Benchmarking
Highlights of MGMA's Ambulatory Surgery Performance Survey
Looking for a snapshot of the financial performance and productivity of today's surgical facilities? You'll be swimming in stats when you peruse the MGMA's ASC Performance Survey, a 120-page report that slices and dices key surgical facility performance indicators every which way. Use the graphs below to compare your facility to the 113 participating centers in such areas as staffing costs, supply costs and net income per case.

A few notes about the survey:

• 62 percent of participating facilities are multi-specialty; 38 percent are single-specialty;
• 59 percent are physician-owned; 33 percent are joint ventures; and
• 43 percent have net medical revenue less than $3 million.

- Dan O'Connor

RNs Pushing Propofol
Gastro Docs, Nurses Support Nurse-Administered Propofol Sedation
With adequate training, physician-supervised nurse administration of propofol can be done safely and effectively, three GI doctors' organizations say in a joint policy statement released last month. Citing new safety data, the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA) and the American Society for Gastrointestinal Endoscopy (ASGE) have endorsed nurse-administered propofol sedation (NAPS) by specially trained gastroenterology nurses. The Society for Gastroenterology Nurses and Associates (SGNA) plans to release a similar statement by next month.

"When administered under a proven protocol, NAPS is safe. Propofol is very desirable, especially for longer, more complex procedures. The drug has extremely high patient acceptance and is metabolized quickly. We use propofol routinely at our practice, and it's been positive," says Bergein F. Overholt, MD, FACP, MACG, of Knoxville, Tenn., a member of the task force that wrote the statement.

The SGNA reversed its non-recommendation of NAPS based on recent safety data, including two studies published last August in the American Journal of Gastroenterology, says SGNA President Jo Wheeler-Harbaugh, RN, CGRN. "We now have substantial evidence showing propofol administration is within the scope of safe nursing practice given proper training," says Ms. Wheeler-Harbaugh.

Already, the joint statement is drawing criticism. Robert Goldstein, MD, an anesthesiologist and executive vice president of Somnia, Inc., an anesthesia service, took umbrage with the policy's contention that with adequate training, physician-supervised NAPS can be done safely and effectively. "This one sentence significantly threatens patient care and undermines the reality that the safety of rapidly acting sedatives like propofol and methohexital is in large part dependent on their being in the hands of anesthesiologists," he says.

The policy notes that regulations vary from state to state; 13 state nursing boards prohibit NAPS. "There's no way around your state regulations. However, my opinion is that state boards prohibiting NAPS need to look at the data and consider making a change," says Dr. Overholt.

- Bill Meltzer

Inside The Numbers
ASC Ownership

• 43%: Percentage of ASCs owned solely by one or more physicians
• 16%: Percentage of ASCs owned in full by a hospital
• 19%: Percentage of ASCs owned by a physician-hospital joint venture
• 11%: Percentage of ASCs owned by a physician-corporation joint venture
• 10%: Percentage of ASCs owned by a physician-hospital-corporation joint venture
• 77%: Percentage of ASCs that are multi-specialty
• 23%: Percentage of ASCs that are single-specialty

Source: February 2004 AAASC ASC Ownership Survey (n=64)

Hospital Reimbursement
MedPAC Recommends Eliminating HOPD Outlier Payments
Congress should eliminate Medicare outpatient outlier payments to hospitals, MedPAC recommends in its recent report to Congress. These payments, which comprise 2 percent of federal hospital outpatient spending, offset some of the financial losses of treating extremely high-cost cases. The cuts, if reflected in future budgets, must be budget-neutral, meaning funds cut from outlier payments must be put back into HOPD base rates.

MedPAC says the outlier payments are unnecessary because of the relatively low variability in costs for many outpatient services not covered in base payments. The report says outlier payments are susceptible to manipulation by hospitals; MedPAC cites distortions created when one hospital's outpatient setting is subject to outlier payments and another's is not. The commission also says community hospitals' overall access to capital is adequate, and aggregate Medicare payments to hospitals in 2004 will cover "efficient providers'" case costs.

"We agree that CMS and Congress should look at changing the outlier payment system. However, rather than eliminating them, the outlier payments should reflect the full array of services hospitals offer on an outpatient basis," says Don May, the American Hospital Assoc-iation's vice president for policy. "A payment system based on averages, which is what the HOPPS is, may not cover the cost of treating our most expensive cases," including X-rays, CAT-scans and EKGs.

"There needs to be a continued financial incentive, where appropriate, to move these from inpatient to outpatient care. Full-service hospitals serve as the first recourse for these patients," says Mr. May.

