Capitalizing on Cardiology

There’s a certain stigma attached to cardiology that makes it difficult for individuals to associate the specialty with something that can be done safely and efficiently on an outpatient basis. But the fact of the matter is nearly 70% of cardiac procedures are currently done in hospital outpatient settings. Increasingly, these procedures are migrating to ASCs — in large part due to CMS approving reimbursements for certain types of procedures in 2019 (see “Focus on These Three Procedure Types”). Of course, commercial payers have been reimbursing outpatient facilities since well before 2019. In fact, we’ve been performing outpatient cardiovascular procedures since 2006. Currently, we’ve performed well over 150,000 outpatient cardio procedures, and we have a wealth of data to support the efficacy of this service line.

As the research continues to back the many benefits of outpatient cardiology, expect CMS’ reimbursement changes to reflect this data. Indeed, we were among the organizations that strongly lobbied CMS — our cardiologists spoke directly with their agency physicians — in 2017 and 2018 to approve the diagnostic outpatient procedures that were ultimately approved the following year. CMS makes decisions based on data, and our data was a key part of the reason why outpatient cardiology has gone from a hypothetical concept to a regularly occurring reality.

If you’re one of the many surgical facility leaders who finds the prospect of adding a cardiology service line appealing, there are certain distinctions that separate heart and vascular procedures from other outpatient specialties.

• Staffing. Cardiology care is highly specialized, and staff must have relevant experience and a variety of technical skills such as advanced cardiac life support (ACLS), catheterization laboratory (cath lab) techniques and critical care certification. Surgical nurses are not cardiology nurses — a fact that can prove problematic in multispecialty facilities that are used to cross-training staff to switch between specialties depending on the ebb and flow of each service line’s case volumes. Therefore, you not only need to find staff specially trained in cardiology, you must worry about whether you will have enough cases to keep the procedure area booked full-time, or figure out what you’re going to do with the staff when they’re not working. Along those lines, you also want to work with seasoned physicians who have many outpatient procedures under their belt, are comfortable handling common complications, and aren’t discouraged by the regulatory and reimbursement challenges of this specialty.

• Patient selection. Cardiology patients are generally more vulnerable than standard ASC patients. After all, we’re talking about individuals with heart-health issues, so they tend to already have comorbidities — whether it’s diabetes or high blood pressure or any number of other issues — that make procedures inherently risky to perform. That’s why clearly defined patient admission criteria are paramount.

Nearly 70% of cardiac procedures are currently done in hospital outpatient settings.

Individual facilities will have their own criteria and lab values based on their unique patient populations and procedure mix, but the important thing is setting crystal-clear parameters about the patients you will and, more importantly, won’t accept. For instance, patients with kidney disease, something you should know through pre-procedure lab work and the screening process, could be at additional risk for complications because the contrast dye used for cardiac procedures can overload the kidneys. In the end, the patient selection criteria you employ will largely dictate the overall safety of your cardiology program.

• Regulatory and reimbursement complexity. While CMS has recently started to approve cardiac procedures performed in ASCs, the approved codes are constantly evolving and reimbursement is a complex, challenging issue. Adding to the complexity is the fact that some states don’t allow cardiac procedures to be performed in an ambulatory surgery setting. The regulatory and reimbursement obstacles facilities face when adding an outpatient cardiology service line are many. Negotiating contracts with payers will remain a constant challenge for surgical leaders, as this is such a new specialty. We spend a significant amount of time with CMS and other payer groups, providing our data, walking them through our processes and emphasizing why certain codes should be reimbursable.

If you’re starting your program from scratch, there’s also the reality of escalating start-up expenses to consider. In the last two years, we’ve witnessed hikes of 25% to 35% due to supply shortages and cost increases. Surgical leaders truly need to ask themselves whether that’s an obstacle they can overcome and whether it makes sense from an ROI perspective to take this challenge on, particularly if you’re in a true multispecialty ASC.