Expanding Access to Care: A Virginia ASC With a Cardiac Service Line
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CLD talks with Ann E. Honeycutt, MSN
Executive Director, Virginia Cardiovascular Specialists, VCS Heart and Vascular Center, LLC (VCS HVC), Richmond, Virginia; Board of Managers, MedAxiom
The Centers for Medicare and Medicaid (CMS) first added cardiology procedures to their fee schedule in November 2019, including pacemakers, right and left heart caths, and percutaneous coronary intervention procedures. At that time, ambulatory surgery centers (ASCs) were already growing nationwide, driven by physicians and health systems building on the successful experience of office-based laboratories in treating vascular patients in an outpatient setting. With the goals of appropriate and safe cardiovascular care, an outside hospital setting serves physicians, patients, and payers alike, offering lower costs, a more personalized and quicker experience for patients, and greater control over costs and time for physicians and health systems.
Ann Honeycutt, MSN, Executive Director of the Virginia Cardiovascular Specialist group, describes her experience building an ASC, the VCS Heart and Vascular Center, that first opened with a focus on electrophysiology and peripheral vascular procedures. Anticipating the outgrowth of additional cardiovascular procedures, the design of the ASC included planning for a future cath lab room, currently under construction after a Certificate of Need was granted from the Virginia Department of Health.
Can you tell us about the Virginia Cardiovascular Specialists group?
Virginia Cardiovascular Specialists (VCS) is a 39-person, private cardiovascular group in Central Virginia. Our primary service area encompasses the greater Richmond metropolitan area, including Chesterfield, Prince George, Hanover, Henrico and Rappahannock Counties. We have been in the community for over 40 years, and are well established between both of the large health systems, HCA and Bon Secours. We offer a comprehensive cardiovascular service line, including cardiac and peripheral vascular interventional procedures, electrophysiology (EP) including pulsed field ablation therapy, a full range of noninvasive services, including cardiac computed tomography, cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET)-CT, outpatient heart failure, and structural heart.
What made you decide that you wanted to expand care into an ambulatory surgery center (ASC), and add cardiac care as a specialty?
VCS conducts a strategic retreat every two years. At our retreat in March 2021, we discussed the evolving role of cardiology in the ASC and the move by Centers for Medicare and Medicaid (CMS) to support additional procedures in an outpatient setting. As a leader in the community with new innovations, we investigated whether an ASC would be beneficial for our patients, referring physicians, and VCS physicians. Our physicians wanted to have more control over what supplies they could use and their daily schedules. At the hospital, you can be interrupted with emergent cases. Our turnover time is around eleven minutes and we have a very dedicated staff. VCS is in an accountable care organization (ACO) with primary care, so it is very important that we continue to focus on cost savings for Medicare. At the VCS Heart and Vascular Center, we are able to offer patients the same quality of care that they expect from VCS in a high-quality, low-cost, and efficient setting. It is clear to us that the future of cardiology will continue to move more to the outpatient setting. The efficiencies have been incredible, frankly, and patients have absolutely loved it. It has been very positive.
Can you tell me about your current patients and how you are using your ASC to serve them while you are waiting on your facility build to be finished?
We built the facility to be prepared for a potential cath lab. The major construction needs are in preparing for the electrical and cabling requirements. We are able to use Room 2 for our existing procedures, including peripheral vascular and cardiac devices.
Can you talk more about the planning process and your role?
I am the executive director for the practice, and was involved from start to finish. I am fortunate to have an incredible management team who worked side by side with me. Several months after the March 2021 retreat, we identified a vacant office with the appropriate ceiling height and square footage. It was located less than half a mile from a top heart hospital that provides a full range of cardiovascular services, including open heart. We created a pro forma around an ASC, with the plan to build out the center to be ready for a cath lab, and worked with an architect who had experience planning a significant number of cardiac cath labs in the city of Richmond. We also used a construction company with experience in building surgery rooms. In our area, no one had built a cardiovascular-specific ASC before; we were the first. One major hurdle was the continuing supply chain challenges, which were prevalent due to the COVID-19 pandemic. A specific example was one significant electrical panel was shipped but never arrived, and when a second later arrived, it did not fit. When the correct panel finally arrived, our contractor worked around the clock to wrap up construction and we were able to install the procedural equipment. After about two weeks’ training, our first case was scheduled for January 3, 2023. Our ASC has now been open for almost two years and has successfully completed over 1000 cases with the focus on peripheral vascular and EP procedures. We have not yet started to do cardiac caths, but have begun construction on the cath lab room with the plan to open the cath lab doors by the end of the year.
Once we were approved for our cath lab certificate of need (CON), administration worked with our physician cath lab committee to determine the specific cath lab vendor and equipment. The physicians decided to go with the Philips Azurion 7, and began working with Philips to get their specifications. We chose the same architect that helped us originally with our ASC. They worked through very complicated design plans to make sure we did everything necessary to accommodate the equipment and meet building code and life safety requirements.
What was the certificate of need (CON) process like and what other accreditations did you need? Can you share more about your overall timeline (Table)?
