skills of an outside expert. The facility searched for a consultant that could help solve their problems. Separated by 1,500 miles, with the days ticking away, recognizing travel arrangement difficulties and skyrocketing travel expenses, they requested FWI Healthcare’s assistance.

Receiving and reviewing their citations, FWI presented a cost-effective proposal to the client that was accepted. The client faxed requested documents for our analysis. We discussed existing materials and the need for changes. FWI also developed some revisions to their policy manual and the plan of correction for submission. This information was provided to the client and after telephone clarification and minor adjustments; the transcripts were ready for use.

The plan of correction was accepted and upon the surveyor’s return for a follow-up visit (finding everything to be acceptable), she recommended the license and certification be renewed.

Many small ASCs do not have personnel with experience, knowledge or time necessary to rapidly respond to deficiencies cited by survey agencies. This is where relying on the resources of consultants (who provide assistance on a fee for service basis) is invaluable. All of FWI’s work was completed with minimal expense and without either party leaving their office.

By Roger Pence, president, FWI Healthcare www.fwihealthcare.com • 419.298.3700

Challenges Unique to De Novo Facilities

De novo projects can be a long and not always painless process, but like turnarounds, they have incentives as well. With a new development, we are able to construct the center from the ground up to ensure our high standards are met and so high-quality care can be administered efficiently from day one. We are also able to form a great group of physician partners with the right balance for a successful ASC. Now, just because we get to make initial decisions on the facility and the business with our partners, it is not always roses when developing a new center. We deal with doubting partners, setbacks, stumbles and roadblocks. In the case of our new de novo facility in Mt. Dora, Fla. we hit an unusual roadblock — gopher turtles. Yes, gopher turtles. This protected species was living on our construction site. We had to have the turtles moved, but that could only be done after three consecutive days of 50 degrees or warmer weather. The turtle relocation caused about a six-week delay in the building process, and while no one could have anticipated a gopher turtle infestation, we took care of the situation and did what we could to get the project back on track.

We found that the perspective of the partnering physicians in de novo projects is quite different from that of partners in turnarounds. While in turnarounds we are often thought of as better managers than we are, sometimes in new developments we are thought of as worse. Partners focused on financial returns view any stumble on the way to distributions as a failure, when in fact, stumbles are a part of the process and sometimes result in positive outcomes. The objective is to have the “wiggle room” to adjust, correct problems, and move forward.

No matter what we encounter along the path to developing a new center, we are committed to our partners and the success of the center and look forward to developing new, successful centers across the country.

By Tom Mallon, CEO, Regent Surgical Health

www.regentsurgicalhealth.com 708.492.0531

Ostrich Strategies for ASCs: Never A Good Idea

The phrase “burying your head in the sand” has become synonymous with hiding from the truth or hiding at the first sign of danger. Ostriches are alleged to do that, but they actually do not. However, owners of distressed outpatient centers sometimes really do.

Our firm gets involved in helping distressed outpatient centers, including surgery centers, and our experience has shown that it is the rare owner who does not “bury his (or her) head in the sand” hoping that something will occur that will cause the source of the distress to simply go away. Employing an “ostrich strategy” is a bad idea, as well as a waste of valuable time and resources because the sources of distress rarely go away simply and easily.

The “ostrich strategy” usually results in the center being behind in payments to lenders, landlords, the taxing authority, staff and most vendors by the time we get involved. The task of pulling your head out of the sand and developing workable strategies is complex and multi-dimensional, and involves lawyers and lots of different personalities. In addition, there are always varying degrees of trust among the owners and the managers (who are also often owners). Getting to the core problems requires information analysis, lots of conversation and a site visit or two. Once those core issues are made clear, then the people leading the charge put a simple strategy in place. It needs to be simple because additional and incremental complexity will only complicate matters and likely make things worse. Our firm often leads the charge, but many times we do it in tandem with the center’s lawyers. Depending upon how far behind the center is with various creditors and what legal actions have already been taken, the lawyers may well take the lead.

Follow your strategies, keep your head out of the sand, stay calm and focused, engage the right professionals for you and you may be able to yourself of the sources of distress that caused you the problems in the first place.

By Robert S. Goodman, managing partner, The Mansfield Group www.mansfield-group.com 609.267.0990

Adding Specialties to Increase Profitability

Foundation Surgery Affiliate of Huntingdon Valley, Pa. is an AAAHC-accredited, multi-specialty ASC that opened in 2003. With four operating rooms, two procedure rooms and 19 surgeon partners, this 18,000-square-foot facility was profitable; however, there was still a tremendous opportunity for growth through increasing OR utilization and case volume. “We continually strive to develop new tools and methods that will enhance the profitability of our centers while also adapting to the changing outpatient surgery environment,” says FSA chief operations officer Thomas A. Newman. He recalls the FSA specialty and case analysis:

1. Take inventory. FSA creates a checklist of all specialties that can be performed at an ASC.

2. Analyze and evaluate. Management performs an extensive cost/benefit analysis, weighing equipment and labor costs against typical revenues provided by the specialty.

3. Determine which specialty is most worth pursuing.

4. Recruit surgeons. Utilize data collected in steps 1-3 and tap existing surgery partners as a primary resource for new partner candidates.

In the case of Huntingdon Valley, a surgeon partner suggested that the center consider adding fertility as a specialty. Based on that recommendation, FSA performed steps 2-4. During the first month of adding fertility, case volume increased 12 percent and overall revenues increased by more than 25 percent. As a result of this exercise, FSA formalized the process and rolled it out to all of its centers.

“Our center was already doing quite well when FSA performed the specialty and case analysis and presented the impact of adding gynecology partners specializing in fertility,” says center administrator Robert Puglisi. “Now, return is even higher as a direct result of adding our reproductive medicine partners.”

Larry Barmat, MD, one of the center’s fertility partners, says, “Reproductive medicine is almost tailored to the ASC environment because the procedures are of short duration and low risk, thereby lending them to being done in an outpatient setting.”

Chairman of the board Robert Mannherz, MD, says, “The addition of reproductive medicine has been positive for the center on several levels. It has increased the utilization of the center and our cash flow, as well as diversified our services to patients.”

By Caleb Germany, Foundation Surgery Affiliates www.foundationsurgery.com800.783.0404

Reimbursement and Billing Compliance Issues

A full financial, business office and clinical evaluation was performed by Surgery Consultants of America (SCA) and Serbin Surgery Center Billing (SCB); however, this case study is reporting only reimbursement and billing compliance issues. The initial findings were determined during the evaluation. The current improvements are results obtained after twelve months of reimbursement management by SCB.

The Medicare-certified, multi-specialty center was open 18 months, has two ORs and performs an average of 100 cases per month; the physician-owned clinic shared the same site with the ASC. The challenges were as follows:

» Practice software not meeting all ASC needs

» Billing outsourced to clinic billing staff resulting in:

•overwhelming volume

•increase in errors due to lack of ASC billing knowledge

» Revenue stream reduced to trickle

» Days in A/R escalating – 97 at time of evaluation

» Claim backlog growing – minimum 7 to 10 days lag time between services rendered and subsequent posting and billing

» Denial rate climbing – 20 percent to 25 percent first time denial rate

» Cost of staffing and supplies as a percentage of revenue continuing to increase because of claim backlog

» Non-compliance concerns mounting

Our findings and recommendations were as follows:

Processes

» Using practice software

» Recommend acquiring ASC software

» No CMS list of ASC covered services or matrix of insurance contracts

» Recommend providing both to scheduler and insurance verifier

» No up-front collections

» Recommend notifying patient of financial responsibility before DOS

Reimbursement

» Billing not up-to-date

» Recommend hiring additional staff or outsourcing

» Coding inaccuracies identified

» Recommend coding audit by certified coder – rebill where necessary

» Not following up on submitted claims

» Recommend audit to determine timely filing, refunds, resubmission claims

Compliance

» Receptionist making patient contact calls

» Recommend moving these calls to back desk for HIPAA reasons

» No notification to payor of out-of-network status

» Recommend notifying payor at time of verification and again at billing

» No advance notification of financial policy to patient

» Recommend providing written policy prior to DOS via phone or brochure

Our evaluation resulted in the following changes:

» Appointed separate ASC administrator

» Changed to ASC software

» Revised fee schedule

» Acquired copies of payor contracts

» Initiated use of bank lockbox

» Created new insurance verification position

» Established process to collect co-pays

» Developed financial policies to handle self-pay patients, payment plans, financial hardship cases, etc.

