stressed is the higher than normal default rate from those payment plans.” Working leaner, however, is not easy,

Tapia says. “You want to do good surgery but now we have a cost-containment issue.” For instance, she says, “we have multiple surgeons who all use different implants with different costs. It would be easier if we could use the cheapest implant and the same one, but we can- not. Some of the carriers will give us one set of reimbursement for the case and others another. It is a challenge because it should not be us nurses telling the sur- geons what implant they should use on their patients because of the cost. They are the surgeons and they should be able to choose what is best for their patients.” Another concern for ASCs, Tapia involves procedures that have


moved into the ASC setting only recently, for example total joint or spine procedures. Medicare won’t reimburse ASCs for providing many of those pro- cedures. “Who wants to go to an ASC and pay out of pocket instead of going to an HOPD and having insurance pay for the procedure? Those kinds of sit- uations make it difficult to educate a patient about the reasons to come to an ASC as opposed to an HOPD. At least patients are becoming more cost-con- scious now. That is a good thing.” An inability to do block scheduling can also act as a hindrance to working leaner, Tapia says. “We run a multi- ple-specialty ASC, and we are trying to convince our physicians to accept block times. We have been offering massage time and/or gift cards to the surgeons who will accept block times. It is hard to do an eye procedure in the same room right after a joint proce- dure, for example. It would be easier if we could get through all the eye pro- cedures of the day before starting the joint procedures in the same room.” Lack of an analytical approach for

expense management also poses a hin- drance to working lean in an ASC, says Jason Schifman, vice president of

(EMR) for at least 50 percent of their cases to qualify as “meaningful users” of those systems although no certified EMR system currently exists for ASCs. “The failure to meet that requirement could financially penalize surgeons, e.g., GI surgeons who treat Medicare patients and are high-volume producers in the ASC,” he says. Another regulation of concern is an

With the Affordable Care Act and its influence on certain insurance carriers, reimbursements are not increasing and, in some cases, are decreasing while expenses are increasing.”

— Gary A. Richberg, RN, CASC Pacific Rim Outpatient Surgery Center

finance at Frontier Healthcare Hold- ings in New York, New York.

Increased Regulations Increased regulations from the state, the Centers for Medicare & Medicaid Services (CMS) and the accrediting bodies are also imposing operational challenges on ASCs, Richberg says. “I applaud ASCA’s efforts in addressing the burden of the Condi- tions for Coverage initial mandate that required patients to have their rights and responsibilities told to them prior to their date of service,” he says. “This change was critical in allowing same- day access to ASCs where the cost of care is lower and the patient outcomes and experience are, in general, higher.” A few of the increased regulations

are burdensome to ASCs, Richberg says. As an example, he cites the mandate that surgeons attest that they are using a cer- tified electronic medical record system

oversight in current law that requires Medicare beneficiaries to cover the cost of their copayment for a “free” screening colonoscopy if a polyp is discovered and removed during the procedure, Richberg says. “This reclassification requires that the patient pay their coinsurance. ASCA recommends that Medicare remove this unexpected cost to Medicare patients, which would encourage higher num- bers of patients to get the screenings that health care professionals recommend and improve mortality rates.”

Management Internal partnership issues and suc- cession planning are two management challenges that ASCs face frequently, Schifman says. “Partnering in an ASC is a bit like getting married,” he says. “The close working relationship can quickly expose differences in culture, approach and expectations.” These differences, how- ever, can be bridged through diligence and systematic work to foster an envi- ronment of transparency, communica- tion and engagement. He recommends regular board, member and commit- tee meetings to ensure that physicians are engaged and empowered by execu- tive summary-level snapshots of their ASC’s performance. “In the relatively rare case where this approach is not suf- ficient, management companies or other outside professionals are often able to serve as objective mediators to help resolve partnership matters in an effi- cient and fair manner.” Through expe- rience working with multiple ASCs, he suggests, outside professionals are able


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