Specialty Spotlight: Integrating Cardiology Into an ASC

Financial feasibility, regulatory compliance and buy-in are paramount to success.

Cardiology has captured the attention of the ASC industry. Historically, these procedures have been performed in a hospital-based cath lab, but due to changes over the last five years, cardiology is one of the fastest-growing ASC specialties, according to a recent ASC Data report.

While predictions point to an influx of cases into ASCs, the reality of integrating cardiology is quite complex. It requires accurately determining financial feasibility, understanding operational and quality requirements, and anticipating barriers to success.

Determine financial feasibility

Assessing the financial feasibility of a new ASC specialty involves several steps, with three posing unique complexities for cardiac procedures: state regulations, volume potential and facility equipment needs.

• State regulations. Even though CMS allows diagnostic coronary catheterization (diagnostic cath), PCI and pacemaker and cardiac defibrillator implantations to be performed in ASCs, state regulations supersede. Regulations must be evaluated at two levels: (1) certificate of need (CON); and (2) state health plan or equivalent regulatory agency that controls new services.

According to a recent VMG report, 20 states require a CON for an ASC. But another regulatory layer that is even more complex than CON is the state agency that governs the allowance or restriction of ASC cardiac services. Only roughly 40% of states currently allow PCI procedures to be performed in an ASC, according to Corazon’s research of state healthcare regulations. State regulations are often not clear in their language and require direct communication with agencies to determine if cardiac procedures are allowable.

ASC volume potential. Determining ASC cardiac volume potential is one of the most difficult tasks because there are many critical variables to consider, such as market responsiveness, physician engagement and expected volume shifts from the hospital.

In terms of market responsiveness, it’s critical to have access to inpatient, outpatient and ASC cardiac claims data to determine the market concentration, growth projections and competitive dynamics. While Medicare claims data is made available to the public for purchase, it is often too expensive for ASCs to justify. However, third-party companies such as consulting firms might be more inclined to purchase claims data. Contracting with a company to gain access to the data needed to make realistic cardiac volume projections might offer a cost-effective option for ASCs.

When projecting cardiac ASC volume, there will be an inherent shift of hospital volume since most of these procedures are still performed in the hospital setting. Determining how much cardiac volume can shift to the ASC requires an understanding of hospital data, such as outpatient volume by CPT code and by physician. This requires a healthy partnership with the hospitals since the data will need to be requested from them. Additionally, the amount of volume that can shift to an ASC varies by procedure and is scalable depending on issues that include physician engagement and ASC investment interest.

• Obtain facility and equipment quotes. ASCs must have the necessary space and equipment to safely and effectively perform cardiac procedures, all of which can come at a high cost. The procedure room must be large enough to accommodate a large, fixed imaging system with a long radiolucent table and multiple ancillary pieces of equipment. The average recommended size for one cardiac procedure room is 600-700 square feet, according to architecture and interior design firm Hord Coplan Macht. Additionally, an adjacent control room for patient monitoring will require at least another 150 square feet. The total cost of cath lab equipment can easily exceed $1 million, so purchasing refurbished equipment should be explored since it can decrease equipment costs by up to 50%.

Operational and quality requirements

Adding a new ASC specialty requires multiple steps to ensure operational and quality excellence, with three areas presenting distinct challenges for cardiac procedures: staffing, efficiency and quality.

• Cardiology staffing and roles. To successfully perform cardiac procedures in an ASC, an experienced team of cardiologists, cardiovascular nurses and radiology technologists are required. Typically, one to two non-physician staff members, such as certified radiology or cardiovascular technologists or nurses, are tableside, with additional staff handling circulating and monitoring/recording roles, which are adjusted based on case complexity. Tableside assistants must be proficient in setting up manifolds and automatic contrast injectors, and preparing wires, catheters, balloons and other devices, while adhering to radiation safety and sterile techniques.

Additionally, the administrative/nursing director or manager should possess at least five years of experience in a cath lab and/or critical care cardiology, along with administrative expertise to contribute to institutional and cath lab decision-making.

The medical director should be a licensed, board-certified invasive or interventional cardiologist with a minimum of five years of experience. Although credentialing decisions are site-specific, the Society for Cardiovascular Angiography & Interventions Expert Consensus Statement on Percutaneous Coronary Intervention Without On-Site Surgical Backup strongly recommends interventional fellowship training, board certification and a minimum annual volume of at least 50 PCI procedures per operator.

• Maximizing cath lab efficiency. This begins with strategic scheduling of cases to maximize the output of cardiologists, anesthesiology and staff.

The target benchmark of 80% for cath lab utilization is widely recognized in the industry as an optimal balance between efficiency and flexibility in surgical scheduling. However, if the cath lab is not achieving 80% utilization or cardiologists are not maximizing their block time, ASCs must allow other physicians to utilize the cath lab for high-value procedures. Because the cath lab fixed imaging equipment is limited to image-guided procedures, additional procedures that can be performed in the cath lab are limited. Cath labs are commonly used by electrophysiologists for device implants, and vascular surgeons and interventional radiologists for a range of non-coronary arterial or venous vascular interventions. The procedure room is also well-suited for interventional pain management cases.

While cardiologists are accustomed to sharing the cath lab with other specialties in the hospital, they aren’t typically accustomed to a culture of ASC cath lab efficiency metrics such as block time utilization, first case on-time starts, staffing levels and instrumentation standardization. It is recommended that every cardiologist interested in performing procedures at the ASC meet with facility leaders and managers to understand expectations.

• Quality. Establishing mechanisms to capture data on patient care and outcomes is essential for evaluating cost and quality. Currently, there are two different organizations that offer a registry suite to track cardiac procedures performed in ambulatory settings, helping ASCs compare their performance with similar facilities.

ASCs should also consider the prospect of accreditation for their cath lab program. It helps ensure compliance with state regulations, which sometimes require third-party oversight for cardiac services, while also providing an ASC with surveyor feedback and compliance with standards.

Anticipate barriers to success

Integration success hinges on anticipating barriers. When adopting cardiac procedures in an ASC, common hurdles fall into the three Ps: 1.) Physician adoption: comfort with performing procedures in an ASC and assimilation into the ASC culture; 2.) Patient adoption: comfort with receiving a heart procedure in an ASC; and 3.) Payor adoption: third-party payor negotiations to include cardiac procedures.

If a breakdown occurs in any of these categories, the financial repercussions can cause cardiac procedures to not be viable or sustainable in the ASC. OSM