June 23, 2021

As more freestanding surgery centers come online, their value to their communities and the nation is clear.

CREDIT: Ridgelight Studio
CASE CATCHER Concord (N.H.) Orthopaedics' new Orthopedic Surgery Center is set to handle a growing influx of hip, knee and spine cases that previously were performed more expensively at inpatient hospitals.

Ambulatory surgery centers (ASCs) are projected to save Medicare an estimated $73.4 billion from 2019 to 2028 thanks to an increasing number of procedures being performed at ASCs instead of hospitals, a study by KNG Health Consulting shows. The massive potential future savings figure was derived in part by estimating which additional procedures are expected to move from hospital outpatient departments (HOPDs) to ASCs.

The study, commissioned by the Ambulatory Surgery Center Association (ASCA), researched work performed at the more than 5,800 Medicare-certified ASCs across the country. Examining Medicare claims from ASCs and HOPDs along with other publicly available data, the study found reimbursement rates for those ASCs were, on average, half of what HOPDs received for identical procedures. That, of course, means CMS enjoys a 50% savings every time one of its beneficiaries chooses to have their elective surgery at an ASC instead of at an HOPD.

ASCs already saved Medicare an estimated $28.7 billion from 2011 to 2018, the study shows. Those savings, to a large degree, came from a stable group of high-volume procedures such as colonoscopies and cataract surgeries. The projected jump in savings to $73.4 billion by 2028 assumes those procedures continue at ASCs, while the migration of more complex procedures such as total knee arthroplasty (TKA) and knee mosaicplasty migrate from HOPDs to ASCs.

"The ASC share of TKA and knee mosaicplasty is estimated to increase from 13.4% in 2020 to 18% in 2028, growing at 3.7% percent annually," states the study. "If the growth rate of outpatient TKA matches growth previously seen in partial knee arthroplasty, ASC savings would be $2.95 billion from 2020 to 2028 for this one procedure alone."

The study also contained a warning to policymakers who undoubtedly want the financial pressures on Medicare to decrease: Don't allow the reimbursement disparity between ASCs and HOPDs to grow. A larger gap could discourage more procedures from moving to ASCs if reimbursements get so low compared to what HOPDs receive.

Grab some key advice from a surgeon whose ortho ASC has done it successfully for eight years.

CREDIT: JIS Orthopedics DAY TRIP Dr. Lombardi says the carefully crafted patient experience at his ASC creates the buy-in necessary to convince patients they really can go home the same day after a joint replacement.

If you're looking to expand your multi-specialty ASC or orthopedic surgery center, adding a total joints program could be the perfect choice to bump up your case volume. CMS approved total knees to be performed in ASCs last year, and total hips got the green light this year.

"These new Medicare recipients are part of your new patient pool, and you'll also get patients with private insurance who now prefer to have their elective surgeries done in a freestanding facility instead of in a hospital," says Adolph V. Lombardi, Jr., MD, FACS.

Dr. Lombardi is president of JIS Orthopedics, which opened its surgery center, White Fence Surgical Suites, in New Albany, Ohio, in 2013. An average of 12 total joints cases are performed at White Fence each day, and its 12,000th joint replacement took place in June. Here are Dr. Lombardi's keys to running a successful program:

• Speak with one voice. Every staff member should convey your value proposition to patients, according to Dr. Lombardi. He suggests telling patients, "Yes, you have a bum knee and we're operating on you, but you're not sick. We're treating you like you're the well patient that you are, and you can focus on the fact that you can get up and go home on the day of your surgery."
• Rethink patient selection. Create a system that enables staff to quickly flag alternate locations for patients to have surgeries, so you don't waste time on unqualified patients. Patients without the right insurance coverage, or who don't have the family structure to support them at home, must have their surgery performed in a hospital. At the same time, if feasible and safe, consider expanding your patient pool to include older or heavier patients.
• Manage PONV and limit post-op pain. Preventing nausea and reducing pain are two crucial ways to ensure your patients can be safely discharged four or five hours after they arrived for surgery. "Always strive to perfect rapid recovery protocols," says Dr. Lombardi.
• Empower staff to help where needed. Most perioperative staff at White Fence are cross-trained. Circulating nurses are trained to scrub, and scrub techs are trained to work in central sterile if needed. The ability to move people around will be a boon to your facility's operational efficiency.
• Provide excellent patient education. Generally speaking, patients should meet with a physical therapist about a week before surgery, as well as on the same day they meet with a physician and get their pre-admission testing done. Outfit patients with necessary equipment such as walkers, canes and compression boots the day their surgery is scheduled.

Dr. Lombardi says some colleagues tell him their patients want to stay in the hospital for a day or two after surgery. "I don't have those patients," he says. "They either don't come to us, or I talk to them in a way that makes them receptive to outpatient procedures. My patients want to go home."

How Stryker helped Dr. Brian Gruber expand to a brand-new surgery center.

Dr. Brian Gruber, MD, MBA

Building a major new surgery center created from a retrofitted retail space takes time, money and collaboration with all the parties involved. Stryker has worked closely with many customers who have made full use of the Stryker's ASC business to consult, renovate and build their new ASCs. An ongoing project in Phoenix, slated to complete in August 2021, showcases the planning and working relationship that is behind such a major construction project. Dr. Brian Gruber from Integrated Orthopaedics recently spoke about his experiences and why he wanted to take the plunge to plan such a large project.

