September 28, 2015

There are more than 5,400 Medicare-certified ambulatory surgical centers (ASCs) in the US today.  Ten more opened within the last month, not an unusual number, according to the latest issue of Becker’s ASC Review.  The Anesthesia Quality Institute’s Anesthesia in the U.S. 2015 shows that the number of cases performed in freestanding surgery centers reported to the National Anesthesia Clinical Outcomes Registry has gone from under 40,000 in 2010 to more than 80,000 in 2014.  Certainly a significant proportion of the anesthesia workforce—anesthesiologists, nurse anesthetists and anesthesiologist assistants—provides services in independent ASCs.  ASCs are even more vital to the practice of pain medicine, which is one of the big four ASC specialties, along with ophthalmology, orthopedics and gastroenterology.

The pressures on ASCs are considerable.  Medicare and private payers are holding down payments to ASCs, as they are to other providers.  More and more health plans are setting utilization limits on pain management procedures and in fact lower payment levels have led many pain specialists to move cases from ASCs to their private offices.

Payer consolidation is constraining many ASCs’ options; ASCs rely heavily on commercial reimbursement, so the impact of the reduction in numbers of and competition among health plans is particularly acute for these organizations and their relative bargaining power.  Dealing with out-of-network patients and collecting from patients with higher deductibles and co-payments can be problematic, just as they are for medical practices.  (On the other hand, high deductibles may be causing patients to become better consumers who seek out alternatives to expensive hospital care.)

Quality measurement and reporting requirements demand the allocation of scarce resources without immediate benefit.  There is an ASC side, as well, to the growing phenomenon of hospital employment of physicians:  as hospitals seek to lock in more and more of their referral base by hiring the surgeons and proceduralists who bring in cases, ASCs in the same markets find themselves with fewer independent physicians on whom to depend.

The anesthesiologists, pain physicians, CRNAs and AAs working in ASCs should recognize these pressures on their facilities—and contribute to meeting the challenges for the simple reason that it is easier to do one’s best work in a high-performance environment than in a workplace that is failing to thrive or falling behind.

Quality and cost-effectiveness—offering value—are as important to the survival of ASCs as they are to the success of anesthesia practices.  Anesthesiologists should note that prophylactic antibiotic prophylaxis is still on the list of quality measures that ASCs must report to CMS in order to receive their full payment update, as are avoiding wrong-site, wrong-side, wrong-implant surgery and hospital transfers or admissions.  Potential measures under consideration for adoption include ones related to postoperative nausea and vomiting and to all-case hospital admissions or emergency department visits within two days of discharge from an ASC.  Patient satisfaction, too, is assuming an ever more important role in ASC quality.  It seems safe to say that ASCs cannot satisfy their quality reporting requirements without anesthesia’s active engagement.

Operating room efficiency is a concept in which many anesthesiologists are well-versed and is an area where they can readily make a difference.  The administrator of an ASC in Florida interviewed for an article posted on the Becker’s ASCReview website on September 11, 2015 (The low-hanging fruit of ASC OR efficiency: 6 best practices) recommended as one of those “best” practices:

Work closely with the anesthesia department.  Keep the anesthesia department in the loop to make the OR ultra-efficient. "If they are on board and helping with every case, it makes the cases more quickly and more smoothly …. [sic].  For example, in our facility if the nurse has trouble getting an IV started they immediately reach out to the anesthesia department who can address the issue quickly. This also leads to an improved patient experience."

Beyond being readily available to resolve clinical difficulties such as the one in the example, anesthesiologists can play a role in helping their ASCs adopt and adapt the other practices identified in the article cited:

1. Get as much information about the patient before he or she comes in for a procedure and prepare to handle such issues as allergies or medication sensitivities.
2. Treat inefficiencies as something within your control and brainstorm ways to tackle them.  As an example, consider automated phone calls to remind patients about their appointments and make sure that the OR staff is ready when the surgeon arrives.
3. Communicate and coordinate to preempt problems.  For example, have the front desk let preop know if the patient is late so that preop can alert the other departments affected.
4. Use the ASC’s data.  Make sure that the software can run regular reports that will allow the identification of recurring inefficiencies and potential workflow improvements.
5. Involve the ASC staff in figuring out how to prevent bottlenecks and other inefficiencies.  Something as simple as putting up a white board in the preop area to communicate the status of patients with the OR may help things run more smoothly, and the potential of such a tool may be apparent only to the staff involved.

Sanford Plavin, MD, a practicing anesthesiologist who is a past president of the Georgia Society of Ambulatory Surgical Centers, wrote of the opportunities for anesthesiologists to affect the profitability of ASCs in Anesthesiologists and the World of ASCs:  A Different Value Proposition published in the Spring 2015 issue of the ABC Communiqué.  Dr. Plavin emphasized the need for anesthesiologists to be flexible, to focus on the needs of their ASC customers and to engage in the entire perioperative process.  As noted in Somnia Anesthesia’s Current Trends in the Ambulatory Surgery Center Marketplace,

[D]eploying screening questionnaires, efficiently completing preoperative evaluations or the use of preoperative regional blocks, all have the potential to improve efficiency outcomes.  Intraoperative efficiency can be improved in a multitude of ways as well—from starting the intravenous prior to entering the operating room, to applying blood pressure cuffs or other monitors preoperatively, to choosing fat onset and quick offset techniques—all can all pare down the turnaround time.  The last way to improve intraoperative efficiency can also improve post-operative efficiency.  A patient who arrives bright-eyed, pain free, and devoid of nausea may be able to go home sooner or even bypass recovery altogether.  Similarly, being judicious with sedative and narcotic-based post-op remedies may help reduce recovery time.

Nishant Shah, MD of Midwest Anesthesia Partners in Illinois likewise stressed the benefits of communication and involvement in all phases of the perioperative period  in Anesthesia practices must embrace new roles to remain profitable:  Dr. Nishant Shah’s insight in the August 12 online issue of Becker’s ASCReview, adding the interesting point that anesthesia’s flexibility ends where patient safety is at issue (“Things are moving towards ASCs … but we have to be firm when certain procedures cannot be done in ASCs due to the safety of the patient.”)

The challenges for ASCs in today’s value-based environment are huge, but so are their advantages.  ASC anesthesiologists will help to secure their own professional future by becoming integral to their facilities’ strategies for meeting the challenges.  To quote the late Yogi Berra: “You’ve got to be very careful if you don’t know where you are going, because you might not get there.”

With best wishes,

Tony Mira
President and CEO