Gastroenterology, Ophthalmology (and Retina) and ENT, Pain Management and Bariatrics in ASCs. What Works and What Doesn t? Tips For Improving Profits

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1 Gastroenterology, Ophthalmology (and Retina) and ENT, Pain Management and Bariatrics in ASCs What Works and What Doesn t? Tips For Improving Profits Anne Roberts, RN Administrator, Surgery Center of Reno, October 23-25,2008

2 Background on Surgery Center of Reno Multi-specialty ambulatory surgery center Turnaround project with 30 physician partners, a hospital and Regent Surgical Health

3 Our Story: Before Shrinking profit margin, hospital department Dated décor, low staff moral Old equipment

4 Our Story: After Key strategy to upgrade equipment, bring in new technology and to meet the changing needs of our surgeons Capital expenditure to update facilities, meet current standards of excellence Re-energized staff Renegotiated contracts Strong physician leader Established leadership team

expenditure to update facilities, meet current standards of excellence

5 Physician Champions

6 Development of Programs of Excellence Focus to include: -Spine -Orthopaedics -ENT -Bariatric surgery -Pain management -Other surgical lines include Ophthalmology, General Surgery, Urology (including Lithotripsy), Podiatry and Dental

management -Other surgical lines include Ophthalmology,

7 Spine Keys to success: - Partnership with three busy neurosurgeons - Purchase state-of-the-art equipment - Outstanding patient care and outcomes - Average of 190 cases of total volume of 4700 cases - Spine carve-outs in our contracts - Work with third party vendor for implants - Represents four percent of total volume - Represents 25 percent of net revenue

of total volume of 4700 cases - Spine carve-outs in our contracts - Work with third party

8 Spine Procedures in ASCs Typical CPTs done in an ASC setting Microdiscestomy with decompression Anterior discectomy single Anterior discectomy - each level Laminectomy Use of microscope Arthodesis ant interbody Anterior instrumentation Allograft for spine surgery

Anterior discectomy - each level - 63047 Laminectomy - 69990 Use of microscope -

9 Partnering with Pain Management State-of-the-art equipment - dedicated c-arm, new pain table, RF machine Efficient scheduling Staffed by PACU nurses and performed in dedicated procedure room

10 Evolution of a Program QI Project - Decreased cost with revision of procedure trays - Fluoro time study - Block scheduling to maximize utilization of procedure room - Accounts for 37 percent of total volume - Average reimbursement $920

scheduling to maximize utilization of procedure room -

11 Bariatrics Partnered with Western Bariatrics Institutes - Four Bariatric Surgeons Restrictive options: Gastric banding Intermediate options: Roux-en-Y gastric bypass (laparoscopic)

12 Morbid Obesity Defined as being 100 lbs. or 100 percent over ideal body weight of a BME of 40 or more Approximately three to five percent of the US population has severe obesity Surgical therapy succeeds - 80 percent of hypertension is cured - 80 percent of insulin-dependant diabetics completely stop requiring insulin - Similar improvements in sleep apnea, GERD, etc.

percent of the US population has severe obesity Surgical therapy succeeds - 80 percent of

13 Gastric Banding for Your ASC Provides a specialized surgical program that can separate you from your competitors Attracts high-quality surgeons performing banding and general surgery cases Opportunity to build a relationship with a local acute care hospital Profitable and sustainable program that will increase volume

banding and general surgery cases Opportunity to build a relationship with a

14 Start-up Costs Start-up costs approximate $250,000 - $60,00 for 20 lap bands - Purchase of laparoscopic equipment - Bariatric adaptive equipment: gurneys, scale, BP cuffs, waiting room furniture, bathroom facilities - Band vendors expanding and hope for more competitive pricing in the future

equipment: gurneys, scale, BP cuffs, waiting room furniture, bathroom

15 Operational Considerations Labor and supplies - One hour or less in the OR - Two to four hours in the PACU - Overnight for Roux-en-Y patients - Transfer agreement with acute care - Cost of bands Reimbursement for the procedure is $9,500 to $20,000

for Roux-en-Y patients - Transfer agreement with acute care -

16 Clinical Considerations Commitment to excellence in the care of bariatric patients with documented in-services for staff, credentialing guidelines for bariatric surgery Bariatric program medical director Transfer agreement Board certified anesthesiologists Equipment specific for bariatric patients, including both surgical and radiological equipment Specific guidelines regarding patient selection -ASA level less than four -PT to be executed and not in need of artificial airway upon arriving to PACU -Meet the standard discharge criteria established by the facility

for bariatric patients, including both surgical and radiological equipment Specific guidelines regarding patient selection -ASA level less

17 Patient Selection Ideally BMI less than 55 BMI greater than 55 to be formally reviewed by medical director, surgeon, anesthesiologist and nursing Age less than 60 Weigh less than 425 lbs. No previous history of DVT or PE

surgeon, anesthesiologist and nursing Age less than 60

18 Measure Outcomes and Quality Indicators Reasonable expectation of 100 bariatric surgical cases annually Develop clinical pathways and outcome measurements Support groups for patients Long-term patient follow-up of at least 75 percent at five years with monitoring and tracking systems for outcomes

measurements Support groups for patients Long-term patient follow-up of at

19 ENT Again, physician partnership Invest in high-quality, stat-of-the-art equipment Video towers Endoscopic equipment ENT Image Guidance System to enable more complex sinus surgeries at the facility Adequate numbers of frequently used instruments

ENT Image Guidance System to enable more complex sinus

20 Focus Limit to primarily reimbursable ENT procedures Focus on processes: - Quick turnovers - Work with physicians to individualize recovery time based on patient assessment - Pediatrics - PALS certified staff - Market to parents of pediatric population - Pediatric anesthesia providers - Recovery area conducive to pediatrics

assessment - Pediatrics - PALS certified staff - Market to parents of pediatric

21 Our ENT Experience 24 percent of our total volume 21 percent of net revenue Focus on quality experience for physicians and the patients and their families Monitor outcomes Market to MD s Strive for excellence

22 ENT in the Big Picture Reasonable reimbursement -Need to evaluate the marketplace and ensure not to be overly dependent on Medicaid -Our average reimbursement per ENT case: $1,850 -The challenge is controlling costs: gold laser, scopes, disposables

23 ENT Continues to be a strong contributor to the bottom line in an ASC setting

Adding Orthopedics and Spine to An Existing ASC

Adding Orthopedics and Spine to An Existing ASC Michael McKevitt, Sr. Vice President Business Development Bo Hjorth, Vice President, Business Development James Lynch, MD, Contributor Discussion Outline