Transcript
Speaker: Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guests, and then we'll close the episode by recapping the latest news impacting surgery centers. We're excited to share with you what we have, so let's get started and see what the industry's been up to.
Speaker: Hi, everyone. Here's what you can expect on today's episode. Matt Kramer is the administrator of Northern Arizona Healthcare Surgery Center. And we sat down with him to chat about case acceptance. And we're talking through the sometimes difficult question, should you accept every case?
Speaker: There are two scenarios where Matt's team will not accept a case and it boils down to patient safety or revenue. So he's sharing why this is important, their approach to coming up with that decision, and the results that they've seen so far. In our news recap, we'll cover a study that compared chat GPT's responses against physician responses, the importance of discussing transportation with every patient,
Speaker: What will disrupt the ASC industry next? And of course, end the new segment with a positive story about a NICU nurse who adopted a teen and her triplets. And one final reminder, if you are going to be at the ASCA conference in Louisville from May 17th to the 20th, make sure you stop by HST Pathways booth to say hello. I would love to see you all.
Speaker: During exhibit hall hours, I'll be holding very quick interviews with people right in the booth, and we're going to compile all the great responses we get and use it for an upcoming episode that will air in late May. So if you want to share your expertise with our listeners or just come by to say hi, we only need a few minutes of your time. So come find us in HSC Pathways at booth 519, and we'll have a big booth right in the middle of the floor. You can't miss it.
Speaker: I hope everyone enjoys the episode and here's what's going on this week in Surgery Centers. Matt, welcome to the show. Yeah, thanks for having me. Glad to be here. Matt, can you give us a quick overview of your background in the ASC industry?
Speaker: Absolutely. So I'm an administrator for Northern Arizona health care and specifically over the orthopedic and spine Institute, which is a comprehensive Institute involving employed providers as well as surgical operations, including ambulatory surgery center.
Speaker: that we have within our organization. And I've been doing that for the last four years. Prior to that, I was also in healthcare as a physical therapist in multiple settings and a healthcare administrator with other HCOs in Arizona. Fantastic. And I want to talk to you today a little bit about case acceptance in an ASC environment.
Speaker: because surgery centers aren't hospitals, it's a different business model, and as more and more case volume gets shifted to outpatient facilities, you know, I think that the ASCs are going to need to start paying more attention to case acceptance, aren't they? Absolutely, yeah. And Matt, what's your point of view been on case acceptance? How do you think about that at your current facility? I mean, that's a
Speaker: tricky situation to kind of manage. Obviously
Speaker: ambulatory surgery centers are built highly on efficiencies and volume and throughput, as well as a great experience for not just the provider performing the surgeries, but for the patients themselves and their recovery. So we're trying to execute on those fronts. At the same time, many times those margins are much less than what they would be in a hospital -based facility with an ASC fee schedule versus an HOPD fee schedule.
Speaker: that also comes into play. So how do you try to achieve the best outcomes for your patients and for your providers, provide the throughput, but then also continue to manage a positive margin from a financial perspective, and then be able to select or accept those cases to keep those providers happy and wanting to bring those cases to your facility. Right.
Speaker: Procedure margin, it's balancing the procedure margin with the patient outcomes. How do you balance those two things? What's been your approach to evaluating cases? Yeah, it's definitely not a straightforward or an easy approach. All the different variables that are in play are things that we have to take into consideration. Patient stability, the type of case being performed,
Speaker: medical equipment or medical supplies required to be able to form those cases. Staff training, some of those cases require additional training or specialization for safe case completion. And then ultimately reimbursement, those payers that are supplying the compensation to the facility,
Speaker: in order to be able to perform those cases for their covered lives, have variances in whether or not they're a government payer or whether they're a commercial payer and contractually with their obligated to perform or provide, and then what they're actually authorized to provide as well. So it's a matter of trying to navigate all those various variables in that one equation, which is that one patient case and determine
Speaker: whether or not it's something we can safely achieve as a comprehensive team and then still manage to keep the lights on. Yeah, that makes sense. And you mentioned a lot of inputs that go into the case, whether that's the supplies and that's reimbursement rates and stuff. One of the things we hear a good amount talking to our customers is, especially in the orthopedics world, hey, we don't always know
Speaker: all of our supply costs, especially on the implant side going in. Sometimes we find out after the fact, based on implants or supplies that were used, a case could have less margin or even be non -profitable, kind of finding that after the fact. At your facility, how well do you feel like you've got a good understanding of what supplies go into the case and what's the cost of that case gonna be?
