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
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
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 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
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 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 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
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
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
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
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
319.321.8157