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Welcome to the Advancing Surgical Care Podcast, brought to you by ASCA, the Ambulatory Surgery Center Association.
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ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in providing safe, high-quality, cost-effective patient care.
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As with all of ASCA's communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.
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Hello and welcome to the podcast.
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My name is Kara Newbury.
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I am ASCA's chief advocacy officer and the host of this recording.
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ASCA's advocacy efforts the past several years have resulted in CMS adding cardiovascular and vascular codes to the ASC Covered Procedures List or ASC CPL.
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Effective January 1st of this year, cardiac ablation codes were added.
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Still, as everyone in the ASC community knows, the migration of cases can take some time after the addition of these procedures to the ASC cover procedures list.
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In addition, in several states, there could be regulatory hurdles to overcome.
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Operating rooms must be configured or reconfigured with specialized equipment, and cardiologists and other medical support teams need to be recruited if they're not already part of the surgery center team.
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And that's where my guest today, Deb Yoder, comes in.
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Deb is an accomplished nurse with frontline experience in operating rooms, cardiac catheterization labs, intensive care, and surgery centers.
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In her career, she has been responsible for overseeing the design and construction of new ASCs and has assisted in developing and equipping more than 30 new facilities.
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At ASCA's annual conference and expo in Washington, D.C.
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this past May, Deb gave a presentation titled Adding Cardiovascular and Vascular Procedures to Your ASC.
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Will it work?
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In her presentation, she went into great detail regarding the design, regulatory, and equipment requirements needed to add cardiovascular and vascular procedures to an ASC.
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She's been on the front line as a consultant helping ASCs prepare for the addition of these procedures.
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And with that introduction, Deb, welcome back to the podcast.
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Thanks, Kara.
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I appreciate that introduction and thanks for having me.
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Absolutely.
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This is a very hot topic right now.
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And as we mentioned in the introduction, we're in the early stages of seeing some of these procedures begin to migrate to surgery centers.
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Could you just talk first about the kind of due diligence that's required for a center to undertake adding cardiovascular and vascular codes to their facility?
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It's very important for each ASC to know what their state licensure will allow them to do.
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And also if they have any type of certificate of need in their state, there may be a certificate of need for a surgery center, or it may be linked to a spend at any kind of healthcare facility, or tied to cardiac procedures.
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And like in some states, they can do ablations and pacemakers generators, loop recorders, but you can't do diagnostic or interventional coronary procedures.
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So it doesn't matter what the federal regulations are and what Medicare is approved, you have to follow your state licensure.
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That's just how it is.
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And then these centers have to be accredited.
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We found in some states they didn't require a certificate of need for a cardiac cath lab ASC, but the managed care contracts required a license.
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And I worked with some sites that kind of got behind the eight ball on that.
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So there's a lot of nuances you have to cover first.
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I think what you noted there, Deb, is important.
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It's not just what the federal government says.
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There are obviously practical implications that you have to be aware of as well.
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And it's not just being regulated or licensed by the state.
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You have to know what the payers are going to be looking for too.
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Deb, we do need to take a quick break to hear a few words from our podcast sponsor.
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Please stand by and we'll be right back.
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This recording is being brought to you by Surgery Partners, a leading owner and operator of ambulatory surgery centers with more than 200 locations nationwide.
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Surgery Partners collaborates with ASC leaders and physicians to acquire, develop, and optimize surgery center operations and helps ASCs scale efficiently, strengthen performance, and drive long-term growth.
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To learn more, visit SurgeryPartners.com.
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Now, Deb, before the break, we talked about the due diligence that a center should undertake before getting started.
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At the ASCA annual meeting, you also shared some slides that showed how to configure an operating room as well as some of the
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essential equipment required specifically for cardiovascular procedures.
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Recognizing we don't have the ability on this podcast to share those great slides, could you just take some time and talk about the configuration and equipment requirements for cardiovascular and vascular procedures?
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I think even before we talk about equipment, what's really important and before you're going into design, you have to understand what the case mix is going to be at this center.
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You have to have aligned physicians who understand what the market can support, what their referral patterns are, not just the payer market, but also do you have a friendly hospital that will accept transfers from these centers?
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You're always going to have that.
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If you don't have a good market to employ the appropriate staff and providers or physicians who don't understand what kind of cases are appropriate, it doesn't matter what you design.
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If you're going to do interventional coronaries, typically in the United States, the physicians will have all trained and expect a fixed cath lab type unit, a fixed fluoro unit.
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And that room's going to require a minimum of 625 square feet plus a control room.
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The vascular rooms you can have a bit smaller because those are typically done with a portable TR.
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But the fixed rooms, you have to have at least that size space.
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And then once you get into electrophysiology type procedures, you're going to have a lot of other added equipment that you bring in, mapping devices, recording devices that in a hospital, they're typically fixed.
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They always live in the same spot in an ASC.
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Sometimes they may move, but when you're going to design this, you also have to know what brand and what type unit you want because there's all sorts of above ceiling and underground conduit works, Unistrut work that you have to have done in the design phase before you even start to build.
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I worked with the center once and midstream, the physicians changed the kind of fixed unit they wanted.
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And it was at least a half a million dollar cost change.
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And we walked into that in the end.
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So if you don't do your due diligence right up front, you're going to run into trouble.
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That's really interesting, Deb.
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And I think that you've done a good job highlighting how complex and how cardiovascular cases are different from anything else that is being done in ASCs.
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With that being said, with the addition of all these codes, I know we
got PCI back about eight years ago, and now the cardiac ablations, understanding the challenges and how much work and really money can go into this.