Speaker: You know, I think we're, we're getting better. Um, we're not where we want to be by any means. Um, I think it's a continual journey, um, which, you know, most performance or process improvement is, um, you know, I'll say two years ago, it wasn't occurring on a, at least on a regular, a regular basis. And the information we had was, I would state maybe 80 % accurate. Um, you know, nowadays I believe the systems that we have in place, the individuals that we have,
Speaker: contributing to performing those analyses are much, much tighter, 90, 95 % accurate. And we've built a bit of a database
Speaker: in identifying exactly all those measures you were just referencing. So how much staff do we need? What is the cost of our staff, our anesthesia, just the overhead, the fixed cost associated with running the facility and how that contributes to your overall volume, and then also those variable costs. So having implants, having capitated contracts with those vendors to ensure that in this facility it's an implant we can't afford to utilize.
Speaker: And then the time that it takes to perform that case, because you mentioned a couple things there, you know, and we've both talked about it thus far, you know, supply cost and your and your labor, you know, or your
Speaker: your employees are your greatest areas of overhead. And so how do you best leverage those resources or minimize the cost as it pertains to the supply? But then how do you leverage that resource of your salary and your benefits of all your employees and so
Speaker: comes down to case consolidation, OR block utilization, turnover times. A lot of the metrics that most of the people that will view this are very familiar with, but really creating a bit of a database as far as by case type, by provider, and even by payer source on whether or not this is going to be either a tight margin, a positive margin, or even sometimes a negative margin.
Speaker: Um, in which case we may consider continuing to perform that case, um, just depending on the necessity of being of, you know, is it a something that's emergent? Um, is it truly the best place to perform that case for that patient? Um, provider preference, those types of things, um, still come into play. So it's even with all that information, it's never really just a black and white, unfortunately. Sure. Sure. But it does sound like with your database, you've got it more dialed in.
Speaker: than some and you've got a kind of a good data set around it. Do you typically make decisions on if you are going to not accept the case? Is that typically kind of a case by case evaluation or is it more hey by case type
Speaker: or the intersection of case type and payors, you know, maybe there's some on the matrix that aren't a good fit and some that are. How do you think about that? Yeah, I mean, I would say between those two options is definitely more of a case by case assessment. You know, we'll never just say, hey, it's just because it's a, you know, whatever type of case, we'll say a hip scope case with this type of payer or this type of implant or anchor system that we're,
Speaker: We're, you know, a hard yes or a hard no on that case. We still will go through the analysis, you know, by provider, by time, by necessity, emergency, all those other factors that I mentioned to determine, you know, nine times out of 10, we might, we might accept this case, but that there's one time we might not, you know, and so we'll, we'll never just be absolute across the board. Okay. It sounds like there's a decent amount of kind of effort and time on the front end to evaluate these cases.
Speaker: Yes, a lot of rigor. And by all means, it's no one individual. For instance, myself as the administrator, I don't make the call. I rely on the consensus of the team. We've got a lot of people behind the scenes with our authorization, verification departments, our RN clinical manager overseeing the operations of the center itself.
Speaker: their team of charges, our lead anesthesiologist, our physician medical director over the facility. So everybody's coming together to perform this analysis and then provide their recommendation on how to move forward or not. Okay. You mentioned safety earlier, Matt, and how that can factor into case acceptance too. How does that come into your evaluation processes, the ability to do a case safely?
Speaker: That's got to be first and foremost. If you're not performing safe cases, you're not going to be in business very long. Forget the finances of it. Forget how shiny or great your technology or your building might be. If you're having poor outcomes or unsafe practices, it's only a matter of time before you're no longer operating. That's got to be first and foremost.
Speaker: We've had situations where we've had to unfortunately refer, or in my case, I believe fortunately refer a case deferred from our facility over to the main hospital because the case is 100 % appropriate to be performed in an ambulatory surgery center by procedural type, by provider, everything in place, even by ASA scores, which is one of our anesthesia measures of safety.
Speaker: However, in deeper review, comprehensive review of that patient's history, we find some anomalies that have us considered, or I'm sorry, have us concerned regarding how that patient might potentially have difficulty with their recovery post anesthesia in the PACU, whether it be phase one or phase two. And is that a longer length of stay? Is it a potential transfer to a higher level of care? Do we believe that they're not gonna be able to
Speaker: return to a normal vitals level in the time that we have in order to achieve that. And so we might have to defer that case over to the main hospital where we know that that patient can spend a longer period of time in the PACU, you know, even be potentially transferred into an observation bed overnight so they can safely discharge home the next morning where we don't necessarily have that luxury in the surgery center.