» Made changes in business office task responsibilities

Improvements included:

» No billing backlog

» Decrease in days in A/R – 58 percent (97 days to 41 days)

» Increase in average net revenue per case – 14 percent

» Increase in average charge per case – 31 percent

» Meeting billing compliance guidelines

By Caryl A. Serbin, RN, SSN, LHRM SURGERY CONSULTANTS OF AMERICAwww.surgecon.com 888-453-1144

Florida ASC Increases Revenues

Acting as a strategic business partner, NovaMeda dedicates an experienced team of experts to help our ASCs grow and prosper, while assuring the best possible experience and outcomes for both patients and physicians.

We recently increased the revenue of our Florida ASCs by employing a comprehensive managed care strategy. Over the last two years, we have renegotiated contracts with major payors in Florida and increased the value of the contracts by as much as 20 percent. This has equated to an increase in revenue of 5 percent to 10 percent for each of our four ASCs in Florida.

Developing and executing an overall managed care strategy can lead to major revenue enhancement and overall improved financial performance of our ASCs. Our strategy is founded upon the principles of maximizing the revenue of all our managed care contracts, assuring that the ASC is getting paid what it should based on the contract, and monitoring the performance of managed-care contracts to ensure the ASC is realizing projected revenue.

Executing our managed-care strategy begins by reviewing our ASC’s total book of business and managed-care contracts. Using best-of-breed financial models, we assign a value to each contract based on payor case/mix and market dynamics, and then negotiate (or renegotiate) each contract to ensure maximum revenue generated for our ASC. An ongoing process, we employ a proactive stance on managed-care contract negotiations to ensure the profitability of our ASCs.

By Lisa Streit, director of managed care, NovaMed www.novamed.com 888-NOVAMED

Implementation, Cons & More

The Practice Partners in Healthcare (PPH) team met with the physicians and began to plan for the implementation of the single-specialty center. During the planning process PPH reviewed volumes, expenses and thresholds in the CON. It was determined that additional surgeons would be necessary to make the center successful. PPH began to recruit additional surgeons to the project. To recruit physicians it was necessary to modify the operating and partnership agreements to make the arrangement fair for all physicians and not have the initial group control the project. PPH negotiated with the groups for a successful operating agreement and partnership arrangement to allow the entry of new physicians.

The ability of a third party to develop an independent plan, negotiate and execute is necessary to assure the original group and joining physicians that the best plan for the total partnership is presented. During the negotiations it was clear that the groups combining were fierce competitors and the role of PPH was to make fair and strategic decisions that would demonstrate to both groups the combined strength in the ASC setting but allowing the market forces to continue in the practice setting. Furthermore, the individuals had to work together to develop block time schedules and utilization of the center that would present the most favorable results. In doing so PPH developed a block time schedule that interfaced with both practices clinic schedule and inpatient surgical schedules. PPH developed a strategy and schedule designed for each group’s physician to follow block time by that same group. In doing so the potential conflicts of another group adding on patients and extending the operative day would only affect that group and not the competitor.

When administrators are considering modifying of implementing block time considerations on the impact of running over to other physician block time may reduce issues by this practice. The physicians could then work within their individual groups to correct reoccurring situations. Additionally, when administrators are planning for block time the utilization of historical operative or procedure times should be utilized when evaluating the duration of the individual block to allow for the anticipated daily throughput for each surgeon.

By Larry Taylor, president and CEO, Practice Partners in Healthcare, Incwww.practicepartners.org 205.824.6250

Joint Venture Feasibility

In early 2005, Alegent Health engaged Health Inventures (HI) to perform a feasibility study for joint-venturing (JV) outpatient surgery services with physicians at their Lakeside and Bergan Mercy Medical Center campuses in Omaha, Neb. HI conducted extensive physician interviews to educate physicians about the JV process and gauge interest. Based on positive feedback from the interviews and HI’s financial forecasts, it was determined that a JV was feasible.

The degree of physician interest showed enough case volume to occupy two new facilities. However, HI determined the most immediate opportunity to establish a JV was to convert an existing two OR HOPD to a free-standing ASC in a medical office building (MOB) on the Lakeside Campus. The conversion process included obtaining licensure and certification to operate as an ASC. This facility would operate for 18 months while a new facility with four ORs and one procedure room was built in the same building.

Throughout 2005, a steering committee with representatives from HI, Alegent Health, interested physician groups and legal counsel met regularly to determine the terms of the operating agreement and the governance structure of the JV. Meanwhile, valuation firm performed a third-party valuation of the existing ASC. Based on financial projections and this valuation, HI and deal counsel developed a private placement memorandum (PPM) and subscription agreement and opened the “offering” for physician investment.

The offering closed in December 2005. Two major surgeon groups and 19 individual physicians invested in the facility for a total of 31 physician users/owners. Alegent maintains 51 percent ownership in the new LLC that leases operating space from Alegent in the MOB.

The owners appointed a management board (MB) and clinical operations committee (COC) as the principal decision making authorities. The MB has equal physician/Alegent representation and the COC is physician-controlled.

In September 2007, the physician owners moved their cases from the upstairs ASC to the newly constructed facility on the ground floor of the MOB. The high subscription rate of the offering and cash flow from the existing facility provided adequate funding for the construction without any term debt financing. Only a line of credit was needed when the facility opened.

By Catherine A. Martin, contract manager, Health Inventures, LLCwww.healthinventures.com 877.304.8940

Compiled by Jessica Barreras

Know Your APCs for ASCs

APCs for outpatient procedures performed in ambulatory surgery centers (ASCs) are part of an averaging and bundling system using CPT® procedure, HCPCS Level II and revenue codes submitted to Medicare on CMS=1500 forms, with UB-04 claim forms used by ASCs to file claims to most other payors. The APC system utilizes “packages” of CPT® and HCPCS Level II codes, based on clinical and facility resources and establishes payment rates for each APC grouping. This means the physical and human resources needed to provide the service and the geographic costs are bundled together using annually adjusted formulae, much as in hospital inpatient billing. Certain medications, services, and durable medical equipment are considered “pass through” and can be reported separately from an APC revenue code.

APCs are assigned based on the CPT® and HCPCS Level II codes reported by the provider for each service. Usually, more than one code will fall into an APC category. More than one CPT® and HCPCS Level II codes can be reported if needed.

But not all CPT® and HCPCS Level II codes qualify. They are all assigned a status indicator denoting the code’s relation to APCs — whether they qualify and how. The ASC must be careful to avoid reporting a code denoted as not reimbursable for ASC services unless a modifier and documentation support it. As a result, a limited group of modifiers are recommended as well. The status indicators can be found on CMS files including the CPT and HCPCS Level II codes, and most commercially published codebooks include them as icons.

Examples of the indicators include the following:

• A: Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS. This means fiscal intermediaries are reimbursing this code via a fee schedule not under APCs.
• C: Inpatient procedures. This is the kiss of death for an ASC claim’s success. This procedure is expected to be done in a hospital with the appropriate resources and an overnight stays.
• N: Items and services packaged into APC rates. This is paid under the APC OPPS and payment is packaged into payment for other services; there is no separate payment for this.

Restricted CPT® modifiers include:

• 50: Used when the exact same procedure is done on the exact body part of the opposite side. Also known as “bilateral”. Some insurance companies prefer the biller use the CPT® code twice instead. Ex: 10220-RT, 10200-LT. Check with carrier on which to use. Payment should be 150 percent.
• 51: Indicates multiple procedures were performed. The 51 appends to the second CPT® code and all CPT® codes thereafter. Medicare does not recognize modifier 51 for ASC services as this modifier is for use on physician claims only.
• 52: Indicates reduced services. Use when procedure is not completed as described in the official CPT® description.
• 73: Used when a procedure is discontinued before the anesthesia administration. Patient must be in the room where the procedure would have taken place. Payable at 50 percent of the Medicare allowable rate. Typically seen when patient’s blood pressure arises to a dangerous rate.
• 74: Used when a procedure is discontinued after the anesthesia administration. Patient must be in the room where the procedure would have taken place. Payable at 100 percent of rate. Typically seen when patient’s blood pressure arises to a dangerous rate.
• 78: Used when the patient has to return to the operating room during the global period for a procedure related to the first procedure, such as control of bleeding following a colonoscopy or sinus procedure.
• 79: Unrelated procedure or service by the same physician during the postoperative period. (Same day for an ASC setting.)

Rhonda Buckholtz, CPC, CPC-I, CGSC, COBGC, CPEDC, CENTC, is vice president of business and member development for the American Academy of Professional Coders (AAPC).

Innovation & Excellence Intersect at Renaissance Surgical Arts of Newport Harbor

Even before the Centers for Medicare and Medicaid Services (CMS) issued its new conditions for coverage relating to improved infection control practices in ambulatory surgery centers (ASCs), Bruce Wallace and Anthony Pings knew that infection prevention would be the cornerstone of their latest development project — a world-class multi-specialty ASC that would be destined to set the bar enormously high in terms of innovation, patient care, and surgeon and staff satisfaction.

