Becker’s Ortho and Spine Conference

June, 2016

Deb Yoder, MHA, RN, CNOR,

Director of Operations

Surgical Management Professionals

Developing a Spine program

at your ASC

Reasons to add spine at your ASC

History of Spine in an ASC

In 2005 ONLY 5% of cases were done in the outpatient arena

From 2005 – 2015 nearly 45% of all spine cases were

performed on an outpatient basis

Procedures haven’t changed – the anatomy of the nerve root

compression remains constant - but the methodology related

to performing the procedure is more refined

What’s changed that allows us to do

these cases in the ASC

Technology

Instrumentation

Pharmacological agents

Improve techniques

Smaller incisions

Less trauma and pain to the patient allowing patients and

surgeons to become comfortable with the concept

What is driving you to add spine to your

center

What is your long term vision

Is there a niche market in your area that could be added to

the spine program

What does your management team believe – are they on

board – are they willing to collaborate and create a viable

service line

What do the feasibility experts say

What is driving your physicians Financial gain

Efficiency

Less travel

Patient cost savings

Added control over implants

Less chance of infection

Risks

Are your physicians ready to take a risk and add another

service line to the ASC

Are all physicians on board – not just the spine surgeons

Will there be liability changes to your facilities insurance

plan

How will the hospital – ASC relationship change if you add

another service

CMS approves new Spine codes

Neck Spine Fusion

Lumbar Spine fusion

Spine fusion extra segment

Neck spine disc surgery

Laminectomy single lumbar

Removal of spinal lamina (63045)

Removal of spinal lamina (63047)

Decompression spinal cord

What changes with the addition of

Medicare codes

Increase in the number of healthy, presumably younger

Medicare patients which will have their surgeries in the ASC

Increased coffers in the Medicare fund – surgeries are less

costly in the ASC

Medicare more aware of the ASC industry and option of

moving other typical in house procedures to the ASC arena

Issues with Medicare Spine cases

Payment is less than the private payers

There is still profitability – but the ASC needs to make sure

ALL implant costs are under control

Implants are a large % of case costs and can cut into profit

margins

Growth Factor Significance Advancements in technology and techniques

Geographical standards and acceptance of procedures in the ASC

Influence of Hospitals and Payers

Surgeon training

Training in ASC setting versus hospital

Added confidence that the procedures can be completed in a surgery center

Key Items to think about Prior to

adding to the service line

Regional needs

Financial implications

Space allocation

Physician involvement

Patient Selection

Anesthesia

Skill sets

Postop Recovery Model

Expert Assistance

Regional Needs

Who’s doing what & where!

What’s going on in your Region Know your market

What types of spine services are being offered

What region are you currently covering

What area does your surgeon(s) service

Number of persons in the immediate and outer region

Number of lives covered in given age groups

Payer mix of persons in your region

How many other options are available for patients

Does the surgeon have enough office time to see additional patients

Financial Implications

What are the actual costs

and What are you going to be paid

Understand the costs Startup Capital

OR bed or Wilson frame (depends on procedures)

Microscope

Postop bed or cart

C Arm

Anesthesia needs

Instruments

Power system – Drill handpeices

Head light

Facility

Is there Adequate space to do additional procedures in the OR and PeriAnesthesia areas

If overnight care – is the building secure safe for patients and staff

SPD needs Ultrasonic Cleaner

Washer and autoclave

Container systems

Costs Continued Marketing

Will you need to promote the new service

Newspaper

Billboards

Radio/TV

Flyers

Food Services

23 hour care – the patient and families need to eat and still meet accreditation needs

Staff

Are staff knowledgeable

Radiology technician

Costs continued

Start up operational inventory

Implants (plates, screws, cages)

Biologicals

Anesthesia (ETT extenders, prone positioners)

Medications

Postop patient needs

IV pumps or flowmeter tubing

Incentive spirometer

Emergency needs

Duracell, vascular clips, suture

Revenue Cycle & Reimbursement

Contracts with all payers

Private, workers comp, Medicare

Know what the true costs are so you can ensure that your contracts cover

all costs and profitability occurs

In Network vs. Out of Network

Carve outs

Biologicals, pharmacy

Regional payer mix

Negotiate with large employers to drive patients to your

facility

Skilled negotiation

Dealing with insurance companies takes a skilled negotiator

and one who understands all the given dynamics

Person who understands what others in the region are

receiving for payments

Are you asking for carve outs

Space Allocation

Is there enough space to add another service line

Space needs OR

• Are the Rooms large enough to accommodate

• Spine table (depending on procedure)