Speaker: Got it. Okay. So that's really helpful in terms of the overall framing of how you think about the case acceptance across those two areas. In terms of giving our listeners some specific examples, maybe to bring it to light a little bit, can you share an example on the safety side of maybe a case that you guys evaluated and said, hey, this doesn't feel right for us? Sure.
Speaker: Yeah, I mean that case actually that I just referenced was an actual case where we had a very appropriate patient coming in for, and I believe it was a shoulder injury, you know, maybe a rotator cuff. It was something very, you know, typical of an ambulatory surgery center and orthopedics for that matter. But unfortunately, some of these other
Speaker: comorbidities or past medical history complications had us reassess or reevaluate the appropriateness of this patient due to some of their respiratory -based complex
Speaker: complexities or complications, that we deferred that case over to the main OR, where you don't typically see a rotator cuff repair performed, but as a result of this patient having some perceived difficulties with their ability to recover post anesthesia, we felt it was just the safer call for them. And same question for you on the financial margin side. Can you give an example of when you evaluated the case?
Speaker: and said, hey, from a margin perspective, this doesn't seem like a good one for us to take on. Yeah. Very similarly, orthopedic case, ACL, allograft case, and was scheduled and no pair issues, no past medical history.
Speaker: complexities that would kind of cloud our ability to accept the case. But in speaking with the provider and in looking at their medical supply requests, identifying that they were actually looking for two graphs for this patient versus one. And then when we looked at that particular case and had the conversation with the performing surgeon, they mentioned that this was in this particular instance, the best
Speaker: Best practice for this patient was going to be to use two different graphs and combine those graphs into this repair. Our approach was to educate the provider on how this was not a financially sustainable model for us, given the amount of reimbursement that we would receive for this case, the amount of supply
Speaker: in the tissue itself, but then also in a longer case time, the labor to support that. We showed this particular provider how it was going to be a significant loss on this particular case. And if they wish to use this type of approach for this patient, and they truly believe that this was the only way to manage this particular patient, that we were going to defer this case and they would need to perform this case in the main OR at the hospital,
Speaker: And this provider essentially said, well, I could probably come around on this and we can make do with this one graft and we can have some further conversations after this case is performed. I really believe the ASC is the appropriate setting for this patient. So we'll move forward with just one graft and go ahead and complete the case, which was then a financially viable option for us.
Speaker: But I think it was an eye -opening experience for the provider. I think they just had an understanding that they were gonna make, we make both loads of money on these cases. So you're sharing some of the margin information and the cost of doing business with them. I think it was a little eye -opening and they started to maybe reconsider some of their approaches with particular patients. Right, so a lot of times the providers of the facilities don't necessarily have the information
Speaker: on the overall profitability as they're developing the list of materials, right? Correct. Sorry, go ahead. I was going to say, in fact, that's 100 % correct. I would say the majority of the time versus many times, I would say probably 90 % of the time the providers don't know.
Speaker: Of that 90 % of the time, those providers almost 100 % of the time want to know. So they want that access to information. They want to know if they're the most expensive provider performing this case type.
Speaker: you know, I will also say that orthopedic surgeons are very competitive human beings. And they're always looking to excel, whether that's outcome based or just to be, you know, one of the most affordable. And so they want to be able to produce an outcome that, you know, is excellent and, you know, leads the league in quality, but then also is also, you know, one of the
Speaker: most least expensive options for their patients or for their surgical center partners. And so they're looking for access to that information. Exactly. And what's interesting is
Speaker: Those two things aren't necessarily mutually exclusive, right? The safety side and the cost side. So that's what's interesting. Correct. You know, and we make strategic decisions sometimes to knowingly accept a case that is going to be, you know, a margin loss or a negative margin because it is the right thing to do. It's the right approach for the patient. It's the right safety or outcome.
Speaker: focused decision, knowing that it's not across the board and potentially it's to help assist a surgeon achieve their targets or their goals as well. Yep. And so you guys have been thinking about this at your center in a thoughtful way in terms of kind of the margin side of these cases. Have you seen the impact on the overall facility profitability?