- Bill Meltzer

Cosmetic Plastic Surgery
One-third More Cosmetic Surgeries Performed in 2003 than 2002
U.S. surgeons performed more than 8.7 million cosmetic plastic surgeries last year, an increase of 32 percent over the previous year, according to statistics released by the American Society of Plastic Surgeons (ASPS). Some key findings:

• More than half (56 percent) of cosmetic plastic surgery procedures were performed in office-based surgery suites. Hospitals did 28 percent of cases last year and ASCs 16 percent.
• Patients ages 35 to 50 made up 40 percent of patients; liposuction was their procedure of choice. Second was the 19-to-34 group (26 percent), with nose reshaping the most common procedure. Third were patients 51 to 64 (24 percent), for whom eyelid surgery was tops.
• Surgeries on the rise: lip augmentation (21 percent), abdominoplasty (18 percent), breast lifts (17 percent), liposuction (13 percent), facelifts (9 percent), and breast augmentation and eyelid surgery (7 percent).
• Surgeons performed nearly one-fourth (24 percent) fewer forehead lifts.
• Surgeons performed more than 52,000 post-bariatric surgery cosmetic procedures to contour loose skin left after massive weight loss.

Back on the Front Lines
From Administrator to Per Diem Nurse
When Mary Louise Dietrich, RN, CNOR, BSHA, decided to retire from nursing in December 2001, she felt she'd accomplished everything she wanted to during her 25 years as a nurse - 19 years as a hospital OR nurse who graduated to management, then four years as an ASC administrator. "When I left, I felt satisfied. I'd evolved into the type of manager I wanted to be and I had no intention of returning to healthcare," she says.

After a year-and-a-half, Ms. Dietrich could no longer fight the urge to return. But she didn't want to manage, turning down an offer to help open an ASC and relocating from California to become a per diem nurse at the Tampa Eye and Specialty Surgery Center in Florida.

A self-described type-A personality, Ms. Dietrich says she had to retrain herself to work where she doesn't control the facility environment, focusing instead on re-honing clinical skills. The danger inherent to being an ex-manager on staff, she says, is "an expectation you know it all or at least think you do. It's tougher to be judged on your merits as a nurse."

Will she ever head back to the boardroom? "As a manager, your eye's always on the long term. There's no instant gratification of a job well done. As a nurse, you get that every time the team successfully performs and discharges a case. I never say never, but I don't foresee a return to management."

- Bill Meltzer

Colonoscopy Best Practices
Inside Colonoscopy Case Times
Colonoscopy case times vary widely among facilities, according to the Accreditation Association for Ambulatory Health Care Institute (AAAHC) for Quality Improvement's newest colonoscopy best practice studies. Here are some key findings from the real-time data collected from March to June 2003 at 61 volunteer ambulatory surgery organizations (1,435 cases):

• The median pre-procedure time is 49 minutes; the fastest is 12 minutes, the slowest is 95 - with the patient spending much of the time in the waiting room. Having the procedure room ready translated to quick patient transfer times.
• The median procedure time was 17 minutes (range: 10 to 49 minutes), accounting roughly for procedure complexity based on the average num-ber of findings, biopsies and removals per case.
• The median discharge time was 41.4 minutes; the low was 21, the high 86. The use of non-narcotic, fast-acting, short-duration sedatives was credited with fast discharges.

- Bill Meltzer

New Facility Staffing
Hospital, Nurse Union Clash on JV
A planned physician-hospital ASC joint venture has upset an unlikely source - the union representing the 300 nurses at Butler Memorial Hospital in Butler, Pa. The union objects to uncertainty about the percentage of ownership, administration and the staffing of the proposed facility. It favors sole hospital ownership and location on hospital grounds rather than at a freestanding facility.

The union members fear for their jobs if the new ASC exists as an entity independent of the hospital. Nurses may be forced to re-apply for jobs at the ASC, jeopardizing seniority and job security in the hospital system, says union vice president Tammy Kaufman. "The hospital hasn't disclosed a lot of key information, [and] many of our members are concerned that they'll have to work for a new employer," says Ms. Kaufman.

"We're not able yet to look at staffing. We're still at the stage of determining the composition of the incorporated entity that will own the center and considering the best location," says John Righetti, hospital vice president for communications. He says that ASC staffing would be determined later in the process.

The hospital, he says, stands behind the joint venture concept because "it provides both the hospital and the investing surgeons the ability to share the responsibility for strategic planning, financial risk and improving vital clinical services to the community."

- Bill Meltzer

Ophthalmology
Preventing Wrong-IOL Placement
Here are several keys to preventing wrong-IOL placement during cataract surgery, according to James J. Salz, MD, a clinical professor of ophthalmology at the University of Southern California and a spokesman for the American Academy of Ophthalmology (AAO).

• Calculate scan with appropriate third-generation formula. Use Holladay II, Hoffer Q or SRT K, he says.
• Double-check the scan numbers to ensure the correct ones were inputted. "The axial-length measurement may be 24.3mm, but 23.4mm is entered mistakenly," says Dr. Salz. "Double-check the IOL calculation sheet in the OR."
• Verify the information for all IOLs in the OR before the procedure start. You can have a complication and in some cases still put a lens in the anterior chamber, he says. "Be prepared for that possibility. It's also best to have only the lenses for the patient undergoing surgery in the OR," he says.

Download the AAO's guidelines for minimizing wrong-IOL placement risk at writeOutLink("www.aao.org/aao/education/library/safety/iol.cfm",1).

- Stephanie Wasek