• Microscope

• C Arm

SPD • Ultrasonic Cleaner • Instrument trays

PeriAnesthesia Are there enough rooms for extended care 23 hour care PACU needs

OR schedule Open block time

Physician Involvement

Find a champion

Physicians

Spokesman and champion

Desire to do cases in the ASC

Are they comfortable at the ASC and with the skill sets of the

staff

Are they willing to champion for best pricing for implants

and disposables with the vendors

Are they comfortable to handle an emergency or untoward

event

Patient Selection

Have criteria that all providers can agree on

Patient selection needs Each patient needs to be evaluated on a case/case basis – starting

with age/general health

Key physical components Age

General Health Obesity

Surgical approach Positioning issue

History or recent respiratory illness Sleep Apnea

Anesthesia Criteria

Continued patient selection needs

Medicare Patients – ensure they meet established Anesthesia

and surgeon criteria – without comorbidities – make sure

MD understands which codes are payable in the ASC.

Additional codes will not be reimbursed

Patients understand process including postop needs

Is the patient cognitive and can they understand potential

issues

Patient confidence

Patient selection needs to ensure that the patient AND family

have confidence in the surgeon and the facility.

Is the patient comfortable being seen and treated outside the

hospital environment

Patient Education

What is the patient perception

Preop education aids in and increases patient comfort and

understanding

Patients need to know that you have emergency supplies and

equipment available – also what occurs if there would be an

unlikely event which warrants a transfer to an acute facility

Anesthesia

It’s not just about the surgeon

Anesthesia needs

Anesthesia needs to be on board and comfortable with doing

this patient population in the ASC

Bring Anesthesia on board early in the process to keep

dialogue open and transparent

Spine patients are typically in a compromised position – not

all providers are comfortable with prone / lateral patients

Anesthesia Supplies

Prone positioners

Chest rolls

Face positioners

Pharmacologic additions

Added drugs with less neurological sluggishness

ETT extenders

Aid in positioning

Temp monitoring devices

Nerve monitoring

BIZ monitors

Staff Skill Sets

Understanding your staff and their needs

Staffing

A program is only as good as the team that it is built on

Are your staff confident in providing the required care to this

patient population

What experience do the staff bring to the facility

PeriAnesthesia staff

Assessment needs, neuro checks, overnight care

Rad techs

Validating location and working efficiently

OR Staff Scrub techs and circulators

Handled spine instruments

Fine tips

Micro instruments

Working with surgeons under a microscope

Positioning needs, are they comfortable positioning patients to insure all

pressure points are padded

Documentation of positioning

Are the surgeons comfortable with the current staff and their skill sets –

both routine and emergent situations

PeriAnesthesia Staff Stage I PACU

Airway issues

S/S postop bleed post ACDF Neuro assessment

Anesthesia drugs Anesthesia may use different drugs – faster wake up less bridge to pain control

Antiemetic's

Stage II Postop and Overnight care Longer postop assessment

Use of hospital bed versus chair/cart IV pumps

Ongoing Documentation (greater than several hours)

Dietary needs Admission and discharge orders

Medication Documentation

Staff Secure

Overnight care requires 2 persons to be in the facility

Contacts and back up

Skill sets to assess and handle emergent needs

Clinical, social, visitor, community

Building needs – alarms, HVAC systems,

Security systems

Camera’s

Monitor of visitors

Secure doors and access area’s

Postop Recovery Model

Care for patients up to 72 hours

Recovery Care Unit Model “Frequently surgical patients need a place to regain strength and have pain controlled” Sonia Foote – Loveland Surgery Center

State regulations currently prohibit Convalescence centers attached to the ASC in most states

If you develop a Recovery Care Unit - What will your philosophy of care be for that unit

Will you provide amenities like a hospital or space for recovery and staff with home health nurses…. Is it recovery or convalesant care?