Speaker: Yeah, I mean, it's definitely not a quick turnaround, so to say, so to speak.
Speaker: It's one of those things where you get it right more times than not, and then you start to get it right even more and more. And so over time, you see your profitability for particular case types or quarter over quarter or year over year start to improve. We've seen a consistent 60 % roughly improvement in our financial performance. Again, incrementally, case by case type, provider by provider,
Speaker: And then eventually quarter over quarter and year over year. So getting ourselves into a position where we're starting to hardwire that model to then ensure financial sustainability long -term. That's fantastic. You start stacking up some of those 50, 60 % quarter over quarter improvement, that's going to really add up over time.
Speaker: It's the little things of taking two teams in two different ORs and being able to consolidate them into one, improving the efficiencies of your turnover times, saying yes to some of those cases that are longer, but then also being able to say no to some of those cases that you believe to be too long or too expensive to perform or that potentially allow for
Speaker: quality indicators to not be met as far as transfers to higher level of care and things like that. And they do. They add up. Those one -off decisions over time start to create a trend. And then they build a culture. Everybody's involved. Everybody's engaged.
Speaker: from the frontline staff, whether they're in the OR, in the pre -op or PACU space, SPD space, or in the insurance verification space, everybody's aware of what it is we're trying to achieve. And then we engage our physician partners to come along with that journey. And it makes all the difference in the world. Love it. Final question for you, Matt. And we do this every week with our guests. What's one thing our listeners can do this week to improve their surgery centers?
Speaker: The easy thing to say is just start looking at these things. Start digging into these details and start performing your own root cause analysis. We started off by just starting to create a spreadsheet. It was one simple spreadsheet where we started to look at case types by provider, by times, the cost of supplies used in those cases.
Speaker: and then based on our general contract averages, what we would expect to see from a reimbursement perspective. And then as we started to build that, that list out, started to notice some trends, you know, and that might have been a trend by case, or by a vendor, or by a contracted payer, or provider, and then have some conversations around that, you know, this case becomes viable, where it might not be viable today, it might become viable if we're able to reduce the case time by 10 minutes. And what are the things that we're doing
Speaker: as part of our preoperative setup or our closing process or our room turnover time in order to shave off 10 minutes. And if you shave off 10 minutes and you save $100 or $1 ,000, now all of a sudden a potential loss on a case is a gain. And now you can recruit more and more of those cases. Not to mention the byproduct typically when you're faster and more efficient is a much happier surgeon
Speaker: Um, you know, happier patient, it's less anesthesia, it's faster recoveries and better outcomes. So awesome. Well, thanks so much for joining us today, Matt. Oh, it was my pleasure. I appreciate you guys having me on. As always, it has been a busy week in healthcare, so let's jump right in.
Speaker: This next story I love, so for an industry that has been notoriously slow to adopt new technologies, it certainly has not been ignoring the latest, which is AI or chat GPT. We're already hearing tons of stories about healthcare leaders using AI in multiple ways, assisting with clinical note -taking,
Speaker: It's being used to generate hypothetical patient questions for medical students to practice with. Last week we reported that it's being integrated into Epic's EHR next year, and there are so many other examples. But most recently, a new study found that chat GPT might actually be useful and successful in providing high -quality answers to patient questions, specifically during a time right now where doctors and nurses are incredibly busy.
Speaker: So the research evaluated two sets of answers to patient questions. One set of answers was written by physicians and the other was written by chat GPT. A panel of healthcare professionals then reviewed all of the responses and actually determined that chat GPT's answers were significantly more detailed and empathetic. And the panel preferred chat GPT's responses 79 % of the time.
Speaker: So I think what's interesting about this is that we're not talking about accuracy. Obviously, the physician's responses were completely accurate. There was actually only, let's see, there was only a handful of the physician responses that were deemed unacceptable by the panel. But the accuracy and experience is not coming into play here.
Speaker: And I but I think the most interesting part to me is the empathy factor. It feels wrong that an AI tool could be deemed more empathetic than a human being. But if you think about it, it really all comes down to time. So the reality is that chat GPT doesn't have a jam packed schedule like our providers do. It isn't suffering from burnout. It isn't thinking about their next case or the fact that they've
Speaker: answered the same question 2000 times in their career, which is the reality for our physicians and our providers. So it's not that the doctors are empathetic, they just don't have the time to express it. So thinking through this, I think the workflow might be that the patient question comes in, chat GPT could do the heavy lifting and answering the patient question initially, but then the physician can review the response for accuracy
Speaker: and I have final sign off before the patient does receive a response. So that way it's being used as a supporting tool and it's a huge time saver and we're still not losing that human element and we don't have to be worried that we're sharing something incorrect with the patient.