Why did you decide to open your own ASC?
For me it was really about the patient experience. I have been in practice for 15 years and first off, you really want to hone your skills….and start to develop your practice. We then added a physical therapy department to enhance patient experience and outcomes. The final piece of the puzzle was to develop a surgery center so we can service all the required needs of our patients. As a surgeon, we spend about half of our time in the surgical setting.  Being able to control that side of the patient experience was very important for my vision.

How did you make this move and pull the trigger and what has it been like doing such a large renovation?
It's been a year-and-a-half in the making….I've done walk-throughs in the early stages to see the locations of different rooms to get equipment in quickly….it's been really important.

Dr. Gruber went on the say that he has a high interest in total hips, shoulder and knee surgeries, and also wanted to expand to spine surgery based on the optimal location of his new build ASC in central Phoenix. He looks at joint surgery as the future of orthopedics which leads to the following question:

Can healthcare do these things safely in an outpatient setting?
I think now is really the sweet spot and it's not really a crowded space. If you look at Phoenix, there are not a lot of places that are doing outpatient joints the way we are doing it.

The Phoenix ASC being built is a giant place that will include top-of-the-line ORs, onsite therapy and suites for overnight stays with rooms of hotel quality. Dr. Gruber described what that can offer:

We're going to be able to do onsite therapy, which is obviously going to help our patients feel confident going home.  We will also have the capability of overnight stays in separate suites.  The Recovery Care Center (RCC) will allow us to serve not only our local market but also our medical tourism campaign.  As far as what we’re developing, there’s really nothing like it in Phoenix. 

How did Stryker come into the picture? What made you think they could do the whole thing?
Stryker was put into the forefront in my mind just because they had a presence….I had a good relationship with the Stryker reps and Stryker folks…and it was always a really positive experience. Then we start to look at things they can offer. I feel like their products are really best in class. It's nice to know your instrumentation, your power, your robotics (come) from one place, and that just makes integration easier. It really streamlines the process. 

Note: Learn more about Stryker's ASC business: https://www.stryker.com/us/en/care-settings/asc.html

Dr. Brian Gruber is a physician customer of Stryker. The opinions expressed by Dr. Gruber are those of Dr. Gruber and not necessarily those of Stryker.

The pandemic provided the impetus to accelerate the migration of more procedures from inpatient to outpatient.

The nation's recovery from the COVID-19 pandemic will include a shift in the sites of many patients' medical care. As such, it's the latest major development that's continuing to drive the already robust growth of ambulatory surgery centers (ASCs), according to a study from healthcare performance improvement company Vizient.

According to the study, ASCs will continue their steadily rapid patient growth. The company predicts 15 million more patients will go to ASCs and hospital outpatient departments (HOPDs) in 2029 than did in 2019, potentially further driving down the costs of surgical procedures within the U.S. healthcare system.

Vizient says this trend will be accelerated by two major steps being taken by CMS: the elimination of more than 1,700 codes on its inpatient-only list by the end of 2023, and the addition of 278 more procedures to its ASC-approved list by that time.

Interestingly, ASCs face competition not just from hospitals and HOPDs, but also from medical offices. The report notes that office-based procedures and care in clinics will grow by 18% by 2029, with the bulk of the uptick fueled by cataract surgeries and endovascular cases.

Bringing it back to COVID-19 and the havoc the pandemic wreaked on elective surgeries throughout 2020: Vizient predicts outpatient surgical patient volume will surpass 2019 levels in 2022. While inpatient volumes are also expected to rebound, they are not expected to surpass 2019 levels. "COVID-19 will leave a lasting impact," the report states.

Assembling an all-star design and build team should occur long before the hardhats come out.

Whether you've opted for new construction or found a building to renovate, getting a new ASC up and running isn't easy. If you don't lean on the advice of trusted professionals while building and planning your dream project, the job will be infinitely more difficult.

That's the advice from Amanda Mewborn, vice president of facility planning and development at Navicent Health, a health system based in Macon, Ga. "Get the right team of people at the beginning," she says. "Once you start making changes during the construction phase, the likelihood of hitting your targeted project dates drops dramatically. Get the design completed, and all the decisions nailed down, before construction begins."

She offers these views on how partnering with expert advisors will keep you on the right track:

• Make the big hires early. Identify the key players who will help you determine the scope of the project, assemble the rest of your team and develop a realistic budget. Start by hiring a project manager. Within a month of that hire, select an architect. Get the general contractor on board soon after. "The project manager will help run the request for proposal process for the architect and general contractor and connect you to the finance companies and attorneys you'll need," says Ms. Mewborn. "The architect will assist with retaining medical equipment planners, landscape architects and IT experts. The general contractor will get the mechanical, electrical and plumbing people on board."
• Right-size spaces. Identify the amount and type of space your facility will need to function efficiently, while also meeting local codes and standards. Your architect will give you feedback on sizing and could also help you with your operational plan; if not, hire an operational planner to figure out the overall patient flow and how the facility will operate.
• Listen to multiple voices. Employee turnover happens during construction projects, so make sure decisions made during the design phase aren't based on an individual physician's or staffer's preference. When they leave, the design might not work for anybody else. Don't focus too much on physician preferences at the expense of others, either. Get input from your business manager, billing and accounts receivable staff, nurses, OR techs and environmental services techs.
• Plan for capital purchases. Get your medical equipment planner on board as the facility's design is taking shape. By doing so, you can make decisions on major medical equipment early on when the size and infrastructure needs of big-ticket items could impact the overall structure of your facility. "Select specific makes and models, but wait to make purchases until almost the last possible moment," says Ms. Mewborn. "This will help with your overall cash flow and ensure you'll purchase the latest technology available."

It truly takes a village to build a great ASC. Start building yours long before the shovels go in the ground.