Wallace, the CEO of Congero Development, architect Ping, the CEO of Anthony C. Pings and Associates, and Kathy Just, vice president of Congero and interior designer on the project were the driving forces behind Renaissance Surgical Arts of Newport Harbor, LLC, designed to be a preeminent medical facility led by notable surgical specialists working with cutting-edge operating room technologies within an innovation-rich, patient-focused, healing environment.

“This facility was truly designed around exceptional patient outcomes,” Wallace says, “and much of that has to do with integration of some newer equipment and emerging technologies that were not readily available before in the U.S. It also more fully addresses the needs of healthcare providers, as we have identified the challenges that their lifestyles incur and we have provided solutions for them.” In addition, Congero desired to bring a center of excellence to Orange County, California, as well as a project that was scalable to emerging technologies as they became available, with minimum invasiveness to the operations overall.

This 360-degree approach starts with the patient. “I conduct a lot of direct research with patients and physicians to determine what makes them happy,” Pings says. “We don’t ask patients what they want; instead, we ask them to describe their experiences and that’s when they are going to tell you what works and what doesn’t. Nobody wants to have surgery, so when we work on a project like this, we want to provide patients with the physical and emotional support they need.” To that end, Just worked to ensure that Renaissance was designed as a healing environment, with a sophisticated and rich décor that promotes pre-operative calm and facilitates post-operative recovery. To maintain normothermia and ward off post-surgical complications, patients are provided with forced-air heated garments and blankets, as well as IV solution warmers.

Pings adds, “We start a project like this from a patient-focused standpoint and blend that with needs of the clinical staff to create solutions that supports both parties in the best possible way.” For example, the center places a high priority on patient privacy; patient entrances and exits are separated, and private spaces have been created all throughout the pre- and post-surgical experience. “We believe in giving patients separate waiting areas,” Wallace says. “Because we are multi-specialty facility we don’t want patients sitting just anywhere — we don’t want a woman who has had a mastectomy sitting next to a woman having augmentation.” Wallace continues, “We accommodate patients in a tremendous number of ways, including doing what we can to make them feel welcome, lower their anxiety and make them comfortable. I want them to feel as though the staff and center was there for each of them personally.”

From the time the patient is prepped for surgery until recovery, aseptic technique is an omnipresent concern. “Infection control considerations were integrated into every decision we made,” Wallace affirms. That starts with the replacement of traditional gurneys with operating tables that first function as patient transport systems and then transfer – along with the patient – to a fixed base in the OR. Not only does this system – the first of its kind in the U.S. — save as much as 40 minutes in transfer time, but it helps eliminate cross-contamination during patient transfer. What’s more, the German-made tabletops by Trumpf can be completely sterilized.

“The tabletop you are on was never shared by another person between being sterilized,” Wallace emphasizes. “A classic place where bacteria transfers is the OR table itself. At other facilities, someone goes in with a squirt bottle between patients and they have 5 minutes to sterilize the table and the fact of the matter is that the table is definitely not sterilized in 5 minutes.”

Recognizing that proper decontamination and sterilization of medical devices and surgical instruments eliminates infections and produces operational cost-savings, the facility features a system that has taken patient and staff safety to the next level. Driven by selective automation, Renaissance’s sterile processing department, supported by Belimed equipment, is able to achieve efficiencies in the way surgical instruments are transported, washed and decontaminated, sterilized, reassembled and contained. Upholding the dedication to stringent infection control practices, instruments are sealed in trays and then pass from a “dirty” room to a “clean” room where they are sterilized and processed further, all in a department that has been designed with the goal of becoming more environmentally responsible in water and energy usage. All instruments have been marked with RFID technology, bar-coded, catalogued and tracked from purchase, and when an instrument approaches a sterilizer, the cycle is automatically set to the individual manufacturer’s care parameters – thus ensuring a longer instrument life and a repeatable sterilization process that ensures uniform processing and meets infection prevention standards. According to Pings, the backbone of the facility is a chamber sterilization system comprised of two discreet, low-intensity, stand-alone sterilization areas located between the operating rooms, and a central, high-intensity processing area in the operating corridor. The combined effect of the chamber system, sterilization process and smart utility use, allows for the elimination of up to eight full-time employees, with processing cut to a fraction of standard times while delivering vastly improved sterility assurance.

“Our system reduces staffing in central sterile (CS) and eliminates a lot of the cross-paths that exist elsewhere,” Pings says. People think if you are six feet away from dirty, you are OK, but those numbers don’t work anymore. Hospital CS departments are essentially one big room with workstations, and even the best-trained staff will violate those boundaries. That’s why the chamber sterilization concept works.”

Contributing to maintaining the line between sterile and unsterile is Congero’s proprietary LED system built into the floor and walls with a laser that resembles a light fixture placed before each terminal end of the OR corridor; this system replaces the traditional red-line tape used to delineate non-sterile areas from sterile areas. The center also features sterile lounges in the sterile corridor for staff to use on surgery days without having to gown out into non-sterile cover-ups to conduct business outside of the OR corridor. Staff can use phones and computers in the area while saving vast amounts of time in gowning out both ways; it adds up to a cost savings of approximately $8 per trip per staff member.

Contributing further to physician convenience is an adjacent, separate entity, the “hot office” area, instead of a conventional medical office building set-up where surgeons can have a place for pre-op and post-op patient consults, a design that extends the full use of the facility to office-based surgery convenience, according to Pings, who notes, “When you provide ways for physicians and staff not to work harder but to work more efficiently, they prefer it, and they are happier people.”

Pings continues, “What I push for the most is an understanding of the different needs of everyone involved at the center, and that includes surgeons. That physician lounge is one way to provide them with the productivity tools they need without having to leave substerile. We wanted to give them the support tools they need within their domain; for example, while they chart they can observe monitors that assist them in real-time tracking of pre-op and post-op patients. Go into the average surgical corridor and you see surgeons sitting on stools trying to have some sort of defendable territory between cases, and that’s neither appropriate nor conducive to surgeon satisfaction.”

The center is powered by a sophisticated IT platform that enables a number of progressive processes such as ultrasonic tracking of patients, staff and physicians for quick-location purposes; biometrics identification for narcotics dispersion; Bluetooth wireless monitoring of patient vitals; advanced telemedicine capabilities; RFID-driven nurse call system and much more. The IT capabilities extend to center management and operations such as inventory control, setting par levels and supplies ordering, plus patient scheduling, patient flow and H&P, and coding and billing, all handled with HIPAA-approved transmittal processes. The center’s eight ORs are equipped with state-of-the-art LCD displays, booms and an audiophile system, as well as CT and MRI in-room imaging. Renaissance is also home to a showroom and telemedicine center of excellence for Olympus Corp., which has installed a digital integration system utilizing rigid and flexible scopes, with one cart handling multiple surgical specialties.

How Renaissance fit into the existing Pacific Medical Plaza building is an achievement in itself, Pings says, since the entire project was a retrofit and where the anchor of the building was the nearly 19,000-square-foot ASC. “We were able to be extremely aggressive in our design in the allotted square footage,” he says. “The original ASC design had elements that were extremely challenging when you realized our space limitations. The design had to be created around the main stairwell in the very center of the structure and we relocated a second stairwell from one side of the building to the other.”

The innovations abound at Renaissance, which required a coordinated process of value engineering driven by the collective experience of the development team to deliver a cutting-edge ASC for very close to the cost of a standard facility. “We knew the challenges related to cost control for an ASC as ambitious as this,” noted Wallace. “However, what we could not have anticipated was trying to accomplish this amid one of the worst economic environments in U.S. history.” The upfront effort will continue to be realized through much lower operating costs thanks to better outcomes, automation and other inherent cost controls. “Cost is an overriding concern at any center but you must remember that upfront costs are ameliorated by cost savings in patient safety and efficiency,” Pings notes.

Key to Renaissance’s success is the partnership between stakeholders, according to Wallace. “This center is a culmination of many years of collaboration with Tony and Kathy as well as the relationship with a cooperative landlord who was of tremendous help in the development process and extremely supportive through the financial crisis. It was also critical to have physicians buy into your vision. We couldn’t have done it without the overwhelming support of the physicians; most of them put their money in, signed on the dotted line and sat back, leaving us to do what we were supposed to do.”