Speaker: In our second story, a new study reveals that patients without reliable transportation miss more healthcare appointments, which makes it harder for them to manage chronic diseases, receive preventative care, make it to surgery, and manage any other healthcare needs in general. So there's an element of that that is, of course, a little bit obvious, right? If someone doesn't have reliable transportation, how could we
Speaker: expect them to reliably show up for their appointments, but it not only affects the health of the patients, which is a whole important conversation, but it also creates a financial burden on healthcare providers. It's actually estimated that missed medical appointments can cost the industry as much as $150 billion annually in the US alone.
Speaker: What do we do about this? In response, some healthcare providers are beginning to offer or continuing to offer transportation services to patients. So some are partnering with the usual suspects like Uber and Lyft to give significantly discounted rides.
Speaker: Other providers are using community vans or buses or just offering reimbursements for the regular taxi fares. And obviously we want to make sure that everybody in our community is able to make it to an appointment if they need it. Obviously receiving regular care or even being able to follow up after surgery to your appointments will help avoid that 911 call and the emergency visit.
Speaker: But I think the biggest takeaway from this study is the importance of addressing transportation as a social determinant of health and investing in solutions to make sure that your patients have reliable access to get to you when they need to.
Speaker: It's all of our responsibility within our communities to address this. So, specifically adults with disabilities, black adults, people with low incomes, and those on public insurance are more likely to report going without healthcare because of transportation issues.
Speaker: So it's important to get ahead of any potential transportation issues during the pre -assessment process. If you are interested in learning more about social determinants of health, Maura Cash is the VP of Clinical Strategies here at HST Pathways, and she will actually be speaking at ASCA in Louisville on Thursday, May 18th in the morning. She has one of the morning sessions. And the topic is the ASC industry's role in reducing the disparity of care.
Speaker: and she will be covering this in detail. So as I said, it's really something that is the community's responsibility to make sure all of our members are able to get to their healthcare appointments, their surgery appointments when they need to.
Speaker: In our third story, Becker's ASC asked four ASC leaders the same question, what will disrupt the ASC industry next? Now they all had really interesting responses. We'll include the link in the episode show notes. I highly recommend reading through all of them.
Speaker: They covered a lot of the usual trends, consolidation, team -based care delivery models, supply chain, and staffing woes. But I wanted to share in detail the responses from Raghu Reddy. He is the Chief Administrative Officer of Surge Center of Western Maryland. And he had five distinct disruptors that he shared that I wanted to pass along that I thought were great.
Speaker: The first is the evolution of out -of -the -hospital strategy for payers in CMS. We've talked about this a couple times now. Specifically, cardiology is making significant in roads already. The second is technology is going to impact the ASE industry significantly with robotics, AI, and 3D printing.
Speaker: The addition of more procedures to the ASC covered procedures list by CMS and the rise of hybrid ASCs to adapt to the reimbursement shifts. The fourth is private equity firms will dominate the mergers and acquisitions market and hospitals will increase their focus on their ASC strategy. And the fifth is implementation of value -based care and stringent certificate of need law states will have to adapt to lower the healthcare costs.
Speaker: So I thought those five points were nice and succinct, and he did an excellent job summarizing what's to come. And I agree that it will be especially interesting to see what happens with the ASC CPL this year, given the push we're seeing from inpatient to outpatient settings.
Speaker: And to end our new segment, on a positive note, Katrina Mullen is a NICU nurse from Cleveland, Ohio, and she has adopted a teen mom in her newborn triplets. The nurse developed a strong bond with the teen when the baby was in her care. The teen had been in foster care and didn't really have a stable home environment, which inspired Mullen to adopt her and provide her with a safe and loving home.
Speaker: The adoption was finalized in January 2021, and the family is now thriving together. So she adopted the mom and her three babies, which is such a beautiful story. I'm so glad that they all got to stay together. And I especially love this story because it really highlights a special relationship that can form between a nurse, a healthcare provider, the patient, and really the impact that they can have on each other's lives.
Speaker: And that news story officially wraps up this week's podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you're listening from. I hope you have a great day and we will see you again next week.