Does your state dictate what can be provided

Recovery care continued

Utilized and licensed in several states

Colorado, Oregon, Washington

CMS does not license or provide accreditation

Requirements ?

Emergency equipment

Pharmacy

PT

Paperwork and documentation

OC MD needs – what does the given state require

Set up for productive and financial success

Staffing Model (recovery care / acute facility)

1 nurse for every 2 patients

Patients do not need to ask for items – concierge

service

Increased interaction

Dietary Assessment

Menu’s – dietary requirements based on chronic conditions

Dietician sets up menus and provides oversite

Monitor food and temp

Recovery Unit – ancillary staff

Physical Therapy

When does the assessment start

Interaction and treatments

Who performs treatments - Physical Therapist or Nursing Staff

Respiratory Therapy

Discharge planning and home needs

Home environment and physical layout

Recovery Care Unit Trend of Future

The Convalescent center may easily become the trend for

ongoing postop healthcare

Less costly to run than an acute hospital

More home like

Healthy patients with less exposure to community and hospital

acquired illness

Adding Recovery Care allows physicians to bring higher

acuity cases into the ASC

Changes the face of and ASC and has long term implications

Expert Knowledge and Service

Who will you choose to partner with to help

Don’t go it alone

Find good people with experience to help you in the process

“it takes a lot of expertise to put together the whole big piece – you

have to define your chunk – expand the management team from the

start to allocate for future work and growth” Robert Bray, MD –

DISC Sports and Spine Center

Guidance

Next steps

People available to help

Negotiate insurance contracts

Procedure costs and negotiate vendor pricing

Develop policy and procedures

Develop documentation and order sets

Go with someone who has been down this road – don’t try and reinvent

the wheel

Trends to watch for

Long and short term

Essential trends in new spine programs

Potential increase in overnight stays

Potential initial increased need for rehab or recovery

Added contingency plans – especially for Medicare patients if

something goes wrong

Coding audits and analysis

Success could bring more codes to the ASC

Lowered commercial payor reimbursements

Commercial payors could start to lower reimbursement rates to

target Medicare rates

Works Cited Anjya, V. (2016, March). 5 Considerations for adding outpatient spinal surgery to a fully equipped center. Chicago, IL, USA.

Beckers Hospital. (2015). Beckers finance trends facing surgery center's. Retrieved from Beckers Hospital Review - CFO: http://www/beckershospitalreview.com/finance/11-trends-facing-surgery-center.html

Caruso, M.D.,F.A.C.S., J. (n.d.). Considering the Move to Outpatient? Hagerstown, MR. Retrieved March 19, 2016, from http://bluechipsurgical.com/articles/BC Caruso ComOutpatientSur W.html

Centers for Medicare. (2004, March 11). Centers for Medicare Ambulatory Surgery Center. Retrieved March 18, 2016, from Department of Health and Human Services - CMS: www.com.gov

Dydra, L. (2013, November 7). Developing a Convalescence Center:One Ambulatory Surgery Center's Journey. Beckers ASC. Chicago, IL, USA. Retrieved April 7, 2016, from Becker's ASC: http:www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/developing-asc

Dyrda, L. (2014, December 16). Spine surgery for Medicar patients in ASCs in 2015 - But will spine make good business sense? Retrieved April 7, 2016, from https://login.sdbmoe.gov/public/services/verficationsearch.htlm

Linder, H. (2012, November 2). 4 Key Lessons for Opening a Spine ASC. Retrieved March 20, 2016, from http://www.beckersspine.com/spine/item/11408-what-percent-spine-surgeries-performed-in=asc.html

OR Manager. (2016, January 20). Recovery centers extend stays beyond 24 hours. Retrieved April 7, 2016, from http://www.ormanager.com/recovery-centers-extend-stays-beyond-24-hours.html

Young, R. (2015, August 27). Big Changes coming to Spine Surgery? Ortho Digest. Retrieved March 20, 2016, from https://ryortho.com/2015/08/big-changes-coming-to-spine-surgery/.html

Thank you

Questions –

Deb Yoder, MHA, BSN,RN, CNOR

Director of Operations

Surgical Management Professionals

Sioux Falls, SD

dyoder@smpsd.com

319.321.8157