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Do you have any evidence, even anecdotally, as to the interest from ASC administrators and/or cardiologists that you're hearing about adding some of these procedures to their centers?
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I think everybody wants to add them, especially electrophysiology, but you have to really understand the total cost of doing the case.
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And you have to understand that you have the right patient coming to your center.
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There was an article in Becker's and several other of the cardiology journals.
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About 33% of all CV procedures will be done in the ASC by the mid-2020s, which we're at now.
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But they also anticipate that to be closer to 50% by 2030.
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And while they migrate, not all the cases should migrate.
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Not all physicians are able to do cases in the ASC.
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You have to have the right staff and the right staff's mindset.
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The cardiology ASCs are not just mini hospital outpatient cath lab units.
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They are there to serve a purpose for more stable patients, more predictable outcomes.
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And they're just a whole different environment.
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We're going to have to have the hospital, but we also need these ASCs.
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And to make any of this work, everybody going into it needs to understand that.
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We know that a case in a surgery center is probably about 30 to 38 minutes less time than what it takes traditionally in the hospital cath lab.
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Our turnovers in the centers that I worked at were very minimal compared to the hospital.
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And they also like the alternate revenue stream.
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They haven't ever had this opportunity like the other specialists have.
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So whether they're owners of the real estate or the ASC itself, it provides them some additional revenue if the ASC is running well.
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Oh, that's great information.
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And I think those numbers are interesting in terms of the volume shift and the migration.
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I think it might be a little bullish, especially considering the limited number of ASCs that currently have cardiovascular capabilities.
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But I guess we're being optimistic here.
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Speaking of being optimistic, do you have any positive, you have any success stories that you could share with us in terms of either a new center coming online with cardiovascular
procedures or existing centers that are now performing some of these procedures on Medicare beneficiaries?
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Yeah, I have one in California that did well.
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They only did vascular work and like rhythm management work, but their patients loved it.
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The physicians loved it.
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You weren't trekking a mile through the hospital.
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Their patients all wanted to go there once they had one procedure done.
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One of my centers that I had worked with in Florida, one of the providers or physicians walked in.
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He had started at 7:30.
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And at 12:30, he had done seven cases that day.
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And they were a mix of diagnostic coronaries, interventional coronaries.
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He had done a generator change, a pacemaker insertion.
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They were using two rooms so he could utilize the most of his time.
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And he's like, I don't know what to do with my day now.
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I'm done at 12:30.
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I'd never have free time.
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If I was at the hospital, I would have been here till five o'clock.
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And so he knew should the cases all go as planned, be able to do at least three more cases in a day, three or four, and still have free time.
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He's like, I'm gonna go to the office and finish dictating and then I'm going home early today.
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I never get to go home early.
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And he was just thrilled.
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So I think that along with happy patients and happy staff and positive satisfaction surveys, those are true testaments.
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But those are centers that are well run and staff who were hired that are experienced and very engaged too.
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And physicians who are engaged.
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Not to put you on the spot, but are there specific protocols or policies that should be in place?
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Are there specific things that the facility should be doing to make sure that they can handle these cases from a policies and procedures, emergency preparedness perspective?
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You have to have really tight patient selection criteria.
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And that's something that was really interesting when we orient new nurses in these ASCs.
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Most of them are coming out of a hospital cath lab or an ICU environment.
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And they're like, I need a pump for this, and we're gonna have to have that med.
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And I'm like, hang on, why do we need that med?
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Because we always do.
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And I said, but that's for after you do an intervention during a STEMI, which is an acute MI or infarction, that you're opening an unstable patient.
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We're not gonna have those here.
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And they're like, oh yeah, I didn't think about that.
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So you have to be very selective with your patients.
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It requires some education from the physicians, too.
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If they do a diagnostic coronary and they see that there's maybe three or four lesions that need to be opened up, we can't do that in the ASC.
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They're gonna have to do those patients at the hospital.
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Or if they get in and I used the intervascular ultrasound, let's say it's a really hard, calcified, gnarly looking lesion, maybe they shouldn't do those either with a lithotripter or something.
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Just because you can do it doesn't mean you should do it.
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And that takes a strong medical director in your ASC and lots of education with the physicians.
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Which is similar in all the service lines.
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Just because you can doesn't mean you should.
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And we need the right patients.
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We don't want transfers.
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So Deb, it's obvious through this discussion that you are a wealth of information on this topic.
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How can listeners find you if they have additional questions?
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My new consulting business is aligned surgery and healthcare consulting.
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And my email is dyoder@alignedsurgeryhc.org.
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And I have a LinkedIn account as well.
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And I think we can make sure to put this in the transcript.
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Deb, I want to thank you for spending time with me and sharing your expertise.
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I know we've called on you often as a guest on this podcast, a speaker at Ask events.
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You've served on some task force with the association.
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We really appreciate your willingness to volunteer your time, knowledge, and experience.
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We at ASCA both the staff and the membership greatly appreciate your contribution.
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Thanks, Kara.
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I appreciate you and the Ask a team for all the work that you've done in this specialty area, and I appreciate being here today.
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So now, before concluding, I would just like to acknowledge the support of our podcast sponsor, Surgery Partners, a leading operator of surgical facilities and ancillary services with more than 200 locations in 33 states.
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Surgery Partners offers multiple types of healthcare services that deliver high-quality healthcare in a convenient and cost-effective manner.
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To learn more, visit surgerypartners dot com.