We filed for our CON for an outpatient cath lab the summer of 2023. The application process is very specific and requires letters of support, financial and case load disclosures, as well as why it would meet an unmet need for the citizens of the planning district. The process included a public hearing where patients could testify, as well as myself and the medical directors. We received approval in late November 2023.
Are you required to go through any additional accreditation or process with Medicare to open the cath lab?
Interestingly, no. Our Quad A accreditation and Medicare certification are sufficient. We will have some filing requirements with the State. The American College of Cardiology does have a cardiac cath registry (CV ASC Registry Suite) that we will certainly evaluate.
Can you talk more about how Philips has been involved in your cath lab planning process?
Philips has been great. They worked with our architects, physicians, and management team in the early stages to make sure the requirement chosen fit our facility and patient care goals. We were able to come to a consensus around the Philips Azurion 7 Image-Guided Therapy System, which could meet our needs from a cardiac cath standpoint, as well as for EP procedures. We plan to continue to use the current C-arm in Procedure Room 2 for EP and peripheral vascular cases.
Can you talk more about the use of cardiac CT in screening patients for outpatient procedures?
For over 20 years, VCS has had the only accredited, dedicated cardiac CT scanner in the region, which allows for early identification of heart disease with noninvasive testing such as calcium scoring, as well as coronary angiography, identifying patients with high-risk coronary lesions through HeartFlow, which offers a 3D model of the coronary arteries identifying potential narrowing and blockages of the arteries that prior could only have been identified in an invasive procedure. This technology will be essential for VCS physicians to identify appropriate patients for an outpatient cath lab, minimizing any chances of high-risk patients being scheduled at the VCS Heart and Vascular Center and helping to ensure patient selection meets the highest standard.
How was patient care organized during the building of the ASC and then again with the cath lab construction?
The location of the VCS Heart and Vascular Center was vacant space that met our requirements for a future cath lab. Once we had construction completed, the equipment was finalized, and all the life safety training finished, only then did we start taking care of patients. As we install the cath lab, our second room is utilized for all cases with our current C-arm and monitoring. Construction for the cath lab is being done on weekends and after hours. The Philips Azurion 7 lab will be delivered in early December 2024, and we hope to go live by mid-December. We have been able to hire incredible staff with cath and OR experience, which is essential as you move forward.
Do you have any advice for other groups who may be looking to open an ASC?
This is a large undertaking. You must have a strategic plan, starting with a demand analysis for the services and patient population, as well as supportive physicians. We considered data such as the number of outpatient EP and peripheral vascular cases performed across the practice and the potential growth of our patient population in the coming years. It is essential to find a location that would fit all of the ASC life safety and building requirements, be safe and convenient for your patients, easily accessible to tertiary hospitals, as well as meet your budget projections for cost of construction!
Other key issues are:
• Develop sound budget and volume projections
• Understand pricing for all supplies and devices; put together an inventory management system
• Meet with your commercial carriers to understand their contracting requirements and level of support for the project
Physician commitment is key, because it is a big financial investment on their part. If you don’t want to do an ASC on your own, there are several management companies that can help you partner and manage the financials. They are paid through a management agreement and/or may want to have a majority ownership stake. Our group has been blessed with a great internal management team. We hired someone early on who had done a lot of work in the ASC world. She was incredibly helpful with accreditation and in knowing regulations for ASCs. However, if you don’t have a large or experienced, internal management team, then partnering with someone is not a bad idea. It can be useful if you want to do an ASC, but lack the infrastructure.
How does reimbursement and CMS affect your path forward?
As little as six years ago, CMS did not have any cardiac cath procedures listed in their ASC fee schedule. Then they added cardiology procedures in November 2019, including pacemakers, and some additional vascular procedures beyond those vascular procedures already approved for office-based labs. As CMS added procedures, it allowed us to consider whether we could financially support an ASC. We were more certain about moving forward because outpatient cath — right heart cath, left heart, and percutaneous coronary intervention — was already on the CMS fee schedule. It allowed us to calculate our numbers accurately and we knew which device patients we could move to the ASC that were not high risk. For the cath lab itself, when we evaluated our numbers, we calculated how many of our caths were done as an outpatient at a hospital and could move into an ASC, and how many procedures were necessary in order to support and pay for the cath lab. Some people thought CMS would move atrial fibrillation ablations to outpatient in 2025, but that procedure was not listed in the 2025 CMS Proposed Rule. I also do not expect procedures like transcatheter aortic valve replacement (TAVR) to move out of the hospitals in the near future, simply because these patients tend to be elderly and sick. However, structural heart procedures like patent foramen ovale (PFO) closure could one day be an option, as well as other similar procedures.
This article is supported by Philips ASC and OBL Solutions.
Ann Honeycutt is a consultant for Philips. She has been compensated by Philips for their services in preparing and presenting this material for Philips’ further use and distribution.
The opinions and clinical expertise presented herein by are specific to the featured speakers and are for informational purposes only. The results from their experiences may not be predicative for all subject, physicians or patients. Individual results may vary depending on a variety of patient-specific attributes and related factors. Nothing in this article is intended to provide specific medical advice or to take the place of written law or regulations.
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