According to Wallace, the center is 70 percent physician owned, with Congero operating as a minority management company. Being a physician-driven facility, the opportunity to do things differently presented itself repeatedly, including how the center was staffed. “We created our own registry and share our staff with other facilities in the area,” Wallace explains. “By doing so we can reduce the labor-related load on the facility; for instance, on slower days with a lower case volume, we can share our staff with other facilities in the area. We believe having people standing around is bad for morale and bad for efficiency’s sake, and this arrangement is better for staff, if they need to take a day to meet personal or family obligations. The registry concept is a better way to accommodate staff who can work the hours they would like to work. And it allows physicians to have a schedule that fits their lives, too. It creates a real team spirit. We also incentivize staff to help increase the efficiency and profitability of the center, linking together their individual success and the success of the center for even better outcomes and operations.”

Making Infection Control Central to an ASC’s Operations

In my parallel life, I also edit one of our company’s sister publications, Infection Control Today (ICT) magazine, so as you can imagine, infection prevention in all healthcare environments is dear to my heart. I have been following closely the new conditions for coverage (CfCs) issued last year by the Centers for Medicare and Medicaid Services (CMS) addressing infection control in ambulatory surgery centers (ASCs), and the sense of panic that these CfCs have triggered. ASCs have traditionally enjoyed a very low infection rate, but some rather high-profile infectious outbreaks at outpatient facilities prompted a greater investigation by the government into the state of infection control at surgery centers and a few bad apples have forced a new regime. But perhaps that’s a very good thing in disguise. It’s true that human nature being what it is, people don’t always do what they are supposed to do, and so rules are made to enforce mandatory compliance. It’s always a shame when doing the right thing must be legislated instead of met voluntarily, but the bright spot in the new CfCs relating to infection control is the hope for even better patient outcomes — a distinct hallmark of the ASC industry in the first place.

In this issue you’ll meet Bruce Wallace and Anthony Pings, two people who have made infection control the focus of every decision they have made in the design and development of Renaissance Surgical Arts at Newport Harbor, LLC, a brand new multi-specialty ASC that will surely be a destination for healthcare in the Orange County, California region. Central to the center’s long list of innovations is the numerous concessions made to making infection control an imperative, from the multi-chamber sterile and substerile areas in between the operating rooms, to the extensively automated surgical device and instrument sterilization systems, to the use of touchless scrub sinks and surfaces impervious to bacteria.

Advocacy Committee Creating Unified Voice for the ASC Industry

In an effort to continue to represent the ASC industry on Capitol Hill and to create a bridge between two existing organizations, the ASC Advocacy Committee was launched last August and has been busy educating Washington policymakers about the value of ambulatory surgery centers. The committee is sponsored by the ASC Association and by the ASC Coalition, an affiliation of ASC associations and ASC management companies.

The Advocacy Committee includes ASCA, some of the largest state ASC associations, and more than a dozen major ASC companies. The funding is provided by the members; separately, ASCA, many state ASC associations, and many companies have their own PACs for direct political giving, according to Andrew Hayek, president and CEO of Surgical Care Affiliates and chair of this new committee.

Despite a health reform-related injection of chaos on Capitol Hill, Hayek says that the committee’s objectives have remained steadfast: “First, to create a clear, compelling message of how ASCs benefit the healthcare system; second, to hire the resources to help communicate this message (e.g,. PR firm, lobbyists, external studies); third, to create an active grassroots network among ASCs to communicate with legislators and policymakers; and, fourth, to create an open, collaborative organization, in which any parties interested in supporting ASCs are welcome to join us and participate.”

One of the most important roles of the committee is to educate lawmakers and to tell the ASC story. Hayek says the committee is in the design process of a PR campaign that will launch early next year. “We have added greater lobbying resources to help us communicate with legislators, policy makers and regulators in Washington, D.C.,” Hayek adds. “We have activated a much greater degree of coordinated grassroots efforts, and we are in the design phase of a grassroots database that will help us take this coordination to a much higher level. Lastly, we are coordinating our messaging across ASCA, state ASC associations, and companies to a greater degree. All of these components work together to help us tell our story in Washington, D.C.”

Another critical item on the committee’s agenda is to help define and promulgate the role that ASCs can play within the context of healthcare reform, and to continue to address key issues of reimbursement and physician ownership. “We have been active in communicating the very positive role that ASCs play in the healthcare system — providing outstanding clinical care at a lower cost to beneficiaries and Medicare,” Hayek says. “We have been active both on the Hill and with the Administration in advocating for higher ASC reimbursement rates, to help facilitate a greater migration of surgical cases from the HOPD setting to ASCs, which will help improve care and save beneficiaries and Medicare money.”

Hayek continues, “We have also engaged in conversations sharing the value of physician ownership in ASCs — ensuring the highest levels of patient care and greater efficiency in the delivery of services. One of the reasons that ASCs provide such outstanding care and simultaneously operate so efficiently is that physicians are ultimately responsible for the operations of the ASCs — clinically, operationally and financially. This leads to aligned interests in ensuring outstanding care, delivered in the most efficient manner.”

Counted among the ranks of the most ardent supporters of the committee is William Kennedy, senior vice president of business development. “We were original members of the ASC Coalition and are now active and enthusiastic supporters of the new group headed by Andy Hayek,” Kennedy confirms. “What we hope to accomplish is to make our industry known in Washington, and that includes CMS as well, so that they understand the good work that surgery centers are doing in terms of delivering low-cost, high-quality patient care to the community. And that we are also a very attractive surgical service at a very attractive price for very attractive outcomes. We want to ensure that our voice is heard above all of the noise made by the hospital associations.”

Kennedy emphasizes the importance of advocacy efforts at the grassroots level as well, something that physicians, administrators and nurses can accomplish to help protect their livelihoods. Because so many issues are springing up at the state level, Kennedy encourages ASC owner/operators to kick complacency to the curb and get involved.

“Many people think that issues impacting our industry are going to start at the state level and will proliferate, rather than coming down from Washington,” Kennedy says, “so there’s a critical need to be involved in your state ASC association.” Kennedy points to the restrictions on ASCs in New Jersey as a recent example. “Legislators are looking to restrict physician ownership and limit the surgery center industry. Grassroots advocacy will ensure that your voice is being heard by your Congress members. There are numerous ways to do this, and our industry has become much better at writing letters to legislators and providing some Congressional pressure. Holding open houses is a great way to get our story to the community; and when it does get out, it is very appealing to healthcare consumers. ASCs make good sense because we deliver the same results for about 40 percent less.”

While not every physician feels that he or she is cut out to be an industry advocate, Kennedy says the industry cannot afford to be bereft of its physician champions. “There’s a core group that galvanizes around advocacy efforts and then there are other people who say someone else can do the work — it’s kind of like public radio,” Kennedy says. “It’s critical to show physicians how not becoming involved can hurt them in dollars and cents. But at the same time it’s also about giving them a sense that they can make a difference. One of the things we are spending a lot of time on now is going back to people who have sent e-mails and letters to legislators to ensure they know their work has paid dividends.”

Hayek welcomes any ASCs or organizations with an interest in the ASC community to join the ASC Advocacy Committee’s efforts. “The Advocacy Committee is designed to be open and transparent — and we welcome both financial support and grassroots support,” he says.

Hayek can be reached at (205) 545-2755 or andrew.hayek@scasurgery.com. Or contact the committee’s executive director, Marian Lowe, at (202) 266-2606 ormarian.lowe@shcare.net.

OR Technology: A Glimpse Into The Future

As we move into 2010, a new wave of technology awaits us. Highly-developed health information technology (HIT)-driven systems and equipment are becoming the standard in many operating rooms (ORs), whether they are in a single-specialty ambulatory surgery centers (ASCs) or advanced surgical hospitals. It is important to stay up-to-date on these new technologies which not only reduce medical errors, but improve patient comfort and post discharge follow-up. The following case studies highlight this trend.

Enhancing Communication, Collaboration and Education: An Olympus Case Study

Three years after adopting integrated ENDOALPHA ORs, Penn State Hershey Medical Center is ready for more. As the only teaching hospital in central Pennsylvania, Penn State Milton S. Hershey Medical Center is one of the area’s largest healthcare providers. The hospital is equipped with 23 surgical suites and its department of surgery performs more than 19,000 procedures annually.

Staying Ahead of the Technology Curve

As industry trends move toward minimally invasive techniques, the hospital was quick to understand the benefits of integrated surgical suites as a way to stay competitive with the specialized technology demands of increasingly sophisticated procedures. “Several years ago, we realized we had a need for advanced, integrated technologies in our OR as we anticipated the convergence of laparoscopic and flexible endoscopic instrumentation,” says Randy Haluck, MD, professor of surgery and division chief for minimally invasive surgery and bariatrics. “We also recognized the need for a sophisticated system relative to data acquisition, storage, and transfer.”

Penn State Hershey began the process of integration in 2005, building three new Olympus ENDOALPHA surgical suites in 2006 and then converting two existing ORs to ENDOALPHAs the following year. The hospital anticipates completion of four more integrated ORs, for a total of 27 surgical rooms with one-third of them set up as state-of-the-art ENDOALPHAs this year.

