Are you ready to offer 23-hour stays? HCFA wants to "level the playing field"
Are you ready to offer 23-hour stays? HCFA wants to level the playing field’
ASCs, hospital SD departments may soon offer same procedures
Ambulatory surgery centers (ASCs) have lobbied for it for years. Hospitals have fought it. And now, the Health Care Financing Administration (HCFA) is saying it’s willing to approve it.
What is it? Equality between hospital same-day surgery (SDS) departments and ASCs in terms of the procedures they can perform.
"We want to level the playing field for outpatient hospital services and ASC services," says Terri Harris, health insurance specialist for HCFA in Baltimore.
As part of the change being considered, Baltimore-based HCFA is "leaning closer" to approving reimbursement for 23-hour care in ASCs, Harris says.
"This is huge news," says Joni M. Steinman, managing principal of San Diego-based AUSMS Healthcare Consultants, which offers strategic business and facility planning services in health care. "It would be a tremendous change and a true leveling of the playing field."
Presently, ASCs are limited to performing services on HCFA’s list of approved ASC procedures. To determine which procedures should be put on that list, HCFA uses the "90 minute/four hour" rule: The procedure must take less than 90 minutes to perform and less than four hours for the patient to recover from. Hospital same-day surgery departments, on the other hand, are not restricted to performing outpatient procedures on the ASC list; however, they cannot keep patients any longer than freestanding surgery centers can keep their patients.
ASCs have complained for years that limiting their services to procedures on the ASC list unnecessarily restricts them.
"I really do think so many surgery centers and hospitals know that there’s really no reason they [surgery centers] shouldn’t be able to keep patients who happen to be 65 years old in an ASC if it’s properly staffed and equipped and good patient care standards are followed," Steinman says. Age is only one of many factors that come into a physician’s thinking when determining the site of surgery, she says. "Up to now, age has been a primary factor and, to some extent, an artificial factor, strictly due to Medicare’s involvement," Steinman says.
Some states, such as California, Illinois, and Texas, have bypassed Medicare’s constraints by passing their own laws or regulations on the definition of an ASC and by permitting same-day surgery programs to offer recovery care for up to 23 hours or, in some cases, up to 72 hours.
Part of the big picture
This latest indication by HCFA that the agency is working toward more equality for hospital same-day surgery departments and ASCs is part of HCFA’s larger effort to examine the definition of an ASC procedure and to consider a new classification system for ASC procedures that is expected to resemble ambulatory patient groups (APGs). (For more information, see Same-Day Surgery, December 1996, p. 133.)
HCFA aims for the new definition, classification system, and reimbursement for 23-hour care to be presented jointly in one large regulatory proposal. This proposal also is expected to include proposed additions and deletions to the list of ASC-approved procedures. However, a new classification system might be proposed first so that it isn’t held up by research on the other proposals, Harris says. While HCFA initially said such a proposal might be published by the end of 1996, the timetable has been reconfigured. The agency now says a proposed rule may be published in January 1998.
These changes being considered by HCFA are good news for ASCs, and good news and bad news for hospitals.
If HCFA adds to the list of approved procedures that can be performed in an ASC, hospital same-day surgery departments would see reimbursement for those procedures move from cost-based reimbursement to a blended rate only partially based on cost.
And although HCFA’s approval of 23-hour stays would open opportunities for both hospital-based SDS centers and freestanding centers, any changes could mean increased competition between the facilities. Surgery centers would be able to perform new procedures approved by HCFA and keep patients longer for recovery.
"That’s always a concern," says Sonia Barness, RN, CNOR, SDS nurse manager at Fairview Southdale Hospital in Edina, MN. "There’s the potential for [surgery centers] to cut into our patient pile."
Why 23-hour care now?
One question on every same-day surgery manager’s mind is, why has HCFA decided to get involved now?
The cry for approval of 23-hour care was heard loud and clear by HCFA when it held a town meeting for members of the ambulatory surgery field during the summer of 1996, Harris says.
"Basically they were saying there was no reason that the same procedure performed on outpatient basis in a hospital can’t be performed in an ASC," she says.
Managed care is putting the pressure on ASCs to offer more difficult procedures, Harris says.
"Payers realize that ASCs can perform surgeries at a more reasonable rate than hospitals," Harris says. "ASCs can compete with hospitals, which they should be able to."
Another factor in HCFA’s involvement is the growth of the ASC field.
"Every year, within the last three to four years, 200 ASCs have been added per year to the Medicare rolls. It’s picking up," Harris says. "We haven’t kept pace with the industry. Even when we get the regulation out, we still won’t have caught up."
If Medicare does follow through and approve 23-hour care at ASCs, the advantages could be many for hospitals’ same-day surgery programs and freestanding centers, say same-day surgery managers.
Same-day surgery managers would be able to use their ORs later in the day, says Bobbie McAdams, RN, director of hospital admissions at Medical College of Georgia Hospital and Clinics in Augusta.
In addition, "I think there’s more assurance that patients recover appropriately, and you’re not hurried to get them out due to reimbursement," McAdams says. "Lots of times, [an overnight stay] is all it takes."
Perhaps most importantly, a 23-hour rule when combined with new regulations on what defines an ASC procedure would open up the types of procedures that could be performed in an SDS setting. Presently, some hospital-based SDS programs and ASCs perform these procedures, but with no reimbursement from Medicare. Examples include laparoscopic cholecystectomy, anterior cruciate ligament knee repair, as well as other orthopedic and some ENT and gynecology procedures.
The centers most likely to take a new interest in offering 23-hour care include multispecialty centers and centers owned by national companies, which would see this extended recovery care as a natural marketing opportunity, Steinman predicts. Others, such as many of the single-specialty centers, may find that they don’t want to jump through "another set of hoops," she says, referring to the regulatory oversight. "If they have a narrow focus, they don’t need that headache," Steinman says.
What will your state do?
Keep in mind, however, that even if Medicare decided to permit 23-hour care, that wouldn’t mean that individual states similarly would permit it, Steinman warns.
"For states that have own their licensing laws governing ASCs, if those laws currently don’t permit 23-hour stays, those laws would have to be amended to permit it," she says.
To address this problem, Steinman predicts the same-day surgery trade associations will move quickly to get approval for 23-hour stays from state legislatures, if Medicare does make such a proposal.
In the meantime, same-day surgery managers are waiting to see what HCFA does next. Currently, HCFA is establishing a regulation team to develop conditions of coverage for ASCs, which include the definition of an ASC and how long an ASC can stay open.
This team will examine several issues that would have to be resolved before 23-hour care is approved for same-day surgery centers. One issue is safety, which could include more stringent life safety code requirements and structural requirements, such as new sprinkler systems.
The group also will be discussing terminology, such as the definition of 23-hour care, i.e., when does it start and end? Once these questions are resolved, HCFA will propose a regulation that same-day surgery managers hope will clear the way for 23-hour care.
"It’s something whose time has come," Steinman says. "Let’s leave it up to physician in concert with patients to decide on the site of surgery and site of recovery."
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