Introducing the Ambulatory CardioVascular Center

Ambulatory surgery centers (ASCs) have experienced rapid growth over the past 20 years. This trend is expected to increase 18% by 2019.¹ This growth is driven by improved outcomes in a patient-friendly, comfortable environment, allowing autonomy for doctors and staff, and reduced costs for the overall healthcare system. Following CMS’ approval for arterial endovascular interventions performed in outpatient centers in 2005, there has been explosive growth of endovascular office-based laboratories (OBLs) throughout the United States. It is estimated that over 500 OBLs are operating, with approximately 25 new centers opening each month. 

Several specialties practice in the OBL setting, but the most common are interventional cardiology, vascular surgery, radiology, and interventional nephrology. Procedure mix varies, but most cases performed are interventions for peripheral artery disease (PAD), interventional radiology, and dialysis work. Growth has been accelerated by significant advances in minimally invasive vascular procedures, and devices which, in turn, enhance efficiency and safety of various vascular procedures performed in the OBL. Almost all peripheral diagnostic and interventional procedures, from peripheral atherectomy to stenting and dialysis work like fistulagrams, thrombectomy, and angioplasty, are performed in this setting.

CMS Changes in Reimbursement

Dialysis vascular access services performed in vascular access centers (VACs) experienced a dramatic overall reduction in reimbursement in 2017. This is due to a CMS policy requiring services that are billed together more than 75% of the time to be bundled. As a result, new interventional CPT code bundles were developed and are highlighted in Table 1, showing the approximate difference in reimbursement for certain interventional dialysis vascular access services performed in a VAC as compared to the same services performed in an ASC setting.

These cuts have led many nephrology practices to consider the financial, operational, and legal viability of converting their office-based vascular access centers (VAC) into Ambulatory CardioVascular Centers.

The Ambulatory CardioVascular Center

An Ambulatory CardioVascular Center can be set up as a brand-new surgery center in the same building as the OBL or contiguous with the office, depending on regulations and the configuration of the current facility. It is a requirement by Medicare to become certified, licensed, and accredited as an ASC, and in some states, to obtain a Certificate of Need (CON). It is also necessary to remain an accredited OBL to access both reimbursement structures, which makes this model so attractive. Cases can be scheduled to best maximize reimbursement by operating as an OBL on certain days of the week and an ASC on other days.

Jason Gries, a partner at McGurieWoods, LLP, has a process map for evaluating whether to convert an OBL to a hybrid ASC. “The first step is to evaluate whether your OBL is significantly adversely impacted by recent CMS rate cuts. Second is an evaluation of the costs to convert to an ASC; third is the estimated conversion timeline. Finally, the legal considerations must be evaluated.” If the analysis points to a conversion, then it is time to start the pre-development process.

In the 2016 book, Developing & Managing Ambulatory Surgery Centers², ASC industry experts Joseph and Robert Zasa state, “Planners should develop ASCs around four basic management cornerstones — patient care, risk management, business office, and payer contracting.” They continue, “Most ASCs are successes or failures before they are built. Certainly, there are exceptions. The point is that planning is absolutely critical to long-term success.”

Several presentations at the 2017 Outpatient Endovascular and Interventional Society (OEIS) meeting³ revealed that approximately 25% of OBLs fail, and almost half are struggling. This is primarily due to inadequate planning on the front end, with a lack of understanding about the business and market dynamics, case volume implications, and the proper reimbursement mix for the center to make the venture profitable. 

Drawing from more than 35 years of experience in ambulatory surgery center development and understanding the trends in health care, ACA Cardiovascular, which plans, develops, and manages Ambulatory CardioVascular Centers as minority partners with physicians, offers a well-tested approach to evaluating the potential success of an ASC. The approach evaluates the case mix, Medicare and private payer reimbursement for that specific zip code, and the local competition. These data points are analyzed and used to create the business plan that will highlight the advantages of this model. 

This evaluation enables physicians to properly analyze the financial impact of developing an Ambulatory CardioVascular Center, which both maximizes the reimbursement and allows the possibility of adding other specialties to further stabilize and or grow the business. A pre-development approach should always be used prior to the opening of a new or converted center, to ensure financial viability.

In conclusion, the Ambulatory CardioVascular Center offers a better experience to patients over a hospital setting due to the convenience, efficiency, and the comfort of a patient-focused environment. It also provides physicians greater control of the entire medical procedure, from initial office greeting to post op care and follow-up. This will lead to lower costs for payers, and offers physician entrepreneurs freedom to operate and provide excellent patient care. 

Converting to an Ambulatory CardioVascular Center widens the scope of practice as compared to an OBL, and offers the ability to operate a specialized center to deliver innovative and economical healthcare. With proper planning, a pre-development strategy, and a solid business plan, the Ambulatory CardioVascular Center is the next wave of delivering high-quality, efficient, endovascular, cardiology, and dialysis vascular access therapy to patients. 

References

1. Advisory Board’s Cardiovascular Roundtable, 2015-2016 National Meeting.
2. Zasa JS, Zasa RJ, eds. Developing and Managing Ambulatory Surgery Centers. Incline Village, Nevada: ASD Management, Inc.; 2016.
3. OEIS 2017 Annual Meeting, Santa Monica, CA April 1-2, 2017.

Marc Toth can be contacted at mtoth@acacardiovascular.com.

Robert Zasa can be contacted at rzasa@asdmanagement.com.