Taking a Comprehensive Approach

True systems integration goes beyond the equipment and operating platform. It also takes into account the ergonomic design, workflow and technology optimization of each surgical suite. This means designing rooms with ceiling-mounted booms for holding imaging equipment and monitors off the floor, allowing for more efficient post-procedure clean-up and ergonomic positioning of monitors during the procedure. It means integrated equipment (scopes, imaging platforms, monitors, video and accessories) that work together and can be easily interchanged during a procedure. And it means a cohesive information management system for patient and procedural data, images, and audio that can be captured, stored, and retrieved from both inside and outside the sterile field. “We needed to have multiple surgical services using the same operating room, between general surgery, urology and minimally invasive GYN surgery,” says Gerald Harkins, MD, medical director for minimally invasive GYN surgery. “We’re all able to function in the ENDOALPHA laparoscopic suites, and it’s been a fantastic platform for that utilization.”

Experiencing the Installation Process

Olympus offers turnkey solutions, working with customers from start to finish on the design, construction and set-up of integrated operating and intervention rooms. “The flexibility of Olympus’ ENDOALPHA system means it can be easily customized to create a right-sized solution unique to each facility,” says David Alexander, Penn State Hershey’s Olympus integration consultant. “We were able to incorporate their legacy equipment along with their pre-existing video-conferencing system and streaming video package into their ENDOALPHA ORs to create one seamless solution. Hershey proved to be very knowledgeable, so it was a highly collaborative effort.”

Taking Centralized Control

The nerve center for each ENDOALPHA OR is a centralized control panel. With audio, video, data and images all controlled via a single touch screen, clinicians have the power to connect, communicate and collaborate with others outside the procedure room. Clinicians can also control surgical and room lighting, in-room observation cameras and all information and imaging systems without ever leaving the sterile field. To further enhance efficiency, the ENDOALPHA system provides preset capabilities so that monitors, lighting and all equipment can be custom-tailored to surgeon preferences and made available at the press of a button.

Communication, Collaboration, and Education

Penn State Hershey Medical Center’s custom-placed displays ensure all team members have the perfect view of live images. They regularly create video networks for sharing, collaboration and education from within and outside the hospital. “There’s no question that the Olympus system has dramatically changed how we teach in the OR,” says Peter Dillon, MD, chairman of Penn State Hershey’s surgery department and surgical director of perioperative services. “We’re now able to broadcast these procedures to first- and second-year medical students, exciting them about the wonders of surgery at a much earlier stage in their training. So it really has changed dramatically and in a very exciting fashion how we teach.” Haluck adds that it also gives the Penn State Hershey team a better way to collaborate with other physicians and share information with patients. “We can educate other physicians and record images for colleagues or bring them in when needed to confer and/or assist on a procedure. We are also able to show patients what their surgery was about and why they were having problems. That’s a great benefit to us, and certainly patients appreciate it as well.”

Interventional Radiology Breaks New Ground: A Skytron Case Study

Philips and Skytron have teamed up to help fully realize the promise of a hybrid angiography suite by implementing new cardiovascular solutions with the latest Allura Xper FD technology from Philips and state-of-the-art surgical lighting and boom technology from Skytron.

For more than a decade, Barry T. Katzen, MD, medical director of Baptist Cardiac and Vascular Institute (BCVI) in Miami, has pioneered the integration of surgical and interventional procedures. Katzen and his team continue to show that surgical procedures in an angiographic environment can be accomplished with the same degree of efficiency as in an OR.

“The specialties of interventional radiology and vascular surgery bring more to each other when we work together,” Katzen says. “Procedures that help drive this relationship include aneurysms of the thoracic aorta and abdominal aorta. Having an environment where we can use a surgical option allows us to think out of the box for individualized patient solutions.”

In 2008, Philips Healthcare and Skytron entered into a collaborative agreement to provide comprehensive, integrated solutions for the cardiovascular environment. Katzen seized the opportunity to refine the surroundings. Based on a well-coordinated plan from Philips and Skytron, a room at BCVI underwent a significant upgrade to enhance hybrid functionality.

“One of the great advantages of the new room design is it’s so spacious that we can all function effectively without being in each other’s way. Information can be transferred to the head of the bed — to the anesthesiologist — down to where we’re working very easily,” says James F. Benenati, MD, medical director of the peripheral vascular laboratory.

A Room That Works

BCVI’s surgical team appreciates the changes made. Katzen believes the upgrade has created a better environment for all involved. A recent experience demonstrated how the teams successfully combined surgical access with an interventional solution. A patient presented with critical narrowing of an artery to the brain and chest, and a narrowing of that same artery in the neck. “It was a very complex situation,” recalls Katzen, “but we combined our skills. The surgeons removed the plaque in the neck with an endarterectomy and we used that same access to go down and stent the chest.”

Installation With Minimal Impact

“We’re a busy lab and taking a room down for a period of time is always an inconvenience,” says Katzen. “The one thing everybody remarked upon was how fast this upgrade was accomplished.” In two and a half weeks, Philips and Skytron, working closely with the implementation team at BCVI, completed the staging and upgrade. The new room reflected the input of interventional radiologists, surgeons and anesthesiologists, with each group helping to define the clinical specifications to make it a multi-disciplinary environment.

OR Technology Update: A Steris Case Study

The epitome of surgical technology today is one OR in which surgeons can perform image-guided, catheter-based interventional procedures; minimally invasive endoscopic procedures; extremely precise robotic surgery; or full open surgery, depending on the case load or discoveries made in surgery. In this type of hybrid OR, integrated imaging, computerized patient information and live video routing technologies instantly display test results and critical real-time information on high-definition monitors in the sterile field. This allows surgeons and staff to ascertain the most timely and accurate diagnosis and treatment for the patient. It also helps them achieve the most flexible and effective uses of the room and optimize scheduling and utilization.

These are also the types of rooms in which medical leaders and pioneers train residents and other clinicians, develop new minimally invasive procedures, such as natural orifice trans-luminal endoscopic surgery (NOTES) and trans-catheter heart valve replacement and master new surgical devices.

These highly advanced rooms can incorporate advanced communications, connectivity, LED surgical lighting and high-definition visualization such as intra-operative fluoroscopy, intra-operative computerized tomography, magnetic resonance imaging, image-guided navigation, 3D software extrapolations of the imaging, robotics and many other technologies. Each of these tools are important in today’s hybrid OR, but when integrated correctly they form a seamless whole that is greater than the sum of its parts.

To accomplish this synergy, STERIS collaborates with leading manufacturers to design and install customized, integrated HD360°™ Hybrid ORs for healthcare facilities. STERIS project design managers configure STERIS’s open infrastructure Harmony® Lighting and Visualization systems, equipment management systems and advanced integration technologies with interoperative imaging, robotics, endoscopic and video technologies and more. The result is a suite that enables fully informed staff, highly efficient procedures, extremely flexible room use, successful surgeon recruitment, medical education, ongoing surgical innovation, leading edge robotic surgery, telemedicine, and new possibilities yet to be imagined.

OR Technology Update: A Berchtold Case Study

Problem

Before hybrid ORs existed, imaging and communications capabilities were not an option during cardiovascular and neurosurgery operations, resulting in patients getting diagnosed and treated in two different visits. Separate procedures and imaging consultation can be costlier for patients and surgeons, can result in additional stress, more down time and longer hospital stays for the patient, and are not conducive to emergencies that sometimes arise during surgery.

Solution

Combine minimally invasive and interventional surgical technologies with medical imaging and communications equipment in one operating room: the hybrid OR.

A growing trend involving endovascular procedures during cardiovascular and neurological surgeries requires equipment to accommodate open and closed procedures in the same room, even at the same time, although this is not necessarily planned from the start. The new hybrid OR model provides the surgeon flexibility in performing a variety of interventional, imaging and surgical services in one setting, eliminating the need to transfer the patient.

For example, two of the most popular hybrid ORs are for cardiovascular and neurosurgical procedures:

» Neurosurgical hybrid ORs can include magnetic resonance imaging (MRI); computed tomography (CT) and angiography equipment within a neurosurgical operating room.

»Cardiovascular hybrid ORs often features: Fixed ceiling- or floor-mounted C-arms, ultrasound and endoscopy equipment, coupled with cardiac catheter laboratories.

Because a hybrid OR is specifically designed for endovascular procedures, careful planning from the beginning can help to ensure all rooms are equipped with necessary tools. Some tips to consider while creating a specially designed hybrid OR include:

»Identify factors that are important to the hospital team, such as, should all equipment hanging from the ceiling (surgical arms, flat panel arms, etc.) be able to cover the whole patient in all orientations?

