Confusion Over Outpatient Gallbladder Surgery
Will Lap Chole Make the 2008 ASC List?
Will laparoscopic cholecystectomies ever appear on the ASC list? Not in 2007, but maybe in 2008, when Medicare's revised ASC payment system takes effect. It's hard to say, because the proposed ASC payment policy for 2008 contradicts itself when discussing lap choles.

Medicare's medical advisors have barred lap choles from next year's list of covered procedures, ruling that lap choles didn't meet the clinical criteria for addition because they either require more than four hours of recovery time or could result in excessive blood loss. Whether lap choles are included on the list of covered procedures in 2008 is anyone's guess. At one point in the proposed payment policy CMS released in August, the agency recommended CPT 47562 (laparoscopic cholecystectomy) and 47563 (laparoscopic cholecystectomy with cholangiography) for inclusion on the 2008 ASC list, but not CPT 47564 (laparoscopic cholecystectomy with exploration of the common bile duct).

"Either CMS erred in leaving [47564] off the proposed list or in adding [47562 and 47563]," says Marie Edler, the director of reimbursement policy for FASA. "We're not sure which way CMS will go, but feel that some clarification will be forthcoming later on this issue." A CMS spokeswoman had this to say: "We are in the comment period at this time. Any concerns about the ASC list should be submitted as part of formal comments." Comments on the changes proposed for 2008 are due Nov 6.

Ms. Edler offers another explanation: Perhaps CMS has identified some clinical issue with 47564 that has led officials to believe the procedure won't meet the proposed new criteria for inclusion on the ASC list, while the other two codes will meet the proposed new criteria. With 47564, surgeons remove the gall bladder and clear the bile duct in a single stage.

Further confounding things is that, elsewhere in the proposed rule, CMS states that CPT 47562, 47563 and 47564 should be excluded from facility fee payment because they require an overnight stay. "There is a substantial risk that the laparoscopic approach will not be successful and that an open procedure will have to be performed instead," reads the rule. "Laparoscopic cholecystectomies should continue to be performed in a hospital setting (either inpatient or outpatient) as is the current practice."

Nancy Petty, RN, the administrator of the Grand Valley Surgery Center in Grand Junction, Colo., is holding out hope that CMS adds lap choles to the ASC list. "Our schedulers have to determine whether a person is on Medicare or Medicaid and exclude them for no medical reasons," says Ms. Petty.

- Dan O'Connor

Study Charts Nurses' Work/Family Conflicts
One-half of the RNs responding to a recent survey reported suffering "chronic work interference" with their family or home life, while another 41 percent reported "episodic interference," according to a study published in October's Research in Nursing & Health. "Work-family conflict has significant implications for nurses in terms of personal health, their ability to provide quality care and for the nursing profession itself," says Joseph Grzywacz, PhD, associate professor of family and community medicine at the Wake Forest University School of Medicine in Winston-Salem, N.C., and the study's lead author.

The study, the first to gauge the incompatibility of the twin demands of healthcare careers and family roles, analyzed the views of 1,906 RNs: 63 percent from hospitals and 14 percent from ASCs; 64 percent were caregivers and 19 percent managers. Researchers defined "chronic work interference" as incidents occurring one day a week or more, while "episodic" interference was one to three days a month. The study also addressed the opposite case, in which personal or family issues interfered with a nurse's work. Only 11 percent reported chronic interference and 52 percent admitted episodic interference. Researchers say future studies should examine the ability of more flexible work arrangements to reduce conflict.

- David Bernard

Benchmarking Study Released
Financial and Operational Data Extracted from 1 Million Cases
Did you know that the two highest volume-producing docs account for 28 percent of all cases in the typical multi-specialty surgery center? Or that the median medical and surgical supply costs for ASCs are 21 percent of net revenue? You'll find that and more in InforMed's Multi-Specialty ASC Intellimarker, a new financial and operational benchmarking study based on the performance of 215 freestanding surgical centers and 1 million cases. A few highlights from the 174-page study ($1,495 from InforMed Healthcare Media), which analyzed facilities by U.S. region, size, number of ORs and case volume:

• The single largest expense among all facilities is employee costs. The median annual personnel costs (including salaries, wages, taxes and benefits) represent 28.9 percent of net revenue.
• The average staffing level in surgery centers is 31.4 FTEs, about 70 percent of whom are medical staff.
• The median administrator salary is $92,765. Nurses in multi-specialty surgery centers earn $55,000 per year ($26.41 per hour), based on a 40-hour work week. Techs earn $35,000 per year ($17.03 per hour). Administrative staff earn $33,000 per year ($16.02 per hour)
• Typical case volume for a multi-specialty facility? At 25 percent, GI/endoscopy is the largest contributor to case volume in multi-specialty ASCs, followed by orthopedics (18 percent), ophthalmology (14 percent), pain management (13 percent) and ENT (8 percent).
• The median case volume is 4,001 cases per year or 16 cases per day.
• Surgery centers report a median of 3.1 surgical cases per OR and 3.0 non-surgical cases per procedure room per day.
• Commercial payers represent the largest group of payers, contributing nearly 60 percent of the median surgery center's gross charges. Medicare and Medicaid were responsible for around 26 percent of gross charges.

