Answers to 11 of your most common questions
Answers to 11 of your most common questions
I've received hundreds of letters and phone calls asking for greater detail on a particular topic or generic information on other areas over the past three years. I thought it might be helpful to others to share some of those questions with you this month. I've summarized the questions and given a capsule of my response to the questions:
Question: We have the opportunity to joint venture an ambulatory surgery center [ASC] with a group of physicians in a new medical office building that is owned by the MDs and is connected to our hospital via a covered walkway. The MDs want to build the ASC in their building. Our administration wants it in the hospital. We are at a stalemate in our talks with the doctors. Any ideas?
Answer: Unless your administrator can do the surgery himself and doesn't need the surgeons, I would find a way to work with the MDs in their building. Physicians are starting to realize the value of their surgery to hospitals. It might be time for hospitals to also realize the fact that there are many options available to surgeons now.
Question: There is a lot of talk now about the new laser pulse treatment for facial wrinkles. Should our ASC buy the equipment (about $120,000), and, if so, what can we expect for reimbursement?
Answer: There are two of these lasers on the market. One costs about $70,000, and the other costs about $130,000. (For more on laser resurfacing, see Same-Day Surgery, March 1996, p. 32.) Some studies have shown the less expensive one is perhaps the one that gives the best results. Check the literature on the two. The reimbursement is all self-pay, usually up front. Charges range from $2,000 to $6,000 for a full face treatment and less for just the lips, around the eyes, etc. We have the machines in four of our centers, and they are very profitable.
We also have found that for the full facial treatment, the patient does better under general anesthesia. You may want to consider joint venturing the machine with a local plastic surgeon; however, that isn't necessary, as I'm told that any trained surgeon can learn the technique. Consider a joint marketing program with the facility and the surgeon.
Question: We have a surgeon who is always after us to buy something, anything. Whenever a new piece of equipment hits the market, she hounds us to buy it, promising new cases and new revenues as a result of this new "toy." What ends up happening is she uses it for a few months, then loses interest in it, and we have to find a place to store it. How can we stop purchasing new equipment without getting her upset and taking her cases elsewhere?
Answer: If it can be legally done in your area (get legal counsel first!), ask the physician to joint venture the equipment with you or lease it back to the center. See if she is willing to put her money where her mouth is.
Question: Our ASC is joint ventured with a group of surgeons in the area. The administrator of the center is now saying that we need to become accredited with either the Joint Commission (the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Facilities) or AAAHC (the Skokie, IL-based Accreditation Association for Ambulatory Health Care). As the administrator of the hospital and general partner of the ASC, I don't believe this is necessary.
Answer: Perhaps not yet. Unfortunately, I believe that eventually reimbursement is going to be tied to accreditation with a group other than Medicare. It is time to actively pursue these organizations and, at the very least, to begin the process. Listen to your ASC manager. She is employed to advise the general partner on these types of issues.
Question: Do other countries have same-day surgery programs, i.e. freestanding surgery centers?
Answer: Yes. I have been to several in Brazil, England, and Turkey. In fact, this September, I will be addressing several ambulatory surgery organizations in Australia.
Question: We have a "pain management program" at our ASC. While it is quite profitable, the anesthesiologists now want to start treating "insurance claim" patients. We will not be reimbursed for the procedure until the claim is settled, often six months after the treatment. I don't think this is a good idea because we may get nothing if the case is settled against the patient.
Answer: I disagree with you. One, your hard cost on these cases is minimal. Two, if you don't take these patients, your anesthesiologists may take them elsewhere, and you run the risk of losing many others, and lastly, it could open the door for many more patients in the future. Avoid becoming too risk adverse, especially in the changing environment.
Question: Several of our surgeons are going back to school to receive an MBA degree. Have you ever heard of this?
Answer: Absolutely! Thousands of physicians are doing it -- as they should. Many physicians are tired of others making financial decisions for them when they don't understand the language or the potential outcomes of these decisions. Due to their potential income, I think it is a wise move. For us, I think they will have a better understanding of what we are trying to accomplish when we talk about cost per case, financial analysis on new equipment purchases, etc. The more informed our surgeons are about the financial side of health care, the better for them and us.
Question: Who should have the final say on clinical issues in the OR: the nurse or the surgeon?
Answer: The medical director.
Question: What federal agency regulates the requirements for pre-op lab testing in an ASC?
Answer: There isn't any. It is up to the individual centers to adopt their own requirements.
Question: As a new ENT surgeon on staff at our hospital's ASC, I have requested that the ASC contract out the management of the center to a professional ASC management company. The ASC is acting only as an extension of the in-house ORs with the same management team and the same inefficiencies as the main ORs. The hospital administrator said as general partner, the hospital was not allowed to bring in an outside management organization to manage the center. I don't believe that is correct.
Answer: While there may be certain restrictions in the partnership agreement that does forbid outside professional ASC management, it is not illegal to do so. All that would be required is to amend the current agreement. There are many ASCs, both freestanding and hospital-based, that are managed by outside individuals. They have the ability to act autonomously from the hospital and are sometimes preferred by surgeons, especially in a new ASC or joint ventures with hospitals.
Question: What is the 50% rule with Medicare about surgery cases in ASCs and a physician's office?
Answer: It refers to the percentage of procedures that are performed in a physician's office 50% or more of the time. Once that 50% margin is passed, it is likely that the procedure will be removed from the Medicare reimbursement list. One high volume procedure that is very close is cystoscopies. Many believe that it will soon lose Medicare reimbursement for a facility charge.
(Editor's note: To suggest ideas on the column or provide feedback, contact Earnhart at 16610 Dallas Parkway, Dallas, TX 75248. E-mail: [email protected].) *
To order the 1996 AORN Standards and Recommended Practices ($43.75 for nonmembers, $35 for members, plus $3 shipping and handling), contact:
* AORN/Book Order, 2170 S. Parker Road, Suite 300, Denver, CO 80231-5711. Payment must be enclosed with orders. Telephone: (800) 755-2676. Fax: (303) 750-3212.
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