»Think as far ahead as you possibly can to “future proof” the room, reducing the need to renovate the OR moving forward. For example, what is the most extreme type of procedure the team might do in the OR? Then outfit the room in preparation for the procedure.

»Involve the end user at the very start of the project to give a real world perspective for offering scenarios, as well as discussing needs and concerns. This can include nurses, surgical technicians and staff, as well as anesthesiologists.

»Consult with the vendor providing lights, booms and imaging equipment to accommodate all of their needs. For example, many imaging companies have different requirements for ceiling heights.

Hybrid therapies enable hospitals and clinicians to provide less invasive care that is safe and cost-effective for the patient. Careful planning can lead to an effective hybrid operating room design that offers the following benefits:

» Cost-effective operations for patients and surgeons, with better outcomes.

» Reduced stress, faster recovery and reduced hospital stays for the patient.

»Safer procedures, especially in the case of an emergency.

New Bair Paws® Gown Brings “Flex Appeal” to Patient Warming: An Arizant Case Study

The recent Centers for Medicare and Medicaid Services (CMS) adoption of the SCIP-Infection-10 normothermia quality measure has made it more important than ever to simplify the process of warming every surgical patient. Arizant Healthcare’s latest innovation in forced-air warming, the Bair Paws Flex gown, does just that by incorporating a surgical warming product — Bair Hugger blankets — into a comfortable patient gown that warms before, during and after surgery.

While clinical versatility is a key benefit of the Bair Paws Flex gown, so is the practical economic approach of standardizing multiple warming capabilities into one gown that can accommodate most perioperative warming needs. While helping to improve outcomes and boosting patient satisfaction, the Bair Paws Flex gown may save facilities money by supplanting multiple OR warming blankets and the warmed cotton blankets and gowns often used to comfort patients.

Just One Gown Warms From Start to Finish

Before surgery, patients appreciate the Flex gown for its controllable warmth; they can simply dial the temperature of the air flowing through the gown to a level that’s comfortable. The surgical warming products built into the gown are unknown to the patient because they are deployed only by surgical staff.

In the operating room, the same Bair Paws Flex gown offers clinicians the ease and convenience of having multiple patient warming options available during surgery. Seamlessly integrated into the gown are: a head drape, adhesive tape to isolate the surgical field, and deployable arm extensions to transition into a Bair Hugger upper body blanket with tie strips. A second insert in the lower portion of the gown may be used to prewarm before surgery and then warm again as a lower body blanket once in the OR. The gown’s design allows upper or lower body warming for any surgical positioning — supine, prone or lateral.

After the procedure is over, the upper body blanket arm extensions, head drape and surgical tape strip perforate off, returning the garment to a standard warming gown for post-operative use through the lower warming blanket insert.

The Bair Paws Flex gown is comfortable for patients, convenient for clinicians and warms from pre-op to the OR to PACU. Best of all, it’s also economical. One gown handles almost all your warming needs, including contributing to quality goals like SCIP-10 and improved patient satisfaction. It incorporates a highly effective surgical warming device directly into a soft, comfortable hospital gown that does something positive for patients and hospital staff. It’s not just a gown. The Bair Paws Flex gown is a patient warming and patient satisfaction tool. It’s the future of patient warming, and it’s available today.

Practicing Arthroscopic Surgery on Computers, Not People: A Toltech/Sensable Case Study

Learning diagnostic knee arthroscopy is not unlike learning to play the violin — both art forms require a mixture of cognitive and proprioceptive skills that can only be developed through rigorous practice. And while both require intensive mentoring, surgical apprenticeship is unique in its resulting increase in operating room time and potentially patient risk. Just as with a violin that makes no sound, little can be learned from surrogate surgical environments having no objective feedback, including costly and labor-intensive cadaver training. And little transference of either skill can be expected from computer based training lacking the feel of the instrument(s).

In late 2009 the University of Michigan Medical Center’s Orthopaedic Surgery department, led by James Carpenter, MD, became an early adopter of the Knee Arthroscopy Surgery Trainer (KAST) from Touch of Life Technologies (ToLTech). This simulator was co-developed with the American Academy of Orthopaedic Surgeons (AAOS), Arthroscopy Association of North America (AANA), and the American Board of Orthopaedic Surgery (ABOS). It provides both cognitive and haptically-enabled skills training for the proper and efficient techniques required for diagnostic arthroscopy of the knee as done on an outpatient basis — including training to competency, and a modality for complete evaluation of residents’ skills.

In the KAST simulator, trainees hold a customized stylus in each hand — emulating the probe and camera used in actual surgery — that are attached to PHANTOM® force-feedback haptic devices, made by SensAble Technologies. The haptic devices allow trainees to navigate in true 3D space while interacting with high-resolution models that are viewed on-screen, as if through an actual arthroscope. The force feedback devices are programmed to push back on the user’s hand to deliver the “feeling” of the soft tissue, cartilage, and ligaments involved in knee arthroscopy.

The “Virtual Mentor” in KAST guides, critiques, and scores the resident on each part of the procedure. In one module, trainees must perform three steps for examining the medial meniscus with a probe. The Mentor requires the trainee to score 100 percent on each step before attempting subsequent tasks, and finally a time-trial. A special “cheater view,” only available at the novice level, shows the outside image of the knee (seen in the right hand portion of the Mentor screen), to help residents understand where the tools they are using are located with respect to the anatomy. KAST switches seamlessly between a right and a left knee, forcing the trainee to be ambidextrous with respect to the camera and probe.

Haptically-enabled surgical simulation provides cognitive and skills-based training — freeing up the outpatient facility’s attending physicians to teach higher-level skills, and giving residents unlimited autonomous practice opportunities. It allows residents’ skills to be objectively measured and validated before they undertake procedures on patients. The University of Michigan Health System’s Orthopaedic Surgery department plans trials comparing beginning residents who have trained on KAST, against a control group. Separate validation studies led by the AAOS using KAST are underway nationwide during 2010.

Are Physicians Political Animals at Heart?

Traditionally, medical schools do not instruct physicians on how to be a politician, nor do they adequately equip them with the tools they need to fend off attackers of their industry, especially if they are in ambulatory surgery. In a recent study, medical researchers asked, to what extent are physicians civic-minded, and do they have a responsibility to advocate for their community? The answer, according to physicians themselves, is yes.

This Commonwealth Fund-supported study found that nearly all of the 1,600-plus physician respondents believe they should play public roles, and two-thirds are actively involved in community activities, political work or advocacy.* More than 90 percent of respondents said that political involvement and advocacy were important roles for physicians. According to the researchers, anesthesiologists and surgeons were significantly more likely to rate political involvement as being very important than were other physicians. The study found that two-thirds of physicians had participated in some type of community, political or advocacy work in the past three years, with one-quarter taking political action and one-quarter encouraging a professional society to advocate for a particular issue. However, there is one important finding revealed by the study — 28 percent of physicians who identified themselves as civic-minded reported had not taken part in public activities in the previous three years. So you can never really tell how physicians see themselves as political animals and what kind of political activity resonates with them.

Trying to change all of that is a number of groups working diligently to cultivate greater participation in advocacy efforts by physicians in ambulatory surgery centers. Chief among them is the ASC Advocacy Committee, which debuted in August and strives to create a unified voice among ASCs in order to convey the compelling ASC story to lawmakers at state and federal levels. You’ll meet Andrew Hayek, chair of this committee, as well as the New Jersey Association of Ambulatory Surgery Centers and a few other champions of ASCs, as part of our annual legislative and regulatory section in this issue. They want to convince you that if you don’t get involved, your enemy certainly will.

* Reference: Gruen RL, Campbell EG and Blumenthal D. Public Roles of U.S. Physicians: Community Participation, Political Involvement and Collective Advocacy. JAMA. 296(20):2467-75.Nov. 22, 2006.

In The Eye of the Political Storm: N.J. Association Advocates for ASCs

Throughout the country, ambulatory surgery center (ASC) associations are fighting back against assaults on their industry. No association has fought harder than the New Jersey Association of Ambulatory Surgery Centers (NJAASC), which has been at the eye of the storm in the attack on physician ownership and referrals. The NJAASC works closely with other specialty medical societies and healthcare groups, and its board is composed of physicians who have ownership interests in ASCs as well as ASC administrators and ASCs that are co-owned by physicians and development companies.

One issue that has taken precedence lately is a recent New Jersey Superior Court decision adopting a strict interpretation of the state’s anti-kickback statute. A Nov. 20, 2007 ruling, Joseph Garcia, MD, et al v. Health Net of New Jersey, Inc. v Wayne Surgical Center, LLC, established that referrals of a patient to an ASC in which the referring physician owns an interest violate N.J.S.A. 45:9-22.5, known as the Codey Act. This ruling prohibits a physician from referring a patient to a healthcare service in which the physician has a significant beneficial interest. The statute contains an exception for physicians who provide the patient with a written disclosure form and post this disclosure form in a conspicuous public place.