- Dan O'Connor

Thyroidectomies Shifting to Outpatient Facilities
Endoscopic thyroid surgery is safe for most patients and can be performed on an outpatient basis, says David Terris, MD, chair of the Department of Otolaryngology at the Medical College of Georgia in Augusta. He presented his findings last month at the annual meeting of the American Academy of Otolaryngology in Toronto.

"This procedure uses established technology for a new purpose," says Dr. Terris, noting that improved optics and hemostatic instruments allow for rapid wound healing, use of a local anesthetic and less chance for wound drainage.

Dr. Terris employs a 30-degree laparoscope and the Harmonic Ace ultrasonic blade for cutting and coagulating. "It's only in the past few years that both of these devices have been used in tandem for thyroid surgery," he says.

According to Dr. Terris, 36 of 125 thyroidectomies performed at the Medical College of Georgia between February 2005 and March 2006 were minimally invasive procedures. Thirty-five of those cases were outpatient, and none reported complications. He says up to 70 percent of his patients are candidates for the outpatient procedure. Dr. Terris notes that selected patients must be non-obese individuals, have a nodule size less than or equal to 2.5cm to 3.0cm and a thyroid less than or equal to 20cc.

The endoscopic procedure calls for two surgical assistants and takes 20 percent to 30 percent longer than open surgeries. But Dr. Terris believes that with superior visualization, smaller incisions and less dissection, the minimally invasive approach is a viable option that will become widely accepted after additional reports of positive experiences and case outcomes.

- Daniel Cook

Sedation Reimbursement
GI Docs Win One on Propofol Payments
One year after Anthem Blue Cross and Blue Shield announced it would stop paying for propofol administration during routine upper and lower endoscopies, the insurer reversed the decision, a move GI physicians are applauding.

"This ensures the highest standard of care will be met in our facilities," says David Cort, MD, the president of Digestive Disease Medical Consultants in Chesterfield, Mo. "Five years ago, insurers were saying epidural anesthesia for childbirth wasn't medically necessary, even though it was the standard of care. No one questions it now. Propofol for endoscopies is part of medicine in 2006. This is what we do."

In September 2005, WellPoint announced it would begin medical necessity reviews on claims filed for anesthesia services at surgical facilities in its central region of Indiana, Kentucky, Missouri, Ohio and Wisconsin.

"Outside the two university hospitals, where private physicians use propofol and house staff use it if there are enough anesthesia personnel available, we estimated that 90 percent of physicians used propofol for routine scopes," says Dr. Cort.

Administration of propofol for such cases has become a hot-button issue in recent years, as more GI practitioners seem to prefer using the sedative hypnotic - and more insurers seem to resist paying for it. The three major GI societies - the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy - have jointly stated that, "The routine assistance of an anesthesiologist or certified registered nurse anesthetist for average-risk patients undergoing standard upper and/or lower gastrointestinal endoscopic procedures is considered not medically necessary."

An Anthem spokesman says it will reimburse the anesthesia professional if the gastroenterologist "feels it is appropriate and requests that an anesthesiologist or CRNA administer sedation for an endoscopy procedure."

- Stephanie Wasek

Wall Street's Dreary View of ASCs.
Shares of publicly traded surgery center companies dropped last month after Bank of America downgraded the entire sector, citing declining case volumes, a clampdown on out-of-network payment arrangements, renewed risks to workers' compensation fee schedules and Medicare's new ASC payment policy - which the bank anticipates will add less than 1 percent to ASC revenues over the next two to three years. "We are lowering our investment view of the ASC industry from overweight to underweight," says Bank of America analyst Gary Taylor in a report to investors in which he lowered ratings on all three surgery center pure-plays (AmSurg, Symbion and United Surgical Partners International) to "sell." "We believe revenue and growth will continue to lag consensus expectations over the next two to three years, with a possible 20 percent correction in sector price-to-earnings ratio." Mr. Taylor says July and August surveys show patient case volumes were up only 2 percent for the quarter and declining sequentially, posing an earnings risk during the third quarter. - Dan O'Connor

- David Bernard

Unapproved Sterilizer Manufacturers Sentenced.
Two former executives of a medical equipment manufacturing firm have been sentenced to federal prison for fraudulent business practices and the unauthorized sale of a surgical sterilizing device that caused blindness in 18 patients. Ross Caputo, president and CEO of AbTox, Inc., of Mundelein, Ill., received 10 years' imprisonment and Robert Riley, vice president and regulatory officer, received six years. The two were jointly fined $17 million, the amount the now-defunct company earned selling the devices between 1994 and 1998, as restitution to hospitals that bought them. AbTox had been approved by the FDA to market a small gas plasma sterilizer, but it also sold the larger, unapproved Plazlyte Sterilization System (pictured), which it promoted with the FDA's earlier clearance letter. About 168 of the $110,000 Plazlyte units were sold nationwide. However, ophthalmic instruments that included brass, copper, zinc or soldered joints reacted to the unit's sterilizing agent, creating copper acetate residue that blinded patients.

- David Bernard