pital used extracorporeal shockwave lithotripsy (ESWL), ureteroscopy or percutaneous kidney stone removal. Treatment has moved almost entirely into the outpatient and, now, the ASC arena. Part of what has allowed us to perform ASC-based stone procedures is improved imaging, the use of digital, flexible instruments and higher-pow- ered lasers. There is also anti-retropul- sion technology that minimizes migra- tion of stones during ureteroscopy. There have been improvements in anesthesia and pain management techniques that have greatly reduced postoperative pain, nausea and vom- iting risks. There have also been advancements in urologic diagnostics as far as different types of imaging we can use for targeted prostate biopsies as well as renal masses and urinary tract stones.

From a reimbursement and regula- tory standpoint, the Centers for Medi- care & Medicaid Services (CMS) is looking favorably at ASCs compared to hospital outpatient departments. Commercial carriers are doing so as well. ASCs also can negotiate with commercial carriers to secure carve- outs and receive improved facility fee reimbursement, making it financially viable to move cases into the ASC. We are seeing some decreases in professional fee reimbursement and bundling of urology codes, particu- larly from CMS. In the past few years, cystoscopy and ESWL experienced decreases in reimbursement. CMS recently bundled one of the codes for percutaneous kidney stone removal. The good news is that CMS and commercial carriers are generally not decreasing facility fees. In some cir- cumstances, urologists might earn less from a professional fee standpoint, but they still maintain a positive margin because of the facility fee. There also seems to be a trend

toward relaxation of certificate-of-need (CON) laws, spurring ASC develop- ment in certain states.

You can perform almost any outpatient urologic case in an ASC setting. In fact, our physicians perform about 90 percent of their surgical cases in such a manner.”

—Brad Lerner, MD, CASC Summit ASC

Q: What opportunities do you see for growth in urology? BL: I see tremendous opportunities. In 2018, it was estimated that there were 52 million people age 65 and over, which is about 16 percent of the total US population. Those figures are going to rise in the coming years. Many of the urologic diseases we treat are found in people of advancing age, meaning there is a large, growing pop- ulation of candidates.

Urology has a broad scope of ser- vice lines, case types and disease pro- cesses. This includes procedures on children, adults and elderly and both males and females. We treat benign and malignant prostate disease; kid- ney and ureteral stones; pelvic health issues and more. Looking toward the future, some groups are considering bringing lapa- roscopy and robotics procedures into the ASC. These have traditionally only been performed in the hospital. In Maryland at least, there are hos- pitals that no longer desire many of the urologic cases because of their global budget revenue methodology. Insur- ance carriers want them out of the hos- pital, and the doctors want them out of the hospital. The ASC is where most urologic cases belong.

Q: What are the most significant challenges facing urology in ASCs today? BL: A big challenge concerns expan- sion of hospitals into the ASC arena.

More hospitals are opening ASCs or seeking partnerships with existing centers. This means increased com- petition for cases, physicians and staff. We used to be able to recruit nurses and technicians from hospi- tals because we could offer no eve- ning, holiday or weekend shifts. Hospitals with ASCs are now offer- ing what we are offering.

While there is relaxation of CON

laws, some states still have strict laws, which can make it difficult for a urology group to open a single-specialty ASC. One final challenge concerns changes in CMS reporting measures. Quality measures are constantly evolving. There is also talk about ASCs reporting costs, although that has been tabled for now. You can never predict when new report- ing requirements will hit.

Q: What advice would you give to ASCs that are considering adding urology? BL: I believe any ASC should strongly consider implementing a urologic ser- vice line. You can perform almost any outpatient urologic case in an ASC set- ting. In fact, our physicians perform about 90 percent of their surgical cases in such a manner.

Since urology is a diverse, high-

volume specialty, you can stage the procedures and lines of services rather than go all-in right away. Consider the low-hanging fruit first—those higher- volume, lower-cost procedures, even though the margins may be lower. Once you get comfortable with those cases, move onto the lower-volume, higher-cost procedures that may bring higher margins.

Based on the data, there is a lot of missed opportunity across the coun- try for urologic-based ASC services. While some may be due to CON laws and some may be because of areas with hospital-employed urologists, there are significant parts of the coun- try where ASC urology can thrive.


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