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Should You Add Mobile Lithotripsy?
Portable technology and Medicare reimbursement make this procedure a lucrative outsourcing opportunity.
David Bernard
Publish Date: October 27, 2008   |  Tags:   Financial Management

Since its introduction in the early 1980s, lithotripsy has revolutionized the treatment of kidney and gall bladder stones through the use of non-invasive shock waves that crush the stones. Recent changes to Medicare's ASC payment policies, the technological advances that have shrunk lithotripsy equipment and the now-common mobile lithotripsy businesses providing regional services have made lithotripsy a procedure within reach of many surgical facilities. Here are a few pointers on what to look for if you're considering bringing mobile lithotripsy to your center.

What lithotripsy offers
The chief advantage of lithotripsy, for the patient as well as for the physician, is that it's able to resolve stone issues without incisions and therefore with minimal tissue trauma.

While lithotripsy originally involved a patient reclining in a water-filled tub as a series of focused, acoustical shock waves were directed at their stones, a newer, waterless method can do the same job, depending on the patient's condition and stone situation. As a sedated patient lies on a table, the attending physician uses fluoroscopic or ultrasonic imaging to locate the stone. An external coupling device targeting the stone delivers the pulses. In either method, a successful outcome means that the stone, crushed into sand-like particles, easily passes from the patient's body.

As a procedure, lithotripsy is low volume and high cost. Experts note that only a fraction of patients suffering kidney stones requires lithotripsy treatment. Plus, the equipment represents a significant capital expense, with most lithotriptor models listing at a half-million dollars or more.

But it's not just hospitals and large, kidney- or urology-oriented ASCs that can profit from lithotripsy. Over the last decade, an increasing number of facilities and physician practices that offer the procedure have invested in and established mobile lithotripsy units that travel regionally, hauling portable equipment to healthcare facilities through lease arrangements. Certified technicians accompany the equipment in order to properly assemble its components and offer assistance to the facility's physicians and surgical staff.

The outsourced services of mobile lithotripsy hold numerous advantages for small and mid-sized surgical facilities, especially rural ones, with urological interests. First and foremost, it's possible to profit from a new service without putting down a major investment in equipment. As disposable supplies are also included, a hosting facility's biggest expense is providing anesthesia medications.

"It's wonderful not to have to buy all the equipment, to have it come in one day a week. It's as if someone else has taken the [startup] risk," says David Moody, RN, administrator of the Knightsbridge Surgery Center in Columbus, Ohio.

Hiring mobile lithotripsy services also benefits your patients in offering them convenient access to care, but it's also a practical marketing move. By arranging for mobile services and offering them at your facility, you're picking up the facility fee reimbursement that you're otherwise leaving on the table when the kidney or urology specialist at your center takes his patients elsewhere for the 45-minute to 60-minute procedure. "If you're in a community that doesn't offer lithotripsy, patients are going to have to travel to another center" in another area, says John Broom, executive director of the Oklahoma Lithotriptor Association, a 48-doctor practice in Oklahoma City.

Adding the service
Besides having the equipment brought to your facility's doorstep, another reason why now might be an opportune time to hire lithotripsy services is that in 2008 Medicare will reimburse ASCs that perform the procedure.

While the federal payor previously only covered lithotripsy - nearly always an ambulatory procedure - when performed in hospitals, CMS's July 2007 final rule on its revised payment system and allowable procedures has extended the coverage to ASCs, effective January. The 2008 payment rate for ASCs is scheduled to be $1,781.66, while the 2008 Hospital Outpatient Prospective Payment System rate is slated to be $2,741.04, up from 2007's $2,676.30.

Your arrangement with a mobile lithotripsy service will take one of two forms. Either the company providing the service will bill and collect for the procedure, paying you a negotiated room rental fee, or your facility will undertake the billing and collection, paying the company for lease of its services, an amount that varies from provider to provider.

"It's one or the other, you bill or they bill," says Thomas Mallon, MBA, the CEO of Regent Surgical Health, a Westchester, Ill.-based healthcare management firm. "There are radically different outcomes depending upon whom does the billing."

The billing arrangement, generally fixed in each company's contract of service, is a tradeoff, but the savvy facility can use either method to its advantage, says Mr. Mallon. While it may initially appear as though self-billing is better for business - collect the reimbursement, pay the company's charges - an arrangement offering hands-free billing may also prove beneficial, particularly if the company has more lucrative carveouts with private insurers than your facility does, offering the possibility of lower charges for the service.

Additionally, Mr. Mallon notes, even if you're not billing for them, the lithotripsy procedures can potentially spin off other cases, such as cystoscopies, for which you can bill, and may attract more urologists to bring cases to your facility.

In terms of the charges, most mobile lithotripsy services operate on fixed per-procedure rates based on the number of patients the equipment is used for or the time that's spent at the facility. Per-case rates means you're only paying for the work that's done, not signed on to a regular contract and paying to retain un-utilized services. It also provides something of an assurance, with moderate patient caseloads, against concerns over whether case volume will recoup the cost of the service to your facility.

Choosing a provider
If your facility is in the position of choosing a mobile lithotripsy provider from more than one that serve your area, there are a few factors besides the bidding of services by which you can judge which one will work best for you.

"Reputation is paramount, just as with any other vendor. You need someone who'll be responsive to you if you need another day, for example," says Mr. Moody.

The billing arrangement is another important issue. Mr. Moody notes that if you've got solid and profitable insurance contracts, you may just want to take on billing yourself. Mr. Broom adds that the company's availability is another essential consideration.

Both also advise looking into whether a company's services require a minimum number of patients treated per visit. Given the unpredictability of demand for lithotripsy services, it's a complex question. "Are they willing to come in for just one patient?" asks Mr. Moody. "It costs them money to come out to you. A growing company will take anything it can, of course, and if they have great contracts, they can probably make money on one case." But if they won't support single-patient visits, or charge more from them, says Mr. Broom, you'll have to decide whether to medicate the patient and wait for service or perhaps give up the facility fee to another center.

As with any purchase, input from your physicians is a critical foundation and it's likely that the doctors may judge the services based on the equipment and technical support they offer. "Some mobile services may provide more recent generations of equipment," says Mr. Mallon, "but doctors use what they're trained on. They'd just as soon use earlier versions because they're used to them." They may also look for technicians who are certified by the American Lithotripsy Society and who have expertise bolstered by continuing education.

Finally, once you've chosen a service provider, there's the logistics of getting the equipment to the patient. The equipment, which includes a control module computer and monitor, C-arm, lithotriptor head and cystography table are delivered in vans and moved into the facility's OR or procedure room for assembly and inspection by bio-med staff.

"You need an OR of a decent size," says Mr. Moody. "The equipment takes up a lot of space once you get it all in" alongside your own anesthesia machine, cystoscope and ureteroscope. The heaviest equipment is moved on motorized casters, he says, which some physician-owners have complained about damaging facility floors, so some manner of drop cloths or runners may be in order. Labor intensive, for sure, but compared to equipping and staffing a lithotripsy service at your own facility, not quite as heavy an investment.