The Garcia case had been on appeal; at press time in late November, the Appellate Division upheld the trial court’s determination that Wayne Surgical Center (WSC) and its physician owners did not violate the Insurance Fraud Prevention Act (IFPA) because they failed to disclose that WSC frequently waived collection of co-insurance due on WSC’s facility fees. Further, the Appellate Division held that there is no New Jersey rule, regulation or directive from any administrative or licensing agency barring the waiver of co-payments or other co-insurance amounts. In support of its decision, the Appellate Division noted that WSC required each patient to sign a form stating that “he or she is fully responsible for 100 percent of the center’s charge.” And further, that at the time claims were submitted, WSC did not know whether it would enforce the patient’s agreement to pay co-insurance.

In March, then-New Jersey Gov. Jon Corzine signed Senate Bill 787, amending the state’s existing physician self-referral statute and significantly changing how ASCs are regulated under state law. In short, the law disallows new ASCs unless an exception applies; allows hospitals to establish new ASCs and enter into ASC joint ventures with physicians or other parties; prohibits indirect referrals from physician owners to their ASCs; requires certain state reporting requirements; and requires accreditation of all ASCs.

Helping the NJAASC navigate this political minefield is attorney John D. Fanburg, managing member of BrachEichler LLC and chair of its Health Law Practice Group. He recalls how he and the NJAASC sprang into action that fateful November more than two years ago: “After reading the decision, we immediately communicated with all of the key people in New Jersey to begin to right the wrong. One of the first calls we made was to Sen. Richard Codey’s office, since he was the author of the original bill, to begin to explain to him what the judge ruled in the Garcia case and how contrary it was to what we believe his original thinking was when he passed the law in the 1990s. We spent the next several months talking with him and also spent time with the state Board of Medical Examiners. We finally got to the point where the bill came up through the Legislature and was then signed by the governor this past March.”

Fanburg acknowledges how the bill split the physician community: “There was great debate as to whether the bill should or shouldn’t go forward, and should it have a grandfather clause, which it did. The radiology society at the time felt it was a good bill and that it should proceed because self-referral was bad. The medical society fought it and ultimately the compromise was that if you had an ownership interest prior to the effective date you could continue to own it; going forward, however, you were prohibited unless you met one of the several exceptions. Questions to the Board of Medical Examiners increased as ASCs began to proliferate and they were deemed and utilized as an extension of the practices. We went to the board and said, ‘Hey, this is what’s going on, would you agree with us that this is an extension of an office and the Codey prohibitions don’t apply,’ and they agreed. Then you had changes on the federal level; when the Feds took the view that an ASC, if structured the right way, would indeed be viewed as an extension of the practice, it added to the proliferation of surgery centers. In time, you have a surgery center on every block and hospitals feel they are being economically challenged by that. So now here we are on the cusp of 2010, and due to the political implications of further ASC development, the hospitals were able to convince the legislators to allow no more ASCs, unless you meet an exception, or you filed your plans in September, the last chance to get a surgery center built.”

The next step for the NJAASC, Fanburg says, is to get involved in the drafting of the rules and regulations associated with the amended Codey Act. “The way the statute is written, it covers the jurisdiction of two of our administrative agencies — the Board of Medical Examiners and the Department of Health and Senior Services,” Fanburg explains. “When a statute is passed, depending on who and what it impacts, these two administrative agencies need to draft, propose and adopt regulations that are used to interpret the statute. So we really won’t know how the exceptions are going to be narrowed or broadened until these agencies do so. We are going to be very active in the development of those rules and regulations, and being involved in that process is better than being shut out. Because of the relationships we have and all of the work we have done over the years, they know that they need to run things past us before they propose them.”

As far as the Codey Act amendments having a chilling effect on ASC development elsewhere, Fanburg says he thinks it will depend upon the political strength of hospitals versus physicians. “Different states may very well look to this to either curtail ASC development or to expand it,” he says. “And that’s something we were well aware of and that’s why we brought in the national ASC Association for its input and support. What happens here could happen elsewhere.”

Just what happens from here is anyone’s guess, but Fanburg believes there may be an acceleration of the development of hospital co-ventured ASCs. “If I were developing a surgery center in the northern part of the state, I would find a hospital in the southern part of the state and say, ‘Why don’t you own 10 or 20 percent of this thing — I am not in your geographic catchment area but these things are profitable; I can only do it if you’re a co-owner, so join me.’ You will probably see more of these kinds of relationships, so surgery centers will continue to proliferate for the sake of quality, efficiency and patient convenience. And maybe this is a product line that hospitals can’t be or shouldn’t be in anymore. I think hospitals must rethink what types of services they can provide. There are quite a few joint ventures between hospitals and physicians in ASCs currently; that’s something many physicians want to continue to do. They recognize an ASC’s economic impact on a hospital and out of loyalty and support they say, ‘We’re going to impact you, we don’t want to kill you, so why don’t you participate with us,’ and many hospitals have taken them up on that offer.”

In addition to working on regulations associated with the Codey Act, Fanburg says the NJAASC has a number of priorities on its agenda, including fighting off an assault by insurance companies on out-of-network providers. “We are very busy right now,” Fanburg says. “We are not resting at all because we think the ASC industry is going to continue to be under attack by hospitals as well as those who feel threatened by ASCs. It’s pretty much a 24/7 job.”

The importance of persistence in any advocacy effort is not lost on the NJAASC. Nor should it be on any ASC owner/operator anywhere else in the country, Fanburg says. “Advocacy by everyone in the industry is critical because the political arena can be where your business is going to be impacted,” he says. “Here in New Jersey, people are surprised at how accessible their local legislators and regulators really are. If you want to go the extra yard you have to be part of an ASC organization so you can be heard on a larger scale. If you don’t do it, your adversaries will, and the people who are going to be making decisions impacting your business are not going to have the benefit of your viewpoint. If you are in business, you have to become involved in politics and advocacy.”

Growing a Grassroots Advocacy Effort

By Kelly M. Pyrek

You first met Marcy Sasso in the December issue of SurgiStrategies; she’s the director of operations at the ASC of Union County in Union, N.J. Sasso has become a seasoned political activist on the behalf of her center and other ASCs in New Jersey, and was successful in launching a political coalition in her region, the Surgery Center Coalition (SCC).

“I knew I needed to become active in the industry when a colleague of mine said she felt we were isolated in the larger New Jersey ASC industry,” Sasso recalls. “We started our grassroots group, the SCC, in her waiting room as a place to share ideas in the day-to-day running of an ASC. We had discussions regarding a number of topics such as inspections, vendors, HR issues and policies and procedures. Word of mouth had our group growing and meeting more frequently. We outgrew her waiting room and with our membership at 70 strong, we found ourselves in the conference room of our generous attorney Bob Towey of Lowenstein & Sandler.”

Sasso continues, “Over the past four months we have not been able to have our usual day-to-day conversations, but rather we found ourselves immersed in the out-of-network (OON) issues facing New Jersey. Our meetings focused on reduced insurance payments, denials, threats to terminate participating physicians, etc. I personally couldn’t sit back and watch things get worse and felt that members of our group were smart and highly dedicated to the philosophy of ASCs, and so from there our advocacy meetings took shape.”

Sasso says she met with two state senators to provide them an educational overview of New Jersey ASCs’ concerns. “They listened and suggested that our ASCs have a louder voice,” Sasso says. “The ASCs and hospitals are really not on the same sides in business; having said that, the insurance carriers end up having to choose sides. The hospitals have lobbyists with louder voices and overpower the ASC industry. So getting our legislators involved is pure necessity. The insurance carriers want to do away with OON facilities, and want the selected centers to be on their panel as in network providers. With more than 300 centers in New Jersey, I personally felt that many centers would never be asked to be on their panel for various reasons and thought 2009 is the time to make a difference in our industry.”

Sasso says she believes that persistence is the key to any grassroots work. “Believing in your cause is essential,” she emphasizes. “Joining your state and national ASC associations will prove to be effective for networking and spreading your message. Stand up to the insurance carriers, and ask questions. Insurance carriers can be powerhouses but the ASC industry can prove itself to the consumer by continued low infection rates, excellent patient satisfaction rates, efficient turn-around times and cost effective rates! I believe in our industry and all of our employees nationwide need to have their voices heard. Why are we here? Because we can provide a service that the consumer requests!”

ASCs in 2009…What a Year to Review!

Following the 2008 economic crisis, 2009 can be seen as a recovery year or will it be better known as the year of the swine? With all the financial problems this country has faced in 2009 it is difficult for us to remember that the end of 2008 left us with the Dow Jones average in the 7,000 range. As of the writing of this column we are sitting slightly ahead of 10,000. All in all, a good year for anyone who had investment money left after the beating we all took in 2008, and furthermore, the gain only went to those stout soles who stayed in the market when most of us were on the sideline.

Why is this important to the ambulatory surgery center (ASC) industry? Because we are, to a large extent, dependent on discretionary spending and certainly dependent on employment and employee benefits. When the unemployment claims rise, more Americans are out of work and are more careful with their spending. This means putting off surgeries that are not urgent and taking a pass on many elective procedures that are commonly done in ASCs. In addition, when spending is down, lower profits or negative profits affect many businesses. When these businesses look at ways to save on expenses they have to look at salaries and benefits. One way to reduce expenses is to increase deductibles and co-payments in their employee health plans.

Economics 101 teaches us that we all try to make the best use of our limited resources; in this case, it’s money. When money is abundant and costs, deductibles and co-pays are low, elective procedures are seen as attractive and affordable and the volume increases. When our valuable resource — money — is scarce or in jeopardy due to the threat of losing one’s job and the personal costs of having surgery increases, the volume drops. It’s simple economics … now, what did we do about it?

Surgery centers across the nation have stepped up to the table and looked the beast in the eye. Working with patients, surgeons’ offices and managed care plans, an untold number of programs have been introduced to assist patients who are having difficulty making their deductable or their co-payments. While the first quarter of 2009 showed lower-volume statistics and decreased profitability, the balance of the year was incredibly strong. In many cases, the lost volume and profits from the first quarter were more than replaced over the next six months, leading to record years for production and profitability. The key to this recovery appears to be the volume of procedures that were delayed from 2008 that needed to be done in 2009, as well as the increase in trust that the economy was starting to recover, giving the patient more confidence to spend. Additionally, the ever-increasing number of Baby Boomers is reaching an age where they consume more healthcare services.

Despite the continued downturn in the economy and the high unemployment rate I am optimistic that the ambulatory surgery center industry will have a banner year in 2010. Patient satisfaction is at an all-time high, clinical quality and outcomes are at record levels, and the Baby Boomers continue to grow at record rates. Balance this against a slowdown in construction and reduction in patient beds and surgery suites due to market conditions and you will see why I am an optimist in the middle of the financial crisis.

Michael J. Lipomi is president of RMC MedStone.

Strictly Pediatrics

Pediatric services in ambulatory surgery centers (ASCs) require a nurturing approach. Recognizing that children are not “little adults,” being aware of the challenges that pediatricians face with outpatient surgery and focusing on a high patient and family comfort level is key to successful pediatric services. With Strictly Pediatrics, the name says it all; employees of this Austin, Texas ASC welcome families to their multi-specialty facility with open arms.

Since opening in 2007, the 20,600-square-foot center has become a central hub for a multitude of pediatric services ranging from ear, nose and throat (ENT), urology, ophthalmology, gastroenterology, orthopedics, and of course, general pediatric surgeries. At 5,000 procedures annually, how does the staff handle the large case volume?

“It’s great team work,” explains Jose Cortez, MD, a pediatric urologist at Strictly Pediatrics. “Running the center is like conducting a symphony. Everyone has a key role and of course you need to have good leadership and good direction, and we are very fortunate that administrative director- Stephanie Stinson has been a great leader in keeping everybody on track. She is a good conductor. Everybody feels like a big family, a team and everyone is important and helps out in their special way.” The strong bond between the staff members can be seen in various ways; for instance, the organization of a staff kickball team. John Williams, MD, a pediatric orthopedic specialist at Strictly Pediatrics, is part of the team. And Cortez expresses his enthusiasm toward becoming a member of the kickball team. “The staff sends out pictures, they are always talking about the games. I keep up with them; I’m a fan,” Cortez says.

Inside the surgery center, a clear mission statement helps set the stage for what physicians and patients can expect. When commitments to the mission’s principles are realized, everyone wins; one of the principles that Strictly Pediatrics abides by is the ethical and fair treatment of all.

“Our practice is completely open to all patients regardless of their insurance,” Cortez says. “Now of course, the center has different contracts with different insurance companies, but, for instance, if there is a patient that has Medicaid or some type of government-sponsored care, we don’t discriminate against those patients. We will see those patients and they are able to have their surgeries in our center the same way someone with insurance can and they are treated the same way. We also have patients who have charity procedures done at the center as well, so if they have absolutely no funding, we try to get them in and make sure they are treated in the same ways as well. These can run the gamut of just simple ear tubes, hernias, testicle operations, those kinds of things — it depends on the referring doctor or physician surgeon.”

Efficiency is essential to maintaining patient satisfaction and comfort. Providing innovative service delivery is another principle that the center values. “As we have become a little busier we found that it’s more efficient in some circumstances for certain patients to be roomed overnight versus going home,” Cortez says. “So, instead of having their surgery and going home as a true ambulatory case, and instead of sending them over to the hospital to be admitted, what we are able to do now is set up 23-hour observations. It’s one way the center is trying to meet the needs of patients and also creating newer modes of post-op care delivery. It’s been working out really well. The response from the physicians has been great.”

A call for compassion is another essential component for pediatric services. It is imperative to have well-trained nurses, anesthesiologists, physicians and other personnel who understand patient safety issues. “This is very true for everybody that works at the center, and also very true for the physicians that work there,” Cortez affirms. “We are all pediatric sub-specialists, we all are fellowship-trained doctors, and we all have a particular interest in the care of children. What’s very different about this group of professionals is that we take a little bit of extra time really trying to earn that level of trust from the families and the patients because these are little ones and families are turning them over to us so that we can take the best of care of them.” Like many of the physicians at the center, Cortez has a routine of meeting with patients and their families to make them feel as comfortable as possible before a procedure is performed. “We always review the intent of the surgery, the planned surgery and the goals,” he says. “I always make sure I answer their questions and review concerns that might have come up since our previous office visit. I always joke around with the little kids if they are old enough.” Developing a close relationship with the families from the very beginning can help cut the pre-op procedure time in half. Cortez and his team are able to greet patients, address procedure logistics, and ease family concerns all within 5 to10 minutes because close relationships have been previously established. “It’s really just a reassurance that we are moving forward doing the right thing and that their babies and kids have the best of care. And of course, we treat these kids like we would our own,” Cortez says.

Some of the challenges ASCs see in pediatrics is dealing with the delicate nature of the child. “You have to realize that some of these kids and babies that are having surgery, need these surgeries to last there lifetime,” Cortez says. “Unfortunately, for some of these little ones that have multiple problems, it’s very well accepted that they will need multiple procedures over time in a staged fashion because you can’t fix everything all at once. Some of the challenges are being able to reach your goals every time you see them and every time you do the procedures. Getting them through that and to the next stage — that’s really one of the most challenging areas in our field. A lot of these little ones have congenital problems that are fairly complex and they may have multiple problems that need to be addressed at different times.”

Williams concurs. “Our first goal is to provide state-of-the-art care for children who have to have surgery,” he says. “We are very careful in doing procedures. Patients who require more complex surgery would have their surgery done at the hospital right next door. We are literally connected to the Dell Children’s Medical Center. So if there is ever a need for hospital admission we can take the patient through an underground tunnel to the hospital.” The community setting also facilitates the center’s success. Easy access to major cities and a family-oriented population are some of the main reasons why, besides exceptional healthcare, Strictly Pediatrics has become a sensation in the ASC community. Williams states, “The referral area is about 1.5 million to 2 million people, it’s a very young population. This is the home of the University of Texas, the state capitol and it’s one of the fastest-growing cities in the country.”

Cortez adds, “Austin is traditionally known as a college town, a family-friendly young city, and a vibrant, growing community.” As far as marketing goes, their target audience lies within the 46-county radius and is extremely easy to reach. William explains, “Most of the marketing has been through the individual physician’s offices.” Cortez adds, “We are fortunate that all of the sub-specialists that perform surgery in this area are associated with this center. In terms of marketing, it’s not difficult; we are basically the center for most of the 46-county area. We set the standard of care. This is the center for pediatric ambulatory surgery.”

How should physicians look to the future of pediatric outpatient surgery as a growing market? “I think this area is going to continue to grow and expand,” Cortez says, “especially as we try to find more efficient and less expensive ways to deliver healthcare and also perform surgeries. If you look at our center, we are more efficient and less expensive for the same procedure than performing it at the hospital. And of course, the insurers and the payors like that and I think that that’s going to be more essential as our country moves toward more efficient delivery of healthcare and less expensive healthcare. I think centers like ours are models of